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The American Journal of Case Reports Oct 2023BACKGROUND Bisphosphonates inhibit bone resorption in patients with postmenopausal osteoporosis and reduce osteoporotic fracture incidence. Medication-related...
BACKGROUND Bisphosphonates inhibit bone resorption in patients with postmenopausal osteoporosis and reduce osteoporotic fracture incidence. Medication-related osteonecrosis of the jaws (MRONJ) and atypical femoral fractures (AFF) are both rare but serious adverse effects of anti-resorptive drugs (ARD) such as bisphosphonates. The most advanced form of MRONJ is termed stage 3 and can lead to severe local sequelae like pathologic mandibular fractures (PMF). This study reports a case of MRONJ-related PMF and AFF with osteomyelitis secondary to bisphosphonate treatment for osteoporosis. CASE REPORT A 63-year-old white woman was diagnosed with PMF related to MRONJ stage 3 during treatment of an AFF with osteomyelitis. She had been treated for postmenopausal osteoporosis with 70 mg of alendronate weekly for 2 years. The PMF was treated by stable internal fixation combined with debridement and sequestrectomy, but further debridement was required and 2 mandibular implants were then removed. Postoperative recovery was uneventful and the mandibular infection was controlled after the second surgery. Three weeks later, she was discharged from the hospital, instructed to discontinue the use of alendronate, and referred for 30 sessions of hyperbaric oxygen therapy. At the 3-year follow-up, the PMF was completely healed without signs of mandibular infection or bone exposure. CONCLUSIONS This report raises awareness of both MRONJ and AFF as possible adverse effects of short-term bisphosphonate therapy for postmenopausal osteoporosis, and highlights the importance of dental and orthopedic follow-ups. It is crucial to emphasize the need for early diagnosis and treatment to prevent MRONJ progression to PMF.
Topics: Female; Humans; Middle Aged; Diphosphonates; Alendronate; Osteoporosis, Postmenopausal; Bone Density Conservation Agents; Mandibular Fractures; Osteoporosis; Fractures, Spontaneous; Femoral Fractures; Osteomyelitis
PubMed: 37867315
DOI: 10.12659/AJCR.941144 -
Dental Traumatology : Official... Dec 2023Although previous studies have revealed the influence of the mandibular third molar (M3) on mandibular condylar fracture risk and that the presence of M3 could result in...
Assessment of relationships between condylar fracture pattern and mandibular third molar position by panoramic radiography and computed tomography: A retrospective comparative study.
BACKGROUND/AIM
Although previous studies have revealed the influence of the mandibular third molar (M3) on mandibular condylar fracture risk and that the presence of M3 could result in different incidences of condylar and angle fractures, there have been no analyses of the influence of M3 on fracture patterns. Moreover, evaluations of M3 position using panoramic radiography have shown insufficient accuracy. This study investigated the relationship between condylar fracture patterns and M3 position using panoramic radiography and computed tomography.
MATERIALS AND METHODS
This retrospective study included 280 patients with unilateral mandibular condylar fractures and ipsilateral M3 admitted to West China Hospital of Stomatology between January 2016 and June 2022. Patient medical records, panoramic radiographs, and computed tomography images were collected. The vertical and horizontal positions of M3 were classified using the Pell and Gregory system. M3 angulation was defined as the angle between the long axis of M3 and the mandibular occlusal plane. Condylar fracture patterns were classified as intracapsular (Types A-C) or extracapsular (neck and base). Data were analyzed using McNemar-Bowker test, Pearson chi-squared test, and Fisher's exact test.
RESULTS
Classification of M3 position differed significantly between panoramic radiography and computed tomography images (p < .05). There was a significant association between the mandibular condylar fracture pattern and M3 horizontal position on computed tomography (p < .05). Class I M3 position on computed tomography was associated with a higher incidence of intracapsular than extracapsular fractures, along with a higher incidence of Type B than base fractures; the opposite relationships were observed for Class II. No such association was identified on panoramic radiography.
CONCLUSIONS
Mandibular condylar fracture patterns were presumably influenced by M3 horizontal position on computed tomography. The imaging modality affected the classification of M3 position and subsequent analyses. Computed tomography is recommended for future studies to improve accuracy and reliability.
Topics: Humans; Retrospective Studies; Radiography, Panoramic; Molar, Third; Reproducibility of Results; Tooth, Impacted; Mandibular Condyle; Mandibular Fractures; Tomography, X-Ray Computed
PubMed: 37529916
DOI: 10.1111/edt.12874 -
Clinical Oral Investigations Dec 2023The need for prevention and management of medication-related osteonecrosis of the jaw (MRONJ) has increased with the growing number of patients using antiresorptive... (Review)
Review
OBJECTIVES
The need for prevention and management of medication-related osteonecrosis of the jaw (MRONJ) has increased with the growing number of patients using antiresorptive agents. The scope of this systematic review (SR) was to determine whether the withdrawal of antiresorptive agents is necessary for tooth extractions in patients receiving each of the antiresorptive medications.
MATERIALS AND METHODS
The searches were performed using the MEDLINE databases. We selected SRs, randomized controlled trials (RCTs), prospective and retrospective non-randomized clinical (observational) studies, and case reports/case series in this order of preference.
RESULTS
We included one SR, one RCT, five observational studies, and three case reports. Meta-analyses were not conducted because the RCT had an extremely small sample size and the observational studies had different definitions of intervention and comparison that could not be integrated across studies. In this SR, no studies showed a benefit (i.e., a reduction in the incidence of osteonecrosis of the jaw) of short-term withdrawal of antiresorptive agents for tooth extraction. Additionally, no studies examined the harm (i.e., an increase in femoral and vertebral fractures and skeletal-related events during bone metastasis) of withdrawal for tooth extraction.
CONCLUSIONS
We were unable to determine whether withdrawal before and after tooth extraction is necessary with a high certainty of evidence. Future systematic reviews including RCTs with larger samples are expected to provide such evidence.
CLINICAL RELEVANCE
This systematic review provides evidence-based information for multidisciplinary collaborations related to patients receiving antiresorptive agents.
Topics: Humans; Bone Density Conservation Agents; Dental Care; Tooth Extraction; Femur; Osteonecrosis
PubMed: 38150155
DOI: 10.1007/s00784-023-05462-9 -
Acta Chirurgica Belgica Feb 2024To provide a critical update identifying the knowledge gaps and controversies in medication-related osteonecrosis of the jaw (MRONJ) within the Belgian healthcare... (Review)
Review
OBJECTIVES
To provide a critical update identifying the knowledge gaps and controversies in medication-related osteonecrosis of the jaw (MRONJ) within the Belgian healthcare context and outline opportunities for improvement and research in these areas.
METHODS
A literature review was performed to identify guidelines from international clinical societies in oncology or oral and maxillofacial surgery on diagnosing, preventing, and treating MRONJ. The recommendations were critically assessed in light of recent developments in the field and confronted with the clinical experience of experts.
RESULTS
Despite progress in the diagnostic criteria of MRONJ, the continued need for an 8-week timeout period should be reconsidered. Furthermore, 3D imaging techniques should be introduced to improve diagnosis and staging. The staging system remains ambiguous regarding Stage 0 MRONJ, and ongoing confusion exists regarding the term non-exposed MRONJ. The prevention of MRONJ should be tailored, considering the individual patient's risk of MRONJ, frailty, and life expectancy. More research seems needed into the efficacy and safety of drug holidays, considering the risks of rebound remodeling on fractures. With renewed interest in surgical and adjunct management techniques, adequately designed clinical studies are needed to help translate trial outcomes into universally applicable treatment guidelines taking into account individual patient characteristics.
CONCLUSIONS
Important knowledge gaps remain and hamper the development of clinical guidelines. Several controversies were identified where consensus is lacking, and further harmonization between stakeholders is necessary. Finally, the need for randomized controlled comparative clinical trials in MRONJ resonates harder than ever to identify the best treatment for individual patients.
Topics: Humans; Diphosphonates; Bone Density Conservation Agents; Bisphosphonate-Associated Osteonecrosis of the Jaw; Fractures, Bone
PubMed: 38059301
DOI: 10.1080/00015458.2023.2291295 -
Journal of the Mechanical Behavior of... Dec 2023Mandibular fractures are one of the most frequently observed injuries within craniofacial region mostly due to tumor-related problems and traumatic events, often related...
Mandibular fractures are one of the most frequently observed injuries within craniofacial region mostly due to tumor-related problems and traumatic events, often related to non-linear effects like impact loading. Therefore, a validated digital twin of the mandible is required to develop the best possible patient-specific treatment. However, there is a need to obtain a fully compatible numerical model that can reflect the patients' characteristics, be available and accessible quickly, require an acceptable level of modeling efforts and knowledge to provide accurate, robust and fast results at the same time under highly non-linear effects. In this study, a validated simulation methodology is suggested to develop a digital twin of mandible, capable of predicting the non-linear response of the biomechanical system under impact loading, which then can be utilized to design treatment strategies even for multiple fractures of the mandibular system. Using Computed Tomography data containing cranial (skull) images of a patient, a 3-dimensional mandibular model, which consists cortical and cancellous bones, disks and fossa is obtained with high accuracy that is compatible with anatomical boundaries. A Finite Element Model (FEM) of the biomechanical system is then developed for a three-level validation procedure including (A) modal analysis, (B) dynamic loading and (C) impact loading. For the modal analysis stage: Free-free vibration modes and frequencies of the system are validated against cadaver test results. For the dynamic loading stage: Two different regions of the mandible are loaded, and maximum stress levels of the system are validated against finite element analyses (FEA) results, where the first loading condition (i) transfers a 2000 N force acting on the symphysis region and, the second loading condition (ii) transfers a 2000 N force acting on the left body region. In both cases, equivalent muscle forces dependent on time are applied. For the impact loading stage: Thirteen different human mandibular models with various tooth deficiencies are used under the effects of traumatic impact forces that are generated by using an impact hammer with different initial velocities to transfer the impulse and momentum, where contact forces and fracture patterns are validated against cadaver tests. Five different anatomical regions are selected as the impact site. The results of the analyzes (modal, dynamic and impact) performed to validate the digital twin model are compared with the similar FEA and cadaver test results published in the literature and the results are found to be compatible. It has been evaluated that the digital twin model and numerical models are quite realistic and perform well in terms of predicting the biomechanical behavior of the mandible. The three-level validation methodology that is suggested in this research by utilizing non-linear FEA has provided a reliable road map to develop a digital twin of a biomechanical system with enough confidence that it can be utilized for similar structures to offer patient-specific treatments and can help develop custom or tailor-made implants or prosthesis for best compliance with the patient even considering the most catastrophic effects of impact related trauma.
Topics: Humans; Finite Element Analysis; Biomechanical Phenomena; Mandible; Mandibular Fractures; Cadaver; Stress, Mechanical
PubMed: 37922761
DOI: 10.1016/j.jmbbm.2023.106207 -
Journal of Oral and Maxillofacial... Aug 2023Computer-aided design and manufacturing (CAD/CAM) is widely used in clinical practice. This technology may change existing methods for mandibular fracture management.
BACKGROUND
Computer-aided design and manufacturing (CAD/CAM) is widely used in clinical practice. This technology may change existing methods for mandibular fracture management.
PURPOSE
The purpose of this in-vitro study was to determine if the reduction for mandibular symphysis fracture can be performed without maxillomandibular fixation (MMF) using 3-dimensional (3D)-printed template.
STUDY DESIGN, SETTING, AND SAMPLE
This in-vitro study was designed as a proof-of-concept. The sample was composed of 20 existing pairs of intraoral scan and computed tomography (CT) data. A mandibular model stereolithography (STL) file was created by merging the STL file obtained for the bimaxillary dentitions with the CT DICOM file, and this was set as the original model. Using the original model, a STL file of a fracture model of the mandibular symphysis was created using CAD. A template similar to a wafer or an implant guide was manufactured to restore original occlusion, and the mandibular fracture model was reduced and fixed using the 3D-printed template and wire. This was set as the experimental group. The 3D coordinate system error was measured at 6 landmarks and statistically compared using scan data between models of the groups.
PREDICTOR/EXPOSURE/INDEPENDENT VARIABLES
Reduction techniques with MMF or without MMF using guide template for mandibular fracture model.
MAIN OUTCOME VARIABLE(S)
The 3D coordinate system error (mm).
COVARIATES
The position of landmarks.
ANALYSES
The Mann-Whitney U test, student's t-test, and the Kruskal-Wallis test were used to analyze the coordinate errors between the landmarks. A P value of < .05 was considered statistically significant.
RESULTS
The 3D error value of the control and experimental group were 1.06 ± 0.63 mm (range: 0.11 to 2.92 mm) and 0.96 ± 0.48 mm (range: 0.2 to 2.95 mm), respectively. There was no statistical difference between the control and experimental group. There was a statistically significant difference in the lower 2 and lower 3 landmarks compared to the upper 1 (P = .001 and .000, respectively) before and after the reduction in the experimental group.
CONCLUSION AND RELEVANCE
This study demonstrates that the reduction using a 3D-printed guide template for the mandibular symphysis fracture could be possible even without the MMF.
Topics: Humans; Printing, Three-Dimensional; Mandibular Fractures; Jaw Fixation Techniques; Computer-Aided Design; Fracture Fixation
PubMed: 37220868
DOI: 10.1016/j.joms.2023.05.002 -
Computer Methods in Biomechanics and... Sep 2023This article presents a new approach for the design of a flexible V-shaped miniplate for mandibular fractures, which combines simultaneous fracture reduction and...
This article presents a new approach for the design of a flexible V-shaped miniplate for mandibular fractures, which combines simultaneous fracture reduction and fixation. A Computerized Tomography (CT) based finite element model was developed to assess the reliability of this design. Muscle and mastication forces were included to replicate post-surgery loading. The V-plate is compared with a standard, linear miniplate, typically used for mandibular fixation. The results indicate that the proposed design can support the fracture while inducing limited fracture displacement, in addition to reducing the duration of the surgery due to fracture reduction by tightening the wire.
Topics: Humans; Mandibular Fractures; Fracture Fixation, Internal; Reproducibility of Results; Biomechanical Phenomena; Mandible; Bone Plates
PubMed: 35901285
DOI: 10.1080/10255842.2022.2105143 -
Journal of Oral and Maxillofacial... Oct 2023Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.
RESULTS
The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).
CONCLUSIONS
This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).
Topics: Adult; Humans; Fracture Fixation, Internal; Malocclusion; Mandibular Fractures; Network Meta-Analysis; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 37423262
DOI: 10.1016/j.joms.2023.06.006 -
Oral and Maxillofacial Surgery Jun 2024To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures.
PURPOSE
To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures.
METHODS
Patients with clinically infected mandibular fracture of the dentate part without preceding surgery were studied retrospectively. Clinical infection was defined to occur if pus, abscess, or a fistula in the fracture area was present. Patient-, fracture-, and surgery-related variables were evaluated, and predictors for postoperative complications were analysed.
RESULTS
Of 908 patients with surgically treated fracture in the dentate part of the mandible, 41 had infected fracture at the time of surgery (4.5%). Of these patients, 46.3% were alcohol or drug abusers. Median delay from injury to surgery was 9 days. Patient-related factors were the most common cause for delayed surgery (n = 30, 73.2%), followed by missed diagnosis by a health care professional (n = 8, 19.5%). Twenty-two fractures were treated via extraoral approach (53.7%) and the remaining 19 intraorally (46.3%). Postoperative surgical site complications were found in 13 patients (31.7%), with recurrent surgical site infections predominating. Notable differences between total complication rates between intraoral and extraoral approaches were not detected. Secondary osteosynthesis for non-union was conducted for one patient treated intraorally.
CONCLUSIONS
Postoperative surgical site complications are common after treatment of infected mandibular fractures, and these occur despite the chosen surgical approach. Infected mandibular fractures heal mainly without bone grafting, and non-union is a rare complication. Due to the high complication rate, careful perioperative and postoperative care is required for these patients.
Topics: Humans; Mandibular Fractures; Adult; Male; Female; Surgical Wound Infection; Middle Aged; Retrospective Studies; Adolescent; Aged; Young Adult; Fracture Fixation, Internal; Postoperative Complications; Time-to-Treatment; Substance-Related Disorders; Delayed Diagnosis
PubMed: 38286958
DOI: 10.1007/s10006-024-01213-6 -
Journal of Oral and Maxillofacial... Jul 2023This study aimed to compile a list of the 100 most cited articles on mandibular fractures and to glean key insights from these articles via a bibliometric analysis. (Review)
Review
PURPOSE
This study aimed to compile a list of the 100 most cited articles on mandibular fractures and to glean key insights from these articles via a bibliometric analysis.
METHODS
This bibliometric analysis was performed using the Web of Science Core Collection database. The search was performed through January 2022. The bibliometric parameters extracted included title, number of citations, citation density (number of citations per year), first author's country, year of publication, study design, and subject. The software program VOSviewer was used to create graphical bibliometric maps.
RESULTS
The articles were ranked by the total number of citations, which ranged from 64 to 374, with 32 articles being cited more than 100 times. The included articles were published from 1952 to 2015, mainly in maxillofacial surgery journals. The most frequent of these were the Journal of Oral and Maxillofacial Surgery (54%) and the International Journal of Oral and Maxillofacial Surgery (14%). The studies were from 29 different countries, with the United States of America (42%) contributing substantially more than others, with the next ranked nation being Germany (9%). The most frequently used keywords were osteosynthesis (25), open reduction (18), and fixation (16).
CONCLUSIONS
The country that contributed most to mandibular fracture research was the United States of America. This conclusion was based on the number of published articles by nation of origin and the origin of the Journal of Oral and Maxillofacial Surgery, in which the majority were published. Osteosynthesis was the most cited field of research among the articles in the sample set.
Topics: Humans; United States; Mandibular Fractures; Bibliometrics; Surgery, Oral; Research Design; Fracture Fixation, Internal
PubMed: 37037374
DOI: 10.1016/j.joms.2023.03.005