Surgical treatment of advanced medication-related osteonecrosis of the jaws: Comparison of soft tissue closure techniques and evaluation of side effects

Efficacy of submental island flap closing advanced mandibular MRONJ lesion in malignancy patients

OBJECTIVE

This study evaluated the effectiveness of a submental island flap in closing advanced mandibular medication-related osteonecrosis of the jaw (MRONJ) wounds in patients with malignant tumors.

SUBJECTS AND METHODS

A total of 85 patients with stage II and III MRONJ of mandible with malignant tumor as their primary disease were retrospectively analyzed. All patients underwent surgical treatment, and the soft tissue wound closure was performed either with a submental island flap (SIF) or mucoperiosteal flap (MF). Univariate and multifactorial models were applied to analyze the factors influencing patients' prognosis.

RESULTS

Univariate analysis (p = 0.004, OR 0.075-0.575, 95% CI) and binary logistic regression (p = 0.017, OR 0.032-0.713, 95% CI) suggested that the surgical prognosis of SIF wound closure was significantly better than that of MF.

CONCLUSION

Closure of wound after resection of mandibular MRONJ lesions in patients with malignant tumors using SIF had a better clinical prognosis compared with MF.

Examination of certain single-nucleotide polymorphisms of interleukins 1A and 1B in medication-related osteonecrosis of the jaw - An ambirectional cohort study

AIM

The aim of this study was to examine particular single-nucleotide polymorphisms (IL-1A-889 C/T - rs1800587, IL-1B +3953 C/T - rs 1143634) of interleukins 1A and 1B in the development and prognosis of medication-related osteonecrosis of the jaw.

MATERIALS AND METHODS

DentiGen Parodontitis Tests were applied for collecting samples. This test is suitable for sampling oral mucosa cells in order to detect interleukins 1A and 1B single nucleotide polymorphisms (IL-1A-889, IL-1B+3953). Genetic samples were evaluated in the Istenhegyi Genediagnostic Center using the DNA-hybridization method. Genetic samples were collected in the patient group and the control group. The role of gene polymorphisms in the development of the disease was investigated by comparing the genetic results for the patient and control groups. The investigation of gene polymorphisms in disease prognosis is based on stage improvement, recovery, and relapses following treatment.

RESULTS

In total, 91 patients with MRONJ and 59 healthy controls were included in the study. 51 patients in the patient group and 37 controls had unfavorable allelic variants. No association (Mp = 1.42, SDp = 0.496, Mc = 1.35, SDc = 0.482, p = 0.52) was found between unfavorable polymorphisms and the development of the MRONJ. In the patient group, surgical therapy was required in 79 cases. Stage improvement was detected in 78 cases, recovery in 67 cases, and relapse in 33 cases. No stage improvement was found in one case, recovery in nine cases, or relapse in 34 cases. Of the 79 patients requiring surgical therapy, 49 had unfavorable allelic variants. No connection was found between the polymorphisms examined and stage improvement (Mp = 1.37, SDp = 0.486, Mnp = 2, SDnp = -, p = 0.800) or recovery (Mp = 1.39, SDp = 0.491, Mnp = 1.44, SDnp = 0.527, p = 0.990). However, a significant association (Mp = 1.21, SDp = 0.415, Mnp = 1.58, SDnp = 0.502, p < 0.001) was found between relapses and the presence of unfavorable allelic variants.

CONCLUSION

Within the possible limitations of this study, it can be assumed that the analysis of certain single-nucleotide polymorphisms of interleukin-1 may have the potential to help define the risk stratification of MRONJ after surgical therapy.

How does the clinical and tomographic appearance of MRONJ influences its treatment prognosis?

OBJECTIVES

To identify clinical and tomographic prognostic factors for conservative and surgical treatment of medication-related osteonecrosis of the jaws (MRONJ).

METHODS

A retrospective search identified patients treated with antiresorptive drugs (ARDs), diagnosed with Stage 1, 2 or 3 MRONJ, and having CBCT scans previous to conservative or surgical treatment. Following data collection, imaging assessment of the following parameters on each MRONJ site was performed: involvement of teeth and/or implants, presence of osteosclerosis, osteolysis, sequestrum formation, periosteal reaction, and pathological fractures. For statistical analysis, patients and lesions were divided into conservative and surgical treatment. Comparisons were made between successful and unsuccessful outcomes. Significance was set at p ≤ 0.05.

RESULTS

115 ARD-treated patients who developed 143 osteonecrosis lesions were selected. 40 patients and 58 lesions received conservative treatment, of which 14 patients (35%) and 25 lesions (43%) healed. Additionally, 75 patients and 85 lesions underwent surgery, with 48 patients (64%) and 55 lesions (65%) that healed. Clinical and tomographic risk factors for conservative treatment were MRONJ staging, tooth involvement, extensive osteosclerosis, and deep sequestrum formation (p < 0.05). Complementarily, poor prognostic indicators for surgical therapy were a short bisphosphonate (BP) holiday, MRONJ staging, absence of sequestrum formation, and presence of periosteal reaction (p < 0.05).

CONCLUSIONS

Lesions at Stage 3 MRONJ, with tooth involvement, or sequestrum formation showed poor outcomes when conservative treatment is chosen. Alternatively, surgical treatment is most effective when BPs are discontinued, in Stage 1 lesions, in the presence of sequestrum formation, and absence of periosteal reaction.

The efficacy of mylohyoid muscle flap use in surgical treatment of 'krokodil' drug-related osteonecrosis of the mandible

The aim of this study is to show the effectiveness of the use of mylohyoid muscle flap in surgical treatment of stage 1 and 2 Krokodil drug-related ON of mandible. Retrospective study of patients with stage 2 Krokodil drug-related ON of distal mandible was performed. Regarding to the used surgical technique the patients were divided into two groups (groups 1 and 2). In group 1(control group) the wound was closed only by the local mucoperiosteal flaps, while in group 2 (experimental group) the wound was closed by combining mylohyoid muscle flap and local mucoperiosteal flaps. 24 patients were included in this study (15 patients in the group 1 and 9 patients in the group 2). In all patients of experimental group the postoperative period was uneventful and no recurrence occurred. In group 1 recurrence was found in 7 patients, which is significantly higher than in group 2 (χ²=5.9, p=0.015). Disease recurrence occurred as wound dehiscence during 4-10 postoperative days. Within the limitations of the study it seems that the adoption of the mylohyoid muscle flap as double-layer closure technique is an effective and predictable method for the treatment of such patients and, therefore, should be chosen whenever deemed appropriate.

Analysis of Factors Associated with the Postoperative Healing of Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

BACKGROUND

Surgical treatment is considered the best approach by many researchers for medication-related osteonecrosis of the jaws (MRONJ). While postoperative outcomes are mainly favorable, wound healing still fails in some cases. This retrospective study aimed to evaluate the factors affecting the postoperative healing of MRONJ.

METHODS

This study involved 400 osteoporosis patients who received surgical treatment from January 2009 to January 2018 in Kyungpook National University Hospital. The patient, drug, and clinical factors were collected as investigation variables. The obtained data were statistically analyzed to identify relationships between the factors and healing aspect.

RESULTS

Univariate logistic regression analysis showed that the route of drug administration, bone exposure, types of surgical management, and wound management had a significant influence (p < 0.05) on the healing outcome. Sequestrectomy with primary closure had a more positive effect on favorable healing. In the multivariate logistic regression test, the effect of wound management alone was not statistically significant (p > 0.05).

CONCLUSION

In patients with osteoporosis, the factors such as intravenously administered drugs, fistulas that were probed to the bone, and surgical management with curettage were associated with a lower rate of postoperative complete healing of MRONJ, whereas primary closure of wounds led, possibly, to good healing outcomes. The strengths of the study include its relatively large sample size and that its results can hopefully aid in the clinical decisions for practitioners and future research studies for researchers.

Analysis of medication-related osteonecrosis of the jaw with bone SPECT/CT: relationship between patient characteristics and maximum standardized uptake value

Objective:

To analyze medication-related osteonecrosis of the jaw (MRONJ) with bone single photon emission computed tomography (SPECT)/CT, especially relationship between patient characteristics and maximum standardized uptake value (SUV).

Methods:

48 patients with MRONJ who underwent bone SPECT/CT were prospectively included. MRONJ patients were included 34 osteoporosis and 14 bone metastases from 6 lung cancer, 6 breast cancer and 2 rectal cancer. The maximum SUV of the MRONJ patient characteristics were analyzed such as gender, location, underlying disease, medication and staging of MRONJ by Mann–Whitney U test. P-values lower than 0.05 indicate significant differences.

Results:

Regarding underlying disease, maximum SUV of patients with osteoporosis (18.69 ± 8.57) were significantly higher than those with bone metastases (12.28 ± 4.32, p = 0.005). Furthermore, maximum SUV of MRONJ was a significant difference for medication (denosumab: 13.62 ± 5.70 and minodronate: 22.98 ± 11.73, p = 0.009) and staging of MRONJ (Stage 2: 15.59 ± 8.06 and Stage 3: 21.51 ± 7.15, p = 0.014).

Conclusion:

Maximum SUV assessed by SPECT/CT was significantly increased in MRONJ patients with osteoporosis and Stage 3. Bone SPECT/CT could be an effective tool for the analysis of MRONJ.

New Perspective for Soft Tissue Closure in Medication-Related Osteonecrosis of the Jaw (MRONJ) Using Barbed Sutures

The aim of this study was to compare the effectiveness of barbed versus smooth sutures for soft tissue closure of exposed jawbone sites in medication-related osteonecrosis of the jaw (MRONJ) patients. Exposed necrotic jawbone sites surgically managed by intraoral soft tissue closure were evaluated. Either barbed sutures (Stratafix™ or V-Loc™) together with Prolene^® or Vicryl^® sutures were used. We estimated the effect of barbed sutures (BS) with Prolene^® compared to smooth sutures (Vicryl^®) on the hazard rate of intraoral soft tissue dehiscence using a multivariate Cox regression model within a target trial framework, adjusting for relevant confounders. In total, 306 operations were performed in 188 sites. In the primary analysis 182 sites without prior surgery were included. Of these, 113 sites developed a dehiscence during follow-up. 84 sites were operated using BS and Prolene^®. A total of 222 sites were operated with Vicryl^® (control group). In the BS group, the median time to event (i.e., dehiscence) was 148 days (interquartile range (IQR), 42–449 days) compared to 15 days (IQR, 12–52 days) in the control group. The hazard rate of developing intraoral dehiscence was 0.03 times (95%-confidence interval (CI): 0.01; 0.14, p < 0.001) lower for BS patients compared to the control group. Within the limits of a retrospective study, BS showed a high success rate and are therefore recommended for soft tissue closure of exposed jawbone sites in MRONJ patients. Additional studies are warranted to further evaluate this novel application of BS.

Effect and timing of parathyroid hormone analog administration for preventing medication-related osteonecrosis of the jaws in a murine model

The aim of this study was to investigate the effect and timing of recombinant human parathyroid hormone analog (PTH) administration for preventing medication-related osteonecrosis of the jaws (MRONJ) using a murine model. After standardized MRONJ induction using zoledronic acid and dexamethasone injections, 48 female Sprague-Dawley rats were divided into four groups according to the timing of PTH administration before or after dental extraction. Rats were euthanized 3 weeks after dental extraction, followed by clinical and histologic analyses. No clinical improvements were observed in the preoperative and postoperative PTH groups, compared to controls (p = 0.638 and 0.496, respectively). However, on histological analysis, the number of empty lacunae reduced significantly, and the number of blood vessels increased in the preoperative PTH group (p = 0.004 and 0.002, respectively). The postoperative PTH group did not show significant differences for empty lacunae and blood vessels compared to controls (p = 0.075 and 0.194, respectively). The reduction in the empty lacunae and the increase in the blood vessels in the preoperative PTH group were significant compared to other groups, suggesting more viable bone tissue in this group. In perspective, preoperative PTH use may represent a better prophylactic regimen for preventing the occurrence of MRONJ after traumatic dental or surgical procedures, especially in patients with a history of long-term bisphosphonate administration or at high risk of developing MRONJ. However, the findings should be proven in further studies on other animals followed by clinical trials.