Surgical treatment of 61 consecutive patients with maxillary stage 3 medication-related osteonecrosis of the jaws using a pedicled buccal fat pad

PURPOSE

Buccal fat pad (BFP) is used for the closure of large oroantral defects caused by surgical removal of the necrotic bone in patients with medication-related osteonecrosis of the jaw (MRONJ). This study aimed to evaluate the use of BFP for the closure of maxillary sinus defects in stage 3 MRONJ patients.

METHODS

This study recruited 61patients with large oroantral defects caused by MRONJ, including 49 patients with cancer and 12 patients with osteoporosis. Lesions were evaluated clinically and radiographically.

RESULTS

Among the 61 patients, 51 (83.6%) healed uneventfully, and 5 patients (8.2%) had local dehiscence and exposed bone; these 56 patients (91.8%) all healed after first or second operation. The Eastern Cooperative Oncology Group Performance Status was associated with being non-cured and might be an indicator for the healing process. All patients experienced a significant increase in body weight postoperatively.

CONCLUSIONS

This study suggest that block resection with removal of the necrotic bone combined with radical sinusotomy and closure of the defect with BFP is a reliable method to cure MRONJ lesions with a high success rate, and successful operation and prosthetic rehabilitation may improve body weight and the quality of life. The study was approved by the appropriate ethical approval for the Copenhagen ONJ Cohort (protocol no. H-6-2013-010) November 20, 2013.

Aromatase inhibitors associated osteonecrosis of jaw: signal refining to identify pseudo safety signals

Background Signal generation through data mining algorithms is an innovative and emerging field in pharmacovigilance. Early detection of safety signals is important for public health safety. However, the possibility of generating pseudo signals should not be overlooked. Objective Our study aimed to identify potential signals of aromatase inhibitors associated Osteonecrosis of Jaw and assess the possibilities of the safety signal to be a pseudo signal/false positive in FDA Adverse Event Reporting System (FAERS). Setting Spontaneously reported data in FAERS database. Methods Data for this study were obtained from the public release of data in FAERS. OpenVigil, a pharmacovigilance analytical tool was used to access FAERS data. Reporting Odds Ratio (ROR) was used to assess the relation between the drug and adverse event. A value of ROR-1.96SE  > 1, (SE-standard error) was considered positive. Main outcome measure Signal strength. Results FAERS database had a total of 15,178 reports for Osteonecrosis of Jaw. Amongst which 617 reports were associated with aromatase inhibitors. Signal strength ROR (lower bound of the 95% CI) for letrozole, anastrozole and exemestane associated Osteonecrosis of Jaw without any background correction was 8.34, 6.64 and 15.14 respectively. Upon removing the reports of concomitantly administered drugs (bisphosphonates and denosumab), signal strength drastically decreased to 0.03, 0.36 and 0.47 for letrozole, anastrozole and exemestane respectively. The signal strength of bisphosphonates and denosumab associated Osteonecrosis of Jaw was not changed significantly upon removal of aromatase inhibitors. Conclusion Our study concluded that the signal generated for aromatase inhibitors associated Osteonecrosis of Jaw in FAERS database can be false positive. Careful background corrections with identification of those risk factors are imperative to exclude false positive results.

The use of buccal fat pad in surgical treatment of 'Krokodil' drug-related osteonecrosis of maxilla

'Krokodil' is the street name of a new synthetic drug mixture. It is a light brown liquid that is used intravenously without previous purification. Osteonecrosis of the jaw (ONJ) is a common complication among Krokodil users. Krokodil drug-related ONJ presents as alveolar process exposure in the oral cavity. Surgery is the main method for treatment of Krokodil drug-related ONJ patients. In a study by Poghosyan et al., no cases of recurrence were seen after surgery on the maxilla, but 38% of cases (8/21) developed an oroantral communication after surgical treatment for maxillary osteonecrosis (Poghosyan et al., 2014). The aim of this study is to report on the results of buccal fat pad use in closure of maxillary sinus floor defects after partial maxillary resection in Krokodil drug-related ONJ patients. Six male patients with Krokodil drug-related distal maxillary osteonecrosis were included in this retrospective study. All patients underwent surgical treatment, which included surgical removal of necrotic bone, and closure of formed maxillary sinus floor defects with buccal fat pad and local mucoperiosteal flaps. In all patients the postoperative period was uneventful. After suture removal small areas of buccal fad pad exposure were found in all patients, which epithelialized successfully over the following month. During the postoperative follow-up period (8-12 months) no signs of recurrence were found.

Denosumab as a potential treatment alternative for patients suffering from diffuse sclerosing osteomyelitis of the mandible-A rapid communication

PURPOSE

Diffuse sclerosing osteomyelitis (DSO) is a rare disease of the jaw bone. Its treatment is challenging. Different medical and surgical treatment protocols have been proposed; however, none of these treatment protocols produce reliable results. Recently, ibandronate administration has been attempted as a treatment alternative in acute cases of DSO. Due to the similar antiresorptive effect, we sought to explore the application of the human monoclonal antibody to the receptor activator of nuclear factor kappaB ligand (RANKL), denosumab, in the treatment of DSO.

MATERIALS AND METHODS

One female patient with histologically verified DSO received subcutaneous injections of denosumab (Prolia^® 60 mg). The further course of the disease was followed clinically and by radiography and scintigraphy.

RESULTS

In this case, the use of denosumab displayed promising results in aiding pain relief and reducing inflammatory activity.

CONCLUSION

We suggest that antiresorptive treatment with denosumab can be considered as an alternative treatment for patients suffering from DSO. However further studies, with respect to clarifying the mechanisms of action and defining the necessary medication dose as well as application intervals, have to be conducted.

Spontaneous bone formation after mandible segmental resection in "krokodil" drug-related jaw osteonecrosis patient: case report

We report a case of a 48-year-old male patient with "krokodil" drug-related osteonecrosis of both jaws. Patient history included 1.5 years of "krokodil" use, with 8-month drug withdrawal prior to surgery. The patient was HCV positive. On the maxilla, sequestrectomy was performed. On the mandible, sequestrectomy was combined with bone resection. From ramus to ramus, segmental defect was formed, which was not reconstructed with any method. Post-operative follow-up period was 3 years and no disease recurrence was noted. On 3-year post-operative orthopantomogram, newly formed mandibular bone was found. This phenomenon shows that spontaneous bone formation is possible after mandible segmental resection in osteonecrosis patients.

Histopathological features of bisphosphonates related osteonecrosis of the jaw in rats with and without vitamin d supplementation

OBJECTIVE

Aim of this study was to investigate the effect of vitamin-D3 on the osteonecrosis of bone that was induced after tooth extraction was conducted on rats that were given zoledronic acid (Z.A).

MATERIAL AND METHODS

Animals were divided into four groups. Two of the experimental groups were divided into two subgroups, third study group was not divided into subgroups, and control group was divided into three subgroups. Z.A was administered twice per week over the course of 7 weeks, dexamethasone was administered twice a week during the 5th-6th-7th weeks to all groups. Dental extraction was performed by drilling around the tooth at 7th week. In study-group-1; vitamin-D was administered twice per week during the 5th-6th-7th weeks. In study-group 2; vitamin-D was administered twice per week during the 8th-9th-10th weeks. In study-group-3; vitamin-D was administered twice per week during the 15th-16th-17th weeks. The animals were sacrificed at 10th-15th-17th weeks, and histologic samples were taken.

RESULTS

Postoperative-15-group had a lower osteoblast number, which was statistically significant as compared to preoperative-15 and control-15-group. Control-10-group showed significantly lower osteoclast number in comparison to preoperative-10 and postoperative-10-group. Osteoclast number was significantly higher in the osteonecrosis-17-group as compared to control-17-group. Preoperative-10-group showed significantly higher inflammation in comparison to control-10-group. Postoperative-15-group had a lower histologic osteonecrosis, which was statistically significant as compared to the control-15-group. Macroscopic osteonecrosis was significantly higher in the control-17-group in comparison to the osteonecrosis-17-group.

CONCLUSIONS

We concluded that there are some proofs for the treatment of BRONJ with systemic using of vitamin-D.

Use of bisphosphonates in orthopedic surgery: pearls and pitfalls

Bisphosphonates are medications known to decrease bone resorption by inhibiting osteoclastic activity. They are the first-line therapy for the treatment of osteoporosis because a significant body of literature has proved their efficacy in reducing the risk of fracture in the hip, spine and other nonvertebral osseous sites. In addition, the use of bisphosphonates has significantly decreased morbidity and increased survival, and they have also proved to be cost-effective. Unexpected adverse effects have been reported recently, but the benefit of bisphosphonates use outweighs the risks. This article reviews the current use of bisphosphonates in orthopedic surgery.