Leon A. Assael

American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws—2009 Update

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) adversely affects the quality of life, producing significant morbidity in afflicted patients. Strategies for the treatment of patients with, or at risk of, BRONJ were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws (Position Paper) and approved by the Board of Trustees in September 2006. 1 The Position Paper was developed by a Task Force appointed by the Board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. The knowledge base and experience in addressing BRONJ has expanded, necessitating modifications and refinements to the original Position Paper. The Task Force was reconvened in August 2008 to review the 2006 recommendations, appraise the current published data, and revise the Position Paper and recommendations, where indicated. This update contains revisions to the diagnosis and staging and management strategies and highlights the status of basic science research. AAOMS considers it vitally important that this information be disseminated to other dental and medical specialties.

American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaw - 2009 update.

0 isphosphonate-related osteonecrosis of the jaw BRONJ) adversely affects the quality of life, producing ignificant morbidity in afflicted patients. Strategies for he treatment of patients with, or at risk of, BRONJ were et forth in the American Association of Oral and axillofacial Surgeons (AAOMS) Position Paper on isphosphonate-Related Osteonecrosis of the Jaws Position Paper) and approved by the Board of Trustes in September 2006. The Position Paper was eveloped by a Task Force appointed by the Board nd composed of clinicians with extensive experince in caring for these patients and basic science esearchers. The knowledge base and experience in ddressing BRONJ has expanded, necessitating modfications and refinements to the original Position aper. The Task Force was reconvened in August 2008 to

Oral Bisphosphonates as a Cause of Bisphosphonate-Related Osteonecrosis of the Jaws: Clinical Findings, Assessment of Risks, and Preventive Strategies

PURPOSE Oral bisphosphonates are known to have potentially profound effects on oral health. A review of the evidence supporting answers to key clinical questions is necessary to assist surgeons in the care of their patients who are receiving oral bisphosphonates. MATERIALS AND METHODS The literature is reviewed to address several questions, ie, what is the risk of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in my patient on oral bisphosphonates? Why are so few cases of BRONJ attributable to oral bisphosphonate use? What is the importance of cofactors in the development of osteonecrosis? How major a clinical problem is BRONJ, typically, in the oral bisphosphonate patient? What dental procedures are associated with a risk of BRONJ? Are other findings apart from BRONJ of importance in the oral bisphosphonate patient? Are there proven strategies to prevent BRONJ in the oral bisphosphonate patient? Should my patient discontinue the use of oral bisphosphonates temporarily or permanently? RESULTS A review of the evidence offers information that will help in clinical decision-making. In general, the risk of BRONJ is between 1 in 10,000 and 1 in 100,000, but may increase to 1 in 300 after dental extraction. The great majority of BRONJ cases will likely remain in the intravenous population. Cofactors have not been firmly established, although smoking, steroid use, anemia, hypoxemia, diabetes, infection, and immune deficiency may be important. Rarely does BRONJ in the oral bisphosphonate patient appear to progress beyond stage 2, and many cases reverse with discontinuation of oral medication. Extraction is the only dental procedure shown to increase the risk of BRONJ. Dental implant therapy should be used with caution in the oral bisphosphonate patient. The benefits and risks of oral bisphosphonate use must be weighed individually and in consultation with the prescribing physician, before determining the need for temporary or permanent cessation of medication. CONCLUSION Emerging evidence supports clinical decisions in favor of the oral and maxillofacial surgery patient taking oral bisphosphonates.

Imaging findings of bisphosphonate-associated osteonecrosis of the jaws

BACKGROUND AND PURPOSE: Bisphosphonates are drugs that decrease bone turnover by inhibiting osteoclast activity. An association between the use of bisphosphonates and osteonecrosis of the maxilla and mandible has recently been described. This study describes the imaging findings of bisphosphonate-associated osteonecrosis of the jaws. MATERIALS AND METHODS: This is a retrospective series of 15 clinically diagnosed patients, identified at 3 centers. Eleven patients were women, of whom 6 had breast cancer, 3 had osteoporosis, and 2 had multiple myeloma. Of the 4 male patients, 2 had prostate cancer, 1 had multiple myeloma, and 1 had osteoporosis. The age range of the patients was 52–85 years (average, 68 years). The mandible was the clinical site of involvement in 11 patients, and the maxilla was involved in 4 patients. Imaging consisted of orthopantomograms in 14 patients, CT scans in 5 patients, and radionuclide bone scan in 1 patient. Nine patients had sequential imaging. Two radiologists reviewed the images. RESULTS: All of the patients had a degree of osseous sclerosis, most commonly involving the alveolar margin, but lamina dura thickening and full-thickness sclerosis were also observed. The sclerotic change encroached on the mandibular canal in 3 patients. Less commonly encountered findings included poorly healing or nonhealing extraction sockets, periapical lucencies, widening of the periodontal ligament space, osteolysis, sequestra, oroantral fistula, soft tissue thickening, and periosteal new bone formation. CONCLUSIONS: The most common finding in bisphosphonate-associated osteonecrosis was osseous sclerosis. This varied from subtle thickening of the lamina dura and alveolar crest to attenuated osteopetrosis-like sclerosis.

Craniomaxillofacial trauma in the elderly

PURPOSE Limited data are currently available regarding the nature of craniomaxillofacial fractures in the geriatric population. This retrospective study reviews 109 hospital records dating from 1981 to mid-1993. The goal of this study was to provide details relevant to these types of injuries. RESULTS Most patients were injured in motor vehicle accidents (MVA) or fall-related episodes. Females sustained 43.9% of the fractures while males sustained 56.1%. In females, falls were the most common cause of fractures, while in males MVAs caused the majority of fractures (P < .01). Most fractures were found in the upper midface region (60.3%) and the mandible (27.5%). MVAs and falls were responsible for 82.7% of all mandibular fractures. The majority of fractures were treated nonsurgically (49.5%); however, 37.6% were treated with open reduction and internal fixation. The in-hospital mortality rate was 11.1%, and there were three postoperative complications. CONCLUSION The geriatric craniomaxillofacial trauma patient is readily treatable with both aggressive surgical measures and more conservative approaches. Elderly patients often have an underlying medical condition that may subsequently alter the patients treatment. The findings of this study also suggest that more preventive measures and methods of minimizing mortality and morbidity need to be implemented.

Deep Space Neck Infection: Principles of Surgical Management

Knowledge of the management of infections of the deep spaces of the neck is essential to the daily practice of oral and maxillofacial surgery. Timely decisions must be made through the acute course of the disease. Interventions must be performed with the appropriate surgical skill. The surgeon must decide on medical and surgical management, including antibiotic selection, how to employ supportive resuscitative care, when to operate, what procedures to perform, and how to secure the airway. To make these decisions the surgeon must understand the anatomy of the region and the etiology of infection, appropriate diagnostic workup, and medical and surgical management. This article provides a review of these pertinent topics.

Evaluation of rigid internal fixation of mandible fractures performed in the teaching laboratory

Rigid internal fixation of mandible fractures is advocated as an effective means of providing undisturbed healing and immediate function. However, its application in the clinical setting has resulted in many technique-related failures. To determine the reasons for clinical failure and to help develop improved means of providing successful fixation, the results of plate application in the teaching laboratory were evaluated. Seventy-four surgeons taking the AO/Association for the Study of Internal Fixation (AO/ASIF) maxillofacial course in Davos, Switzerland and 56 surgeons taking the advanced AO/ASIF course in Naples, FL applied rigid internal fixation devices to a mandibular fracture model. Treatment was evaluated for anatomic morbidity and effectiveness. In Davos, 92 of 121 subcondylar, body, symphysis, and ramus fractures (76%) were treated effectively. This included 22 of 34 symphysis fractures (65%). In Naples, 11 of 28 symphyseal fractures (39%) were fixed effectively with lag screws without anatomic morbidity. Technique failure is a frequent event in the application of rigid internal fixation devices to mandible fractures. Lag screw fixation of symphyseal fractures had a particularly high rate of technique-related failure.

Comprehensive Review of Bisphosphonate Therapy: Implications for the Oral and Maxillofacial Surgery Patient

J a m r o i T u b o p Bisphosphonate medications have a broad array of ndications including the use of intravenous bisphoshonate medications in the management of hypercalemia of malignancy, skeletal-related events associted with bone metastases from solid tumors, and in he management of bone lesions in the setting of ultiple myeloma. Newer indications for intravenous isphosphonate medications include their use in steoporosis as alternatives to oral bisphosphonates. ral bisphosphonates are approved to treat osteopoosis. They prevent from 40% to 70% of fractures of he hip, spine, and other osteoporotic fractures. While steoporosis is the most common reason for the adinistration of oral bisphosphonates, their use in the reatment of Paget’s disease and osteogenesis imperecta has been described, and the use of bisphosphoate medications in the management of giant cell esions of the jaws has also been recommended. No oubt, the quality, and often the length of life of atients with many types of bone disease, is enhanced n patients treated with bisphosphonate medications. Until approximately 2003, cases of osteonecrosis of he jaws were primarily noted in patients with osteoyelitis and osteoradionecrosis, and associated with rominent bony protuberances, such as exostoses, ori, and mylohyoid ridges that underwent traumatic r spontaneous exposure to the oral cavity. Osteonerosis of the jaws has also been noted in patients with ome rare infections, diabetes and other endocrinopahies, as well as in some patients with cancer being reated with chemotherapy. In 2003 and 2004, oral and axillofacial surgeons were the first to recognize the resence of exposed and necrotic bone of the jaws in atients who underwent extraction of a tooth or placeent of an endosseous implant and who were taking isphosphonate medications. The identification of steonecrosis of the jaws in patients taking bisphospho© d

The double-reversing Z-plasty in primary palatoplasty : Operative experience and early results.

The double-reversing Z-plasty of Furlow for closure of the soft palate was used in 34 children with various types of cleft palate. Mean age at repair was 12.8 months. Intraoperative experience was favorable, with acceptable operating time and blood loss. Length of hospitalization averaged 1.9 days. Postoperatively, two children experienced temporary stridor, which resolved within 24 to 48 hours. One child had dehiscence of the hard palate (Von Lagenbeck repair) 4 weeks postoperatively, and three children developed small oronasal fistulae. Early speech evaluation demonstrated adequate soft palate mobility in 33 of 34 patients, with observable velopharyngeal function. Twelve children had mild velar compromise, with eight exhibiting slight nasal air escape.

Lag screw technique for orbital floor reconstruction with autologous bone grafts

The goal of orbital floor reconstruction in trauma surgery is to restore the functional anatomy. Recent advances in orbital reconstruction include the use of immediate autogenous bone grafts for support of the orbital contents, as well as the capability to use rigid fixation within the bony orbit.’ Stable bone grafts seem to undergo less resorption and are less prone to infection.2s3 AND DAVID M. FEINERMAN, DMD, MD-f