L. Chiarini

Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology

OBJECTIVES Recently, jawbone osteonecrosis has been reported as a potential adverse effect of bisphosphonates administration. This paper considers and highlights histopathologic and radiologic features of this condition. STUDY DESIGN Eleven patients, owing to unresponsiveness to conservative treatment and uncontrollable pain, underwent surgical resection of diseased jawbone after extensive hyperbaric oxygen therapy. A thorough clinical, laboratory, and imaging study was performed. Surgical specimens underwent histopathologic and immunohistochemical evaluation. RESULTS Computerized tomography (CT) scans showed increased bone density, periosteal reaction, and bone sequestration in advanced stages. With magnetic resonance imaging (MRI), exposed areas showed a low signal in T1- and T2-weighted and inversion recovery images, which suggests low water content and is histopathologically correlated with paucity in cells and vessels (osteonecrotic pattern). Unexposed diseased bone was characterized by T1 hypointensity and T2 and IR hyperintensity, which suggests high water content and inflammation, associated with hypercellularity, osteogenesis, and hypervascularity (osteomyelitic pattern). CONCLUSIONS Diseased bone extends beyond the limits of the bone exposed in the oral cavity. Histopathologic examination correlated well with CT and MRI, which are the choice for the evaluation of bisphosphonate-associated jawbone osteonecrosis.

Vascularized fibula flap reconstruction of the mandible in bisphosphonate-related osteonecrosis.

AIMS To point out the feasibility of microsurgical reconstruction of the mandible in patients with bisphosphonate-related osteonecrosis (BRONJ). METHODS Seven patients with extensive mandibular osteonecrosis underwent subtotal mandibulectomy and immediate reconstruction with a free fibula flap. They were six women and one man aged 49-72 years. The mean size of the bone and oral mucosa defects were 18.5 and 22.5 cm(2) respectively. RESULTS The mean time of surgical intervention was 12 h. All flaps survived and the postoperative course was uneventful. Oral feeding was resumed 14 days after surgery in all cases. The donor legs healed without complications. The pathology report confirmed the diagnosis of BRONJ in all patients. Normal bone was detected at the resection margins in six out of seven patients. Patients were followed-up at intervals of 3 months. After a median follow-up time of 23 months, no clinical and radiographic evidence of recurrent BRONJ were detected in six patients. One patient with osteomyelitis at the resection margins had signs of recurrent BRONJ 6 months after surgery. The overall curative rate of the population was 86%. CONCLUSIONS Despite the limited number of patients studied so far, our data show that mandible reconstruction with the fibula flap is feasible and does not influence the natural course of the primary disease in BRONJ-resected patients.

Functional rehabilitation of the atrophic mandible and maxilla with fibula flaps and implant-supported prosthesis.

Historically, nonvascularized bone grafts have been the standard treatment for severe mandibular and maxillary atrophy, followed by immediate or delayed implant placement. Extreme atrophy is an unfavorable biological and mechanical location for nonvascularized autologous bone transplants. The authors present the results of a multidisciplinary treatment protocol for rehabilitation of extreme mandibular and maxillary atrophy by use of the vascularized fibular flap. This protocol includes bone augmentation, implant surgery, soft-tissue management, and prosthetic restoration. Since 1993, 18 patients with a mean age of 47.5 years presented with extreme mandibular and/or maxillary atrophy and underwent alveolar crest augmentation with vascularized fibular flaps. Bone healing was achieved in 17 of the 18 patients. Seventy-three osteointegrated implants were inserted in 12 of 17 fibular flaps. Altogether, 62 implants were loaded and 11 dental prostheses were made. Average follow-up of the loaded implants was 41 months. The success rate of loaded implants was 100 percent. The authors strongly recommend the use of the fibular bone flap when dealing with extreme atrophy of the mandible and maxilla and suggest the protocol outlined in this review.

Bioactive glass/hydroxyapatite composites: mechanical properties and biological evaluation.

Bioactive glass/hydroxyapatite composites for bone tissue repair and regeneration have been produced and discussed. The use of a recently developed glass, namely BG_Ca/Mix, with its low tendency to crystallize, allowed one to sinter the samples at a relatively low temperature thus avoiding several adverse effects usually reported in the literature, such as extensive crystallization of the glassy phase, hydroxyapatite (HA) decomposition and reaction between HA and glass. The mechanical properties of the composites with 80wt.% BG_Ca/Mix and 20wt.% HA are sensibly higher than those of Bioglass® 45S5 reference samples due to the presence of HA (mechanically stronger than the 45S5 glass) and to the thermal behaviour of the BG_Ca/Mix, which is able to favour the sintering process of the composites. Biocompatibility tests, performed with murine fibroblasts BALB/3T3 and osteocites MLO-Y4 throughout a multi-parametrical approach, allow one to look with optimism to the produced composites, since both the samples themselves and their extracts do not induce negative effects in cell viability and do not cause inhibition in cell growth.

Sol-gel derived bioactive glasses with low tendency to crystallize: synthesis, post-sintering bioactivity and possible application for the production of porous scaffolds.

A new sol-gel (SG) method is proposed to produce special bioactive glasses (BG_Ca family) characterized by a low tendency to devitrify. These formulations, derived from 45S5 Bioglass®, are characterized by a high content of CaO (45.6 mol%) and by a partial or complete substitution of sodium oxide with potassium oxide (total amount of alkaline oxides: 4.6 mol%), which increases the crystallization temperature up to 900°C. In this way, it is possible to produce them by SG preserving their amorphous nature, in spite of the calcination at 850°C. The sintering behavior of the obtained SG powders is thoroughly investigated and the properties of the sintered bodies are compared to those of the melt-derived (M) counterparts. Furthermore, the SG glass powders are successfully used to produce scaffolds by means of a modified replication technique based on the combined use of polyurethane sponges and polyethylene particles. Finally, in the view of a potential application for bone tissue engineering, the cytotoxicity of the produced materials is evaluated in vitro.

Cosmetic Procedures in Orthognathic Surgery

PURPOSE Orthognathic surgery produces cosmetic and functional effects, and patients should be evaluated for additional cosmetic improvements beyond those possible with orthognathic surgery. Soft tissue procedures can be performed on an outpatient basis in an office environment and can be combined with orthognathics and delayed in a second stage. METHODS Systematic accurate facial evaluation is necessary to focus on cosmetic soft tissue problems. Features that make the patient look unattractive, old, tired, out of shape, weak, or sad must be identified by accurate clinical analysis and 3-dimensional planning. Then it will be possible to select the treatment plan according to the patients input, prioritizing the additional cosmetic improvements that can be added to primary surgery. RESULTS It is particularly important to review the results and the patients satisfaction by clinical examination, a questionnaire, and with 3-dimensional pictures, and to understand if the treatment options have been accurately chosen and their lasting effect on follow-up. The treatment sequence is analyzed, and if there are residual defects, a secondary cosmetic procedure can be planned to complete the result. CONCLUSIONS The surgeons goal must be the simultaneous treatment of malocclusions and facial esthetic disharmonies, and orthognathic surgical procedures and facial cosmetics must be performed simultaneously, if possible. Residual defects must be treated after at least 6 to 12 months.

How to improve retromandibular transmasseteric anteroparotid approach for mandibular condylar fractures: our clinical experience.

Fractures of the mandibular condyle are common and account for 25-35% of all mandibular fractures reported in the literature. Even with the development of a consensus on the preference for open reduction and internal fixation of these fractures, the clinician is still faced with a dilemma concerning the optimal approach to the ramus-condyle unit. Limited access and injury to the facial nerve are the most common problems. The most commonly used extraoral approaches are the submandibular, retromandibular and preauricular methods. In this study, we propose a modified cosmetic preauricular incision with a short end in the neck, to improve the transmasseteric anteroparotid (TMAP) approach previously described by Wilson et al. in 2005. We retrospectively analysed 13 patients treated in our department for mandibular condylar fractures. Post-operative complications, occlusal status, interincisal opening and joint tenderness were evaluated at 3 months after surgery. The wider skin incision described here provides a convenient approach for open reduction and rigid internal fixation, and good results were obtained. The follow-up ranged from 6 to 40 months.

Otolaryngology fantastica: The ear, nose, and throat manifestations of munchausen's syndrome†

Munchausens syndrome (MS) is a form of severe, chronic, factitious disorder with physical symptoms. Some essential features define MS, such as recurrent, feigned, or simulated illness; peregrination (traveling or wandering); pseudologia fantastica; and drug abuse. Munchausens syndrome by proxy (MSBP) classically involves a parent or other caregiver who inflicts injury or induces illness in a child. The aim of the present study was to summarize and study the main ear, nose, and throat (ENT) manifestations of MS and MSBP.

Surgical treatment of unilateral condylar hyperplasia with piezosurgery.

IntroductionUnilateral condylar hyperplasia (UCH) is a disorder of unknown etiology mainly seen in growing patients, which results in facial asymmetry. High condylectomy alone or in association with orthognathic surgery can improve the occlusion and the facial aesthetics. Materials and MethodsBetween 2005 and 2012, a total of 5 patients underwent high condylectomy for UCH using a piezoelectric cutting device. All patients were treated postoperatively with functional rehabilitation. ResultsThe long-term follow-up showed that all patients had a satisfactory temporomandibular joint articular function associated with stable occlusion without any recurrence of further condylar growth. ConclusionsHigh condylectomy in the surgical treatment of unilateral UCH seems to be the procedure of choice in growing patients. The use of a piezoelectric cutting device allows a safe and less invasive high condylectomy.

Eagle syndrome surgical treatment with piezosurgery.

IntroductionEagle syndrome (ES) is an uncommon complication of styloid process elongation with stylohyoideal complex symptomatic calcification. It is an uncommon condition (4% of the population) that is symptomatic in only 4% of the cases. Eagle syndrome is usually an acquired condition that can be related to tonsillectomy or to a neck trauma. A type of ES is the styloid-carotid syndrome, a consequence of the irritation of pericarotid sympathetic fibers and compression on the carotid artery. Clinical manifestations are found most frequently after head turning and neck compression. Although conservative treatment (analgesics, anticonvulsants, antidepressants, local infiltration with steroids, or anesthetic agents) have been used, surgical treatment is often the only effective treatment in symptomatic cases. Materials and MethodsWe present the case of a 55-year-old patient, successfully treated under endotracheal anesthesia. The cranial portion of the calcified styloid process was shortened through an external approach, using a piezoelectric cutting device (Piezosurgery Medical II; Mectron Medical Technology, Carasco, Italy) with MT1-10 insert, pump level 4, vibration level 7. ResultsNo major postoperative complications such as nerve damage, hematoma, or wound dehiscence occurred. After 6 months, the patient was completely recovered. Two years after the surgery, the patient did not refer any symptoms related to ES. ConclusionsThe transcervical surgical approach in patients with ES seems to be safe and effective, despite the remarkable risk for transient marginal mandibular nerve palsy. This risk can be decreased by the use of the piezoelectric device for its distinctive characteristics—such as precision, selective cut action, and bloodless cut.