Ilaria Giovannacci

Medication-Related Osteonecrosis of the Jaw Around Dental Implants: Implant Surgery-Triggered or Implant Presence-Triggered Osteonecrosis?

Introduction: Dentoalveolar surgery including tooth extractions and dental implants placement is considered the major risk factor for developing medication-related osteonecrosis of the jaw (MRONJ). In this study, a patient series of MRONJ around dental implants were carefully analyzed to describe the findings and to assess the possible risk factors. Methods: Fifteen patients with peri-implant bone osteonecrosis were selected out of a group of 250 patients (6%). Patients were divided into 2 groups according to the temporal relationship. Group 1 (G1)—necrosis immediately after implant placement (from 2 to 10 months) and defined as “implant surgery-triggered” MRONJ. Group 2—necrosis distant (from 1 to 15 years) from implant placement and defined as “implant presence-triggered” MRONJ. Epidemiological and pharmacological variables were recorded as well as specific data about osteonecrosis and dental implants. Results: G1 included 6 patients: 5 (83.4%) treated with oral bisphosphonates (BPs) for osteoporosis and 1 (16.6%) with intravenous BPs for breast cancer. Mean duration of BP therapy (BPT) was 83.7 months. G2 included 9 patients: 8 patients (88.89%) treated with intravenous BPs for malignant disease and 1 (11.11%) with oral BPs for osteoporosis. Conclusions: Data confirms that not only surgical insertion of dental implants is a potential risk factor for the development of osteonecrosis but also the presence itself of the implant into the bone can be associated with this disease. Therefore, it is necessary to inform of the increased risk for MRONJ also the patients who have already osteointegrated implants and are going to start the BPT. The risk is lower for patients receiving oral BPs but it exists and seems to be higher if the implant is located in the posterior areas, if the duration of BPT is more than 3 years and if the patient is under corticosteroid therapy.

Tooth extractions in high-risk patients under bisphosphonate therapy and previously affected with osteonecrosis of the jaws: surgical protocol supported by low-level laser therapy.

AbstractTrauma during dental surgery is a predisposing factor for medication-related osteonecrosis of the jaws (MRONJ). There are no specific guidelines for the management of dental extractions in patients under bisphosphonate therapy (BPT).The authors proposed in 2013 a successful protocol for tooth extractions in patients under BPT supported by Nd:YAG low-level laser therapy (LLLT).The aim of this study was to validate the safety and efficacy of this protocol reporting the data related to its application in a particular category of patients under BPT at high risk for MRONJ and who were previously affected with MRONJ.Eighty-two tooth extractions were performed in 36 patients previously affected with MRONJ. Antibiotic treatment was administered 3 days before and 2 weeks after tooth extractions. Patients were additionally treated with Nd:YAG LLLT, 5 applications of 1 minute each. Patients were evaluated 3 days and once a week for 2 months after the extractions and every time they received LLLT.In a total of 82 extractions, minimal bone exposure was observed in 2 cases, treated with Er:YAG laser vaporization and then completely healed.The data confirmed that laser biostimulation is a reliable technique that can be considered in the surgical protocol for patients under BPT.

Odontogenic myxofibroma: a concise review of the literature with emphasis on the surgical approach.

Purpose: The aim of this work is to report a review of the literature concerning epidemiology, clinical and radiographic features as well as treatment of odontogenic myxofibroma (MF). Methods: The PubMed database was searched using the following keywords: “odontogenic myxofibroma”, “odontogenic fibromyxoma”, “myxofibroma of the jaw” and “fibromyxoma of the jaw”. Results: Fifteen articles reporting the experience with 24 patients were identified. Male/female ratio was 1:1.4 and the average age was 29.5 years. The most frequent location was the mandible. In 66.7% of the cases the radiographic appearance was a multilocular radiolucency. Swelling was observed in 13 patients (92.86%), varying degrees of pain in 5 (35.71%) and paresthesia in only one patient (7.14%). Six out of 24 patients (26.09%) were treated with radical surgery and 17 (73.91%) with a conservative approach. In two out of 21 cases (9.52%) a recurrence was reported. Conclusions: MF is an extremely rare tumor and no agreement exists on the causes of its development. According to the present review, the choice of treatment should depend on variables such as localization, presence of a primary or of a recurrent lesion, age, general medical conditions and aesthetic needs of the patient. Key words:Odontogenic myxofibroma, myxofibroma of the jaw, odontogenic tumors, oral surgery, oral pathology.

Peripheral ossifying fibroma: A clinicopathologic study of 27 cases and review of the literature with emphasis on histomorphologic features

Context: The peripheral ossifying fibroma (POF) is a relatively uncommon, reactive gingival overgrowth usually composed of cellular fibroblastic tissue containing one or more mineralized tissues, namely bone, cementum-like material, or dystrophic calcification. The aetiology and pathogenesis of POF are yet not clear, but some authors have hypothesized a reaction originating from the periodontal ligament, as a result of irritating agents such as dental calculus, plaque, orthodontic appliances, and ill-fitting restorations. Aims: The aim of our study was to report the clinicopathologic features of a case series of POF from a single Italian institution. Materials and Methods: A total of 27 cases were collected over an 18-year period. Detailed relevant medical history, clinical and histological information were recorded for each patient. Results: The age range of patients (m = 6; f = 21) was 17.2-80.1 years with a mean of 42.9 ± 18.1 years. Occurrence of the lesion in the mandibular and maxillary arches was similar, and 67.0% occurred in the incisor-cuspid region. The lesions ranged in size from 0.3 to 5.0 cm (mean, 1.3 cm ± 1.1 cm). All the different types of mineralization were present, with higher prevalence of lamellar bone. The lesions were treated by surgical excision and four lesions in three patients recurred after surgery. Conclusions: Surgeons should consider the high recurrence rate of POF and remove the lesion down to the bone involving also the adjacent periosteum and the periodontal ligament. Professional prophylaxis should precede any surgical procedure, and periodical dental hygiene recalls are important in order to remove any possible irritating factor.

Clinical Differences in Autofluorescence Between Viable and Nonvital Bone: A Case Report With Histopathologic Evaluation Performed on Medication-Related Osteonecrosis of the Jaws

Medication-related osteonecrosis of the jaws (MRONJ) is an adverse side effect of several drug therapies, including bisphosphonates (BPs). Osteonecrosis of the jaw specifically related to BP therapy is usually referred to using the acronym BRONJ. However, no consensus has yet been reached regarding the most appropriate management of BRONJ. The greatest success rates have been recorded with surgical removal of necrotic bone. In particular, erbium:yttrium-aluminum-garnet (Er:YAG) laser-assisted surgery has shown significantly better results than conventional surgical approaches. According to a position paper reported by the American Association of Oral and Maxillofacial Surgeons in 2007, the identification of necrotic bone margins during osteonecrosis removal can be very difficult. In 2015, a review of treatment perspectives for MRONJ reported that both surgical debridement and resection cannot be standardized owing to the lack of guidance to define the necrotic margins. Recently, the use of autofluorescence (AF) of the bone as a possible suitable guide to visualize necrotic bone during surgical debridement or resection was proposed. It seems that vital bone could be highlighted by its very strong AF. In contrast, necrotic bone loses AF and, thus, appears much darker. The molecular sources of the phenomenon of AF are the specific amino acids of the collagen molecules that show AF when irradiated by ultraviolet or blue light. The use of AF as an intraoperative diagnostic tool is entirely new in the management of MRONJ, although it has been used for several years in other fields (eg, intervertebral disc surgery). The aim of the present report was to describe a case of mandibular BRONJ treated with a new surgical approach performed with an Er:YAG laser and guided by AF. The histopathologic evaluation of the removed hypofluorescent bone block and hyperfluorescent surrounding bone has also been reported in detail.

Non-invasive visual tools for diagnosis of oral cancer and dysplasia: A systematic review

Background Gold standard for the diagnosis of oral dysplasia (OD) oral squamous cell carcinoma (OSCC) and malignant lesions is the histological examination. Several adjunctive diagnostic techniques have been proposed in order to increase the sensitivity (SE) and specificity (SP) of conventional oral examination and to improve the diagnostic first level accuracy. The aim of this study is to perform a systematic review on non-invasive tools for diagnosis of OD and early OSCC. Material and Methods Medline, Scopus, Web of Knowledge databases were searched, using as entry terms “oral dysplasia AND diagnosis” / ”oral cancer AND diagnosis”. Data extracted from each study included number of lesions evaluated, histopathological diagnosis, SE, SP, positive and negative predictive values (PPV and NPV), diagnostic accuracy (DA) and the main conclusions. Results After title and abstract scanning of 11.080 records, we selected 35 articles for full text evaluation. Most evaluated tools were autofluorescence (AF), chemiluminescence (CL), toluidine blu (TL) and chemiluminescence associated with toluidine blue (CLTB). Conclusions There is a great inhomogeneity of the reported values and there is no significant evidence of superiority of one tool over the other. Further clinical trials with a higher level of evidence are necessary in order to assess the real usefulness visual diagnostic tools. Key words:Oral dysplasia, oral cancer, diagnosis, visual diagnostic tool, systematic review.

Soft Tissue Chondroma of the Oral Cavity: An Extremely Rare Tumour Localized on the Hard Palate

Chondromas are benign cartilaginous tumors usually localized within the tubular bones of the extremities. Soft tissue chondromas (STCs) are rare and only few cases have been reported in the oral cavity. The present case documents the exceptional finding of a 12-year-standing STC of the hard palate of a 63-year-old man. The tumor measured approximately 6 cm in its larger size and it was radically excised through the use of a quantic resonance molecular (QRM) lancet. No recurrence was observed during 1-year follow-up. A concise review of the relevant literature is included in the present paper.

Erratum to: Advantages of new technologies in oral mucosal surgery: an intraoperative comparison among Nd:YAG laser, quantic molecular resonance scalpel, and cold blade.

The aim of this study is to evaluate the possible intraoperative advantages of Nd:YAG laser and quantic molecular resonance (QMR) scalpel in oral soft tissue surgery. One hundred sixty-three interventions were evaluated. Group 1 (G1) included 77 interventions performed with Nd:YAG laser, group 2 (G2) 45 with QMR scalpel, and group 3 (G3) 41 with cold blade. Parameters analyzed were as follows: speed of incision, time of intervention, intraoperative bleeding, number of stitches, patient compliance, and operator comfort. Data were analyzed using software STATA 12 (StataCorp LP, College Station, TX, USA). Mean speed of incision was 0.54 mm/s in G1, 2.83 mm/s in G2, and 1.58 mm/s in G3, Nd:YAG laser being the slowest. However, no significant differences among times of intervention were found. In particular, interventions in G1 (221.15 ± 220.89 s) have a mean duration lower than G2 (280.56 ± 248.31 s) and G3 (316.10 ± 248.69 s). Intraoperative bleeding occurred in 29.9 % (n = 23/77) of interventions in G1, 97.8 % (n = 44/45) in G2, and 97.6 % (n = 40/41) in G3 (p < 0.0001). Mean number of stitches in G1 was statistically lower (G1, 0.10; G2, 2.07; G3, 2.29; p < 0.0001). No differences with regard to patient compliance were detected. Operator comfort was higher in G1 (p < 0.0003). Nd:YAG laser and QMR scalpel give several advantages in oral mucosal surgery: Nd:YAG laser cuts tissue slowly, but it provides a good visibility and excellent hemostasis. QMR scalpel allows a very rapid cutting with no considerable temperature increase, but there is major risk of bleeding and need for sutures with lower operator comfort.