CLINICAL REPORT
Conservative management of medication-related osteonecrosis of the maxilla with an obturator prosthesis Matthias Troeltzsch, MD, DMD,a Florian Probst, MD, DMD,b Markus Troeltzsch, MD, DMD,c Michael Ehrenfeld, MD, DMD, PhD,d and Sven Otto, MD, DMD, PhDe Obturators are a viable method ABSTRACT of restoring the sequelae of Advanced maxillary medication-related osteonecrosis of the jaw can cause extensive hard and maxillary defects, namely loss soft tissue destruction that results in long-term oroantral fistulae. The surgical treatment of of chewing ability, impaired medication-related osteonecrosis of the jaw may relieve acute symptoms and eliminate the signs esthetics, hypernasal speech, of inflammation, but the primary and sustained plastic closure of these defects can challenge impaired deglutition, and nasal both the clinician and the patients. Although the use of obturator prostheses for maxillary defects after ablative oncologic surgery is well documented, studies about this treatment for similar fluid leakage.1-8 Most of these medication-related osteonecrosis of the jawerelated defects are missing. This presentation of defects are created by ablative clinical situations describes the use of obturators as a conservative alternative to repetitive surgery surgery in oncology patients.7-9 for the rehabilitation of selected maxillary defects with oroantral communications. (J Prosthet Dent Reconstruction can be achieved 2015;113:236-241) surgically with local or distant flaps, prosthetically with obtuas stage III by the American Association of Oral and rators, or with combined therapy.5-8,10 Satisfactory levels Maxillofacial Surgery, has been described as causing of functionality and quality of life have been reported for both treatment alternatives.1,2,4,9,11-13 The defect size, its extensive, painful lesions of the hard and soft anatomy and geometry, residual bone, soft tissue support, tissue and oroantral fistulae. The disease poses new challenges for prosthodontists and surgeons.14,15,23-29 remaining dentition and underlying diseases, and the MRONJ may be induced by a variety of established patient‘s general health have to be considered in the and new antiresorptive or antineoangiogenetic drugs, selection of a suitable treatment option.6-8,10,14,15 Sophisincluding bisphosphonates (BRONJ), denosumab, or ticated classification systems for maxillary defects with other agents.15 After successful surgical debridement of implications for treatment have been suggested.7,8,16 the necrotic bone, pain relief, and elimination of inSatisfactory reconstruction of unilateral maxillary defects flammatory signs, patients are often left with maxillary and oroantral fistulae with limited vertical extension defects that are too large for predictable primary defect and an intact soft palate can be achieved with obturaclosure.14,23,24,30-35 A tailored treatment plan should be tors.4-9,11,13,16,17 Obturator retention can be enhanced with designed with respect to defect geometry, the anatomy of retentive clasps, refined fit at the defect borders, or imthe surrounding structures, and the patients‘ comorbidplants.3,18-21 Microvascular free flaps are recommended for ities.14,36,37 A prosthodontic approach with an obturator large defects with a more complex geometry.7,8,10,22 may be the therapy of choice for maxillary defects Advanced-stage maxillary medication-related osteowith favorable anatomy and oroantral fistulization.14,23 necrosis of the jaw (MRONJ), especially those categorized
a
Resident, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. Resident, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. Resident, Department of Oral and Maxillofacial Surgery, University of Göttingen, Göttingen, Germany. d Professor and Department Chair, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. e Associate Professor, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. b c
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Figure 1. Stage III maxillary bisphosphonate related osteonecrosis of the jaw with purulent nasal discharge and inflamed soft tissues.
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Figure 2. Panoramic radiograph, showing bony sequestrum and shadowing of right maxillary sinus.
Figure 3. A, Intraoperative view of exposed necrotic bone before resection. B, Intraoperative view after bone resection and primary wound closure.
Furthermore, the limited surgical intervention reduces the hospitalization time, perioperative risk, and postoperative complication rate for patients who are critically or terminally ill and improves nasal leakage, hypernasal speech, and esthetics.3-5,11,14,15,38 The following reports are intended to describe clinical situations that involved specific maxilary defects with oroantral fistulae caused by MRONJ that could be managed successfully with obturators as an alternative to surgical treatment. CLINICAL REPORTS Patient 1 A 62-year-old woman was referred to the department of oral and maxillofacial surgery of the Ludwig-Maximilians University of Munich (Germany) for the evaluation and treatment of right maxillary, stage III BRONJ15 (Fig. 1), which had developed after the extraction of the right premolars and molars.39 She reported purulent nasal discharge and severe mid facial pain. She had received intravenous zoledronic acid (Zometa 4 mg per 5 mL; Troeltzsch et al
Novartis Pharma) for more than 3 years for the treatment of osseous metastases of disseminated breast cancer. Her medical history also revealed hypertension and osteoporosis. Radiological imaging (panoramic radiograph, cone beam computed tomography) showed insufficient bony consolidation and also shadowing of the right maxillary sinus (Fig. 2). After antibiotic pretreatment (Augmentin 875/125 mg twice daily [GlaxoSmithKline], and doxycycline 200 mg twice daily [Ratiopharm]), the patient underwent surgical fluorescence-guided debridement of the necrotic bone,30 maxillary sinus surgery on the right side, and primary local defect closure with the buccal fat pad (Fig. 3A, B).31-35 After an initially uneventful healing process, the wound developed a posterior dehiscence, which led to a long-term oroantral fistula (Fig. 4) with sinus drainage23 but without signs of inflammation or pain. In the course of healing, the remaining left premolars had to be extracted because of advanced caries. The defect size and anatomy allowed surgical and prosthodontic options for reconstruction, which were THE JOURNAL OF PROSTHETIC DENTISTRY
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eventually led to a long-term oroantral fistula after complete healing. The patient experienced nasal leakage when swallowing fluids but had no pain or inflammatory symptoms (Fig. 6B). He refused a secondary surgical intervention for personal reasons (home care of his wife who was critically ill) and agreed to the prosthodontic treatment approach that involved an obturator prosthesis fabricated as described in Patient 1. The patient was satisfied with this treatment and died without reoccurrence of BRONJ after a follow-up period of almost 3 years.
Figure 4. Clinical image of long-term oroantral fistula after wound dehiscence, with no signs of sinus discharge or inflammation.
discussed with the patient. The patient‘s impaired health and the increased risk of repetitive surgical failure led to the decision to fabricate an obturator prosthesis to close the oroantral communication. After complete healing, maxillary and mandibular impressions with irreversible hydrocolloid were made and poured with dental stone (Silky Rock; Whip Mix Corp). An individualized maxillary impression tray then was fabricated, and the impression was repeated with polyvinyl siloxane (Optosil; Heraeus Kulzer GmbH) and poured with dental stone (Silky Rock). These casts were used to design the denture bases with heat-polymerized acrylic resin (Paladon Ultra; Heraeus Kulzer GmbH). The casts were mounted in an articulator after facebow registration (SAM Dental). Acrylic resin denture teeth (Phonares; Ivoclar Vivadent) were set in balanced occlusion, wire clasps that rest on the remaining anterior dentition were added for increased stability,3 and the prostheses were finalized after clinical evaluations (Fig. 5A, B). A satisfactory closure of the oroantral fistula prevented nasal leakage and hypernasal speech and enabled proper deglutition. The patient was pleased with the result and has remained free of disease for the follow-up period of 4 years. Patient 2 An 81-year-old man with a history of intravenous treatment with zoledronic acid (Zometa 4 mg per 5 mL; Novartis Pharma) over a period of 4 years because of disseminated prostate cancer and osseous metastases presented for treatment of a right maxillary, stage III BRONJ15 (Fig. 6A), which had been triggered by tooth extractions in this area.39 He reported severe pain that originated from this site and that reduced his quality of life. Previous surgical debridement and wound closure had not relieved the discomfort. The patient underwent treatment analogous to the protocol in patient 1. The postsurgical oroantral fistula was covered with a buccal fat pad flap initially,32,33,35 but wound dehiscence THE JOURNAL OF PROSTHETIC DENTISTRY
Patient 3 A 72-year-old woman was referred for further examination of a long-term oroantral fistula in the left posterior maxilla, which had developed after the extraction of 2 left maxillary molars. She had been treated for the osseous sequelae of multiple myeloma with intravenous bisphosphonates for the previous 14 months. Her medical record also included hypertension and hypothyroidism. The clinical and radiological findings led to the diagnosis of stage III maxillary BRONJ15 (Fig. 7A), and the patient was treated by following established treatment protocols as in patient 1.30,40 Primary defect closure was achieved with a buccal fat pad flap.32-34 However, severe hemorrhage within the surgical site after 4 days necessitated emergency revision of the wound, and wound dehiscence finally led to a long-term oroantral fistula free of inflammatory signs (Fig. 7B). The patient’s compromised medical condition necessitated a conservative treatment approach for the oroantral fistula, and an obturator prosthesis was designed as described in the previous reports. She remains under clinical observation. DISCUSSION The purpose of the clinical reports was to discuss a conservative therapeutic alternative for the rehabilitation of patients with oroantral fistulae after surgical resection of maxillary MRONJ. Oroantral communications may occur after MRONJ resection in situations of extensive bony and soft tissue destruction or after wound healing disturbances after primary wound closure as in the reported clinical situations.14,23,24,27,38 Impaired general health, anatomic changes after bone resection, a lack of soft tissue, and scarring complicate repeated surgical approaches for defect reconstruction, increase the risk of failure, and may cause prolonged hospitalization for patients who are terminally ill.14,23,24,27,29,38 Therefore, the use of obturators for the reconstruction of maxillary defects after BRONJ resection was suggested by Marx14 and Ruggiero.23 When used in suitable situations, obturators may reduce the surgical intervention and limit the hospital stay while providing acceptable functional and esthetic results.6-8,16 All the presented patients favored the prosthodontic solution with an obturator instead of a Troeltzsch et al
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Figure 5. A, Occlusal view of obturator prosthesis. B, Anterior view of maxillary and mandibular prosthesis.
Figure 6. A, Stage III maxillary BRONJ with inflamed tissues and presence of oroantral fistula. B, Clinical image of long-term oroantral fistula after wound dehiscence with no signs of sinus discharge or inflammation.
Figure 7. A, Stage III maxillary BRONJ showing extensive oroantral communication. B, Clinical situation with stable tissues and long-term oroantral communication after wound healing disturbance after extensive hemorrhage.
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second surgical intervention and reported high levels of satisfaction with their restorations. Although obturator treatment is a well-documented treatment after ablative cancer surgery in the maxilla,1,2,5,6,9,12,13,22 a literature search failed to reveal clinical studies that examined the long-term performance of obturator prostheses for these defects in patients with MRONJ. Removable prosthodontic rehabilitation of patients with MRONJ is under scientific debate because denture trauma has been mentioned as a risk factor for MRONJ development,26 and few reports are available about optimal denture base design for this patient cohort.28 BRONJ recurrence was not reported in any of the described patients, although all obturator prostheses were partly supported by oral mucosa. The clinical follow-up period ranged between 7 months (patient 3) and almost 4 years (patient 1). However, patients with MRONJ with mucosa-supported dentures have to be monitored closely, and denture base relining must be carried out frequently to prevent imbalanced occlusal force distribution, which may induce denture trauma and reactivate MRONJ.14,15,23,28 The defect geometry and the anatomy of the adjacent structures must be respected.3,7,8 Obturators can be considered as a conservative treatment alternative for posterior maxillary oroantral fistulae of limited diameter (widely classified as class Ib or II defects) as suggested by various investigators.7,8,16 The presence of adjacent teeth is favorable for increased obturator retention.3 If there is no remaining dentition, then the use of dental implants for obturator anchorage can be considered.7,18 However, this is a controversial issue with patients with MRONJ because implant failure is increased after bisphosphonate intake and regarded to be contraindicated for patients who receive high-dose bisphosphonate treatment in oncologic treatment regimens.15,19-21 It is worth noting that obturation of oroantral communications may only replace elaborate surgical reconstructive procedures (such as with complicated local or free flaps34,38) but does not constitute an alternative for primary curative MRONJ treatment because only healthy oral tissues may bear the load of the obturator prosthesis. SUMMARY Obturators can be considered a safe and predictable therapy option for long-term oroantral fistulae after the surgical treatment of MRONJ in well-selected situations and can reduce the burden of disease and therapy for affected patients. REFERENCES 1. Chigurupati R, Aloor N, Salas R, Schmidt BL. Quality of life after maxillectomy and prosthetic obturator rehabilitation. J Oral Maxillofac Surg 2013;71:1471-8. 2. Omondi BI, Guthua SW, Awange DO, Odhiambo WA. Maxillary obturator prosthesis rehabilitation following maxillectomy for ameloblastoma: case series of five patients. Int J Prosthodont 2004;17:464-8.
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3. Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9. 4. Eckardt A, Teltzrow T, Schulze A, Hoppe M, Kuettner C. Nasalance in patients with maxillary defects: reconstruction versus obturation. J Craniomaxillofac Surg 2007;35:241-5. 5. Devlin H, Barker GR. Prosthetic rehabilitation of the edentulous patient requiring a partial maxillectomy. J Prosthet Dent 1992;67:223-7. 6. Sharma AB, Beumer J III. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770-3. 7. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86:352-63. 8. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001-8. 9. Rieger JM, Tang JA, Wolfaardt J, Harris J, Seikaly H. Comparison of speech and aesthetic outcomes in patients with maxillary reconstruction versus maxillary obturators after maxillectomy. J Otolaryngol Head Neck Surg 2011;40:40-7. 10. Nguyen CT, Driscoll CF, Coletti DP. Reconstruction of a maxillectomy patient with an osteocutaneous flap and implant-retained fixed dental prosthesis: a clinical report. J Prosthet Dent 2011;105:292-5. 11. Irish J, Sandhu N, Simpson C, Wood R, Gilbert R, Gullane P, et al. Quality of life in patients with maxillectomy prostheses. Head Neck 2009;31: 813-21. 12. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174-81. 13. Kornblith AB, Zlotolow IM, Gooen J, Huryn JM, Lerner T, Strong EW, et al. Quality of life of maxillectomy patients using an obturator prosthesis. Head Neck 1996;18:323-34. 14. Marx RE. Reconstruction of defects caused by bisphosphonate-induced osteonecrosis of the jaws. J Oral Maxillofac Surg 2009;67:107-19. 15. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jawse2014 update. J Oral Maxillofac Surg 2014;72:1938-56. 16. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: Classification. 1978 [classical article]. J Prosthet Dent 2001;86: 559-61. 17. Ono T, Kohda H, Hori K, Nokubi T. Masticatory performance in postmaxillectomy patients with edentulous maxillae fitted with obturator prostheses. Int J Prosthodont 2007;20:145-50. 18. Roumanas ED, Nishimura RD, Davis BK, Beumer J III. Clinical evaluation of implants retaining edentulous maxillary obturator prostheses. J Prosthet Dent 1997;77:184-90. 19. Bedogni A, Bettini G, Totola A, Saia G, Nocini PF. Oral bisphosphonateassociated osteonecrosis of the jaw after implant surgery: a case report and literature review. J Oral Maxillofac Surg 2010;68:1662-6. 20. Madrid C, Sanz M. What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res 2009;20(suppl 4):87-95. 21. Yip JK, Borrell LN, Cho SC, Francisco H, Tarnow DP. Association between oral bisphosphonate use and dental implant failure among middle-aged women. J Clin Periodontol 2012;39:408-14. 22. Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998;108:215-9. 23. Ruggiero SL, Drew SJ. Osteonecrosis of the jaws and bisphosphonate therapy. J Dent Res 2007;86:1013-21. 24. Mast G, Otto S, Mucke T, Schreyer C, Bissinger O, Kolk A, et al. Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw. J Craniomaxillofac Surg 2012;40:568-71. 25. Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo SB. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005;136:1658-68. 26. Hasegawa Y, Kawabe M, Kimura H, Kurita K, Fukuta J, Urade M. Influence of dentures in the initial occurrence site on the prognosis of bisphosphonaterelated osteonecrosis of the jaws: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:318-24. 27. Maurer P, Sandulescu T, Kriwalsky MS, Rashad A, Hollstein S, Stricker I, et al. Bisphosphonate-related osteonecrosis of the maxilla and sinusitis maxillaris. Int J Oral Maxillofac Surg 2011;40:285-91. 28. Gollner M, Holst S, Fenner M, Schmitt J. Prosthodontic treatment of a patient with bisphosphonate-induced osteonecrosis of the jaw using a removable dental prosthesis with a heat-polymerized resilient liner: a clinical report. J Prosthet Dent 2010;103:196-201. 29. Reid IR, Bolland MJ, Grey AB. Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity? Bone 2007;41:318-20. 30. Pautke C, Bauer F, Otto S, Tischer T, Steiner T, Weitz J, et al. Fluorescenceguided bone resection in bisphosphonate-related osteonecrosis of the jaws: first clinical results of a prospective pilot study. J Oral Maxillofac Surg 2011;69:84-91.
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31. Ashtiani AK, Fatemi MJ, Pooli AH, Habibi M. Closure of palatal fistula with buccal fat pad flap. Int J Oral Maxillofac Surg 2011;40:250-4. 32. Awang MN. Closure of oroantral fistula. Int J Oral Maxillofac Surg 1988;17: 110-5. 33. Poeschl PW, Baumann A, Russmueller G, Poeschl E, Klug C, Ewers R. Closure of oroantral communications with Bichat’s buccal fat pad. J Oral Maxillofac Surg 2009;67:1460-6. 34. Visscher SH, van Roon MR, Sluiter WJ, van Minnen B, Bos RR. Retrospective study on the treatment outcome of surgical closure of oroantral communications. J Oral Maxillofac Surg 2011;69:2956-61. 35. Yalcin S, Oncu B, Emes Y, Atalay B, Aktas I. Surgical treatment of oroantral fistulas: a clinical study of 23 cases. J Oral Maxillofac Surg 2011;69:333-9. 36. Carlson ER, Basile JD. The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 2009;67:85-95. 37. Pautke C, Otto S, Reu S, Kolk A, Ehrenfeld M, Sturzenbaum S, et al. Bisphosphonate related osteonecrosis of the jaw: manifestation in a microvascular iliac bone flap. Oral Oncol 2011;47:425-9. 38. Vercruysse H Jr, Backer TD, Mommaerts MY. Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw:
systematic review and a new case series. J Craniomaxillofac Surg 2014;42: 377-86. 39. Otto S, Schreyer C, Hafner S, Mast G, Ehrenfeld M, Sturzenbaum S, et al. Bisphosphonate-related osteonecrosis of the jaws: characteristics, risk factors, clinical features, localization and impact on oncological treatment. J Craniomaxillofac Surg 2012;40:303-9. 40. Otto S, Baumann S, Ehrenfeld M, Pautke C. Successful surgical management of osteonecrosis of the jaw due to RANK-ligand inhibitor treatment using fluorescence guided bone resection. J Craniomaxillofac Surg 2013;41:694-8. Corresponding author: Dr Matthias Troeltzsch University of Munich Lindwurmstrasse 2a 80337 Munich GERMANY Email: [email protected] Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Influence of two different machined-collar heights on crestal bone loss Herrero-Climent M, Romero Ruiz MM, Díaz-Castro CM, Bullón P, Ríos-Santos JV Int J Oral Maxillofac Implants. 2014 Nov-Dec;29(6):1374-9 Purpose. The purpose of this trial was to evaluate crestal bone level changes radiographically in a standardized fashion over a period of 12 months in humans for implants with a 0.7-mm machined collar (implant type A) versus type B implants with a 1.5-mm machined collar. Materials And Methods. Twenty-five patients with multiple missing teeth in posterior sectors were randomly assigned to one of the twogroups: A (0.7-mm machined-collar implants) or B (1.5-mm machined-collar implants). Changes at crestal bone level were assessed by measuring the shoulder-crest distance (SCD) on the mesial and distal aspects of each implant on customized periapical radiographs, which were taken on the day of surgery and 3, 6, and 12 months after surgery. Results. Eighty-one implants were included in the study. Mean SCD was 0.54 ± 0.53 mm at baseline and 1.49 ± 0.40 mm after 12 months. For 0.7-mm-collar implants, mean SCD was 1.40 ± 0.39 mm, while it was 1.56 ± 0.40 mm for 1.5mm-collar implants. Statistically significant differences were found only between the two types of implants for distal measurements at 3 and 12 months after placement. Conclusions. Both 0.7- and 1.5-mm machined-collar implants can be used with predictable results, as changes in periimplant crestal bone levels are similar for both implant types and do not seem to be significant from a clinical point of view. The SCD may well depend more on the location of the abutment-implant interface than on machined-collar height. Reprinted with permission of Quintessence Publishing.
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Conservative management of medication-related osteonecrosis of the maxilla with an obturator prosthesis Matthias Troeltzsch, MD, DMD,a Florian Probst, MD, DMD,b Markus Troeltzsch, MD, DMD,c Michael Ehrenfeld, MD, DMD, PhD,d and Sven Otto, MD, DMD, PhDe Obturators are a viable method ABSTRACT of restoring the sequelae of Advanced maxillary medication-related osteonecrosis of the jaw can cause extensive hard and maxillary defects, namely loss soft tissue destruction that results in long-term oroantral fistulae. The surgical treatment of of chewing ability, impaired medication-related osteonecrosis of the jaw may relieve acute symptoms and eliminate the signs esthetics, hypernasal speech, of inflammation, but the primary and sustained plastic closure of these defects can challenge impaired deglutition, and nasal both the clinician and the patients. Although the use of obturator prostheses for maxillary defects after ablative oncologic surgery is well documented, studies about this treatment for similar fluid leakage.1-8 Most of these medication-related osteonecrosis of the jawerelated defects are missing. This presentation of defects are created by ablative clinical situations describes the use of obturators as a conservative alternative to repetitive surgery surgery in oncology patients.7-9 for the rehabilitation of selected maxillary defects with oroantral communications. (J Prosthet Dent Reconstruction can be achieved 2015;113:236-241) surgically with local or distant flaps, prosthetically with obtuas stage III by the American Association of Oral and rators, or with combined therapy.5-8,10 Satisfactory levels Maxillofacial Surgery, has been described as causing of functionality and quality of life have been reported for both treatment alternatives.1,2,4,9,11-13 The defect size, its extensive, painful lesions of the hard and soft anatomy and geometry, residual bone, soft tissue support, tissue and oroantral fistulae. The disease poses new challenges for prosthodontists and surgeons.14,15,23-29 remaining dentition and underlying diseases, and the MRONJ may be induced by a variety of established patient‘s general health have to be considered in the and new antiresorptive or antineoangiogenetic drugs, selection of a suitable treatment option.6-8,10,14,15 Sophisincluding bisphosphonates (BRONJ), denosumab, or ticated classification systems for maxillary defects with other agents.15 After successful surgical debridement of implications for treatment have been suggested.7,8,16 the necrotic bone, pain relief, and elimination of inSatisfactory reconstruction of unilateral maxillary defects flammatory signs, patients are often left with maxillary and oroantral fistulae with limited vertical extension defects that are too large for predictable primary defect and an intact soft palate can be achieved with obturaclosure.14,23,24,30-35 A tailored treatment plan should be tors.4-9,11,13,16,17 Obturator retention can be enhanced with designed with respect to defect geometry, the anatomy of retentive clasps, refined fit at the defect borders, or imthe surrounding structures, and the patients‘ comorbidplants.3,18-21 Microvascular free flaps are recommended for ities.14,36,37 A prosthodontic approach with an obturator large defects with a more complex geometry.7,8,10,22 may be the therapy of choice for maxillary defects Advanced-stage maxillary medication-related osteowith favorable anatomy and oroantral fistulization.14,23 necrosis of the jaw (MRONJ), especially those categorized
a
Resident, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. Resident, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. Resident, Department of Oral and Maxillofacial Surgery, University of Göttingen, Göttingen, Germany. d Professor and Department Chair, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. e Associate Professor, Department of Oral and Maxillofacial Surgery, University of Munich, Munich, Germany. b c
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Figure 1. Stage III maxillary bisphosphonate related osteonecrosis of the jaw with purulent nasal discharge and inflamed soft tissues.
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Figure 2. Panoramic radiograph, showing bony sequestrum and shadowing of right maxillary sinus.
Figure 3. A, Intraoperative view of exposed necrotic bone before resection. B, Intraoperative view after bone resection and primary wound closure.
Furthermore, the limited surgical intervention reduces the hospitalization time, perioperative risk, and postoperative complication rate for patients who are critically or terminally ill and improves nasal leakage, hypernasal speech, and esthetics.3-5,11,14,15,38 The following reports are intended to describe clinical situations that involved specific maxilary defects with oroantral fistulae caused by MRONJ that could be managed successfully with obturators as an alternative to surgical treatment. CLINICAL REPORTS Patient 1 A 62-year-old woman was referred to the department of oral and maxillofacial surgery of the Ludwig-Maximilians University of Munich (Germany) for the evaluation and treatment of right maxillary, stage III BRONJ15 (Fig. 1), which had developed after the extraction of the right premolars and molars.39 She reported purulent nasal discharge and severe mid facial pain. She had received intravenous zoledronic acid (Zometa 4 mg per 5 mL; Troeltzsch et al
Novartis Pharma) for more than 3 years for the treatment of osseous metastases of disseminated breast cancer. Her medical history also revealed hypertension and osteoporosis. Radiological imaging (panoramic radiograph, cone beam computed tomography) showed insufficient bony consolidation and also shadowing of the right maxillary sinus (Fig. 2). After antibiotic pretreatment (Augmentin 875/125 mg twice daily [GlaxoSmithKline], and doxycycline 200 mg twice daily [Ratiopharm]), the patient underwent surgical fluorescence-guided debridement of the necrotic bone,30 maxillary sinus surgery on the right side, and primary local defect closure with the buccal fat pad (Fig. 3A, B).31-35 After an initially uneventful healing process, the wound developed a posterior dehiscence, which led to a long-term oroantral fistula (Fig. 4) with sinus drainage23 but without signs of inflammation or pain. In the course of healing, the remaining left premolars had to be extracted because of advanced caries. The defect size and anatomy allowed surgical and prosthodontic options for reconstruction, which were THE JOURNAL OF PROSTHETIC DENTISTRY
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eventually led to a long-term oroantral fistula after complete healing. The patient experienced nasal leakage when swallowing fluids but had no pain or inflammatory symptoms (Fig. 6B). He refused a secondary surgical intervention for personal reasons (home care of his wife who was critically ill) and agreed to the prosthodontic treatment approach that involved an obturator prosthesis fabricated as described in Patient 1. The patient was satisfied with this treatment and died without reoccurrence of BRONJ after a follow-up period of almost 3 years.
Figure 4. Clinical image of long-term oroantral fistula after wound dehiscence, with no signs of sinus discharge or inflammation.
discussed with the patient. The patient‘s impaired health and the increased risk of repetitive surgical failure led to the decision to fabricate an obturator prosthesis to close the oroantral communication. After complete healing, maxillary and mandibular impressions with irreversible hydrocolloid were made and poured with dental stone (Silky Rock; Whip Mix Corp). An individualized maxillary impression tray then was fabricated, and the impression was repeated with polyvinyl siloxane (Optosil; Heraeus Kulzer GmbH) and poured with dental stone (Silky Rock). These casts were used to design the denture bases with heat-polymerized acrylic resin (Paladon Ultra; Heraeus Kulzer GmbH). The casts were mounted in an articulator after facebow registration (SAM Dental). Acrylic resin denture teeth (Phonares; Ivoclar Vivadent) were set in balanced occlusion, wire clasps that rest on the remaining anterior dentition were added for increased stability,3 and the prostheses were finalized after clinical evaluations (Fig. 5A, B). A satisfactory closure of the oroantral fistula prevented nasal leakage and hypernasal speech and enabled proper deglutition. The patient was pleased with the result and has remained free of disease for the follow-up period of 4 years. Patient 2 An 81-year-old man with a history of intravenous treatment with zoledronic acid (Zometa 4 mg per 5 mL; Novartis Pharma) over a period of 4 years because of disseminated prostate cancer and osseous metastases presented for treatment of a right maxillary, stage III BRONJ15 (Fig. 6A), which had been triggered by tooth extractions in this area.39 He reported severe pain that originated from this site and that reduced his quality of life. Previous surgical debridement and wound closure had not relieved the discomfort. The patient underwent treatment analogous to the protocol in patient 1. The postsurgical oroantral fistula was covered with a buccal fat pad flap initially,32,33,35 but wound dehiscence THE JOURNAL OF PROSTHETIC DENTISTRY
Patient 3 A 72-year-old woman was referred for further examination of a long-term oroantral fistula in the left posterior maxilla, which had developed after the extraction of 2 left maxillary molars. She had been treated for the osseous sequelae of multiple myeloma with intravenous bisphosphonates for the previous 14 months. Her medical record also included hypertension and hypothyroidism. The clinical and radiological findings led to the diagnosis of stage III maxillary BRONJ15 (Fig. 7A), and the patient was treated by following established treatment protocols as in patient 1.30,40 Primary defect closure was achieved with a buccal fat pad flap.32-34 However, severe hemorrhage within the surgical site after 4 days necessitated emergency revision of the wound, and wound dehiscence finally led to a long-term oroantral fistula free of inflammatory signs (Fig. 7B). The patient’s compromised medical condition necessitated a conservative treatment approach for the oroantral fistula, and an obturator prosthesis was designed as described in the previous reports. She remains under clinical observation. DISCUSSION The purpose of the clinical reports was to discuss a conservative therapeutic alternative for the rehabilitation of patients with oroantral fistulae after surgical resection of maxillary MRONJ. Oroantral communications may occur after MRONJ resection in situations of extensive bony and soft tissue destruction or after wound healing disturbances after primary wound closure as in the reported clinical situations.14,23,24,27,38 Impaired general health, anatomic changes after bone resection, a lack of soft tissue, and scarring complicate repeated surgical approaches for defect reconstruction, increase the risk of failure, and may cause prolonged hospitalization for patients who are terminally ill.14,23,24,27,29,38 Therefore, the use of obturators for the reconstruction of maxillary defects after BRONJ resection was suggested by Marx14 and Ruggiero.23 When used in suitable situations, obturators may reduce the surgical intervention and limit the hospital stay while providing acceptable functional and esthetic results.6-8,16 All the presented patients favored the prosthodontic solution with an obturator instead of a Troeltzsch et al
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Figure 5. A, Occlusal view of obturator prosthesis. B, Anterior view of maxillary and mandibular prosthesis.
Figure 6. A, Stage III maxillary BRONJ with inflamed tissues and presence of oroantral fistula. B, Clinical image of long-term oroantral fistula after wound dehiscence with no signs of sinus discharge or inflammation.
Figure 7. A, Stage III maxillary BRONJ showing extensive oroantral communication. B, Clinical situation with stable tissues and long-term oroantral communication after wound healing disturbance after extensive hemorrhage.
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second surgical intervention and reported high levels of satisfaction with their restorations. Although obturator treatment is a well-documented treatment after ablative cancer surgery in the maxilla,1,2,5,6,9,12,13,22 a literature search failed to reveal clinical studies that examined the long-term performance of obturator prostheses for these defects in patients with MRONJ. Removable prosthodontic rehabilitation of patients with MRONJ is under scientific debate because denture trauma has been mentioned as a risk factor for MRONJ development,26 and few reports are available about optimal denture base design for this patient cohort.28 BRONJ recurrence was not reported in any of the described patients, although all obturator prostheses were partly supported by oral mucosa. The clinical follow-up period ranged between 7 months (patient 3) and almost 4 years (patient 1). However, patients with MRONJ with mucosa-supported dentures have to be monitored closely, and denture base relining must be carried out frequently to prevent imbalanced occlusal force distribution, which may induce denture trauma and reactivate MRONJ.14,15,23,28 The defect geometry and the anatomy of the adjacent structures must be respected.3,7,8 Obturators can be considered as a conservative treatment alternative for posterior maxillary oroantral fistulae of limited diameter (widely classified as class Ib or II defects) as suggested by various investigators.7,8,16 The presence of adjacent teeth is favorable for increased obturator retention.3 If there is no remaining dentition, then the use of dental implants for obturator anchorage can be considered.7,18 However, this is a controversial issue with patients with MRONJ because implant failure is increased after bisphosphonate intake and regarded to be contraindicated for patients who receive high-dose bisphosphonate treatment in oncologic treatment regimens.15,19-21 It is worth noting that obturation of oroantral communications may only replace elaborate surgical reconstructive procedures (such as with complicated local or free flaps34,38) but does not constitute an alternative for primary curative MRONJ treatment because only healthy oral tissues may bear the load of the obturator prosthesis. SUMMARY Obturators can be considered a safe and predictable therapy option for long-term oroantral fistulae after the surgical treatment of MRONJ in well-selected situations and can reduce the burden of disease and therapy for affected patients. REFERENCES 1. Chigurupati R, Aloor N, Salas R, Schmidt BL. Quality of life after maxillectomy and prosthetic obturator rehabilitation. J Oral Maxillofac Surg 2013;71:1471-8. 2. Omondi BI, Guthua SW, Awange DO, Odhiambo WA. Maxillary obturator prosthesis rehabilitation following maxillectomy for ameloblastoma: case series of five patients. Int J Prosthodont 2004;17:464-8.
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3. Keyf F. Obturator prostheses for hemimaxillectomy patients. J Oral Rehabil 2001;28:821-9. 4. Eckardt A, Teltzrow T, Schulze A, Hoppe M, Kuettner C. Nasalance in patients with maxillary defects: reconstruction versus obturation. J Craniomaxillofac Surg 2007;35:241-5. 5. Devlin H, Barker GR. Prosthetic rehabilitation of the edentulous patient requiring a partial maxillectomy. J Prosthet Dent 1992;67:223-7. 6. Sharma AB, Beumer J III. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770-3. 7. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86:352-63. 8. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001-8. 9. Rieger JM, Tang JA, Wolfaardt J, Harris J, Seikaly H. Comparison of speech and aesthetic outcomes in patients with maxillary reconstruction versus maxillary obturators after maxillectomy. J Otolaryngol Head Neck Surg 2011;40:40-7. 10. Nguyen CT, Driscoll CF, Coletti DP. Reconstruction of a maxillectomy patient with an osteocutaneous flap and implant-retained fixed dental prosthesis: a clinical report. J Prosthet Dent 2011;105:292-5. 11. Irish J, Sandhu N, Simpson C, Wood R, Gilbert R, Gullane P, et al. Quality of life in patients with maxillectomy prostheses. Head Neck 2009;31: 813-21. 12. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174-81. 13. Kornblith AB, Zlotolow IM, Gooen J, Huryn JM, Lerner T, Strong EW, et al. Quality of life of maxillectomy patients using an obturator prosthesis. Head Neck 1996;18:323-34. 14. Marx RE. Reconstruction of defects caused by bisphosphonate-induced osteonecrosis of the jaws. J Oral Maxillofac Surg 2009;67:107-19. 15. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jawse2014 update. J Oral Maxillofac Surg 2014;72:1938-56. 16. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: Classification. 1978 [classical article]. J Prosthet Dent 2001;86: 559-61. 17. Ono T, Kohda H, Hori K, Nokubi T. Masticatory performance in postmaxillectomy patients with edentulous maxillae fitted with obturator prostheses. Int J Prosthodont 2007;20:145-50. 18. Roumanas ED, Nishimura RD, Davis BK, Beumer J III. Clinical evaluation of implants retaining edentulous maxillary obturator prostheses. J Prosthet Dent 1997;77:184-90. 19. Bedogni A, Bettini G, Totola A, Saia G, Nocini PF. Oral bisphosphonateassociated osteonecrosis of the jaw after implant surgery: a case report and literature review. J Oral Maxillofac Surg 2010;68:1662-6. 20. Madrid C, Sanz M. What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res 2009;20(suppl 4):87-95. 21. Yip JK, Borrell LN, Cho SC, Francisco H, Tarnow DP. Association between oral bisphosphonate use and dental implant failure among middle-aged women. J Clin Periodontol 2012;39:408-14. 22. Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998;108:215-9. 23. Ruggiero SL, Drew SJ. Osteonecrosis of the jaws and bisphosphonate therapy. J Dent Res 2007;86:1013-21. 24. Mast G, Otto S, Mucke T, Schreyer C, Bissinger O, Kolk A, et al. Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw. J Craniomaxillofac Surg 2012;40:568-71. 25. Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo SB. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005;136:1658-68. 26. Hasegawa Y, Kawabe M, Kimura H, Kurita K, Fukuta J, Urade M. Influence of dentures in the initial occurrence site on the prognosis of bisphosphonaterelated osteonecrosis of the jaws: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:318-24. 27. Maurer P, Sandulescu T, Kriwalsky MS, Rashad A, Hollstein S, Stricker I, et al. Bisphosphonate-related osteonecrosis of the maxilla and sinusitis maxillaris. Int J Oral Maxillofac Surg 2011;40:285-91. 28. Gollner M, Holst S, Fenner M, Schmitt J. Prosthodontic treatment of a patient with bisphosphonate-induced osteonecrosis of the jaw using a removable dental prosthesis with a heat-polymerized resilient liner: a clinical report. J Prosthet Dent 2010;103:196-201. 29. Reid IR, Bolland MJ, Grey AB. Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity? Bone 2007;41:318-20. 30. Pautke C, Bauer F, Otto S, Tischer T, Steiner T, Weitz J, et al. Fluorescenceguided bone resection in bisphosphonate-related osteonecrosis of the jaws: first clinical results of a prospective pilot study. J Oral Maxillofac Surg 2011;69:84-91.
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31. Ashtiani AK, Fatemi MJ, Pooli AH, Habibi M. Closure of palatal fistula with buccal fat pad flap. Int J Oral Maxillofac Surg 2011;40:250-4. 32. Awang MN. Closure of oroantral fistula. Int J Oral Maxillofac Surg 1988;17: 110-5. 33. Poeschl PW, Baumann A, Russmueller G, Poeschl E, Klug C, Ewers R. Closure of oroantral communications with Bichat’s buccal fat pad. J Oral Maxillofac Surg 2009;67:1460-6. 34. Visscher SH, van Roon MR, Sluiter WJ, van Minnen B, Bos RR. Retrospective study on the treatment outcome of surgical closure of oroantral communications. J Oral Maxillofac Surg 2011;69:2956-61. 35. Yalcin S, Oncu B, Emes Y, Atalay B, Aktas I. Surgical treatment of oroantral fistulas: a clinical study of 23 cases. J Oral Maxillofac Surg 2011;69:333-9. 36. Carlson ER, Basile JD. The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 2009;67:85-95. 37. Pautke C, Otto S, Reu S, Kolk A, Ehrenfeld M, Sturzenbaum S, et al. Bisphosphonate related osteonecrosis of the jaw: manifestation in a microvascular iliac bone flap. Oral Oncol 2011;47:425-9. 38. Vercruysse H Jr, Backer TD, Mommaerts MY. Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw:
systematic review and a new case series. J Craniomaxillofac Surg 2014;42: 377-86. 39. Otto S, Schreyer C, Hafner S, Mast G, Ehrenfeld M, Sturzenbaum S, et al. Bisphosphonate-related osteonecrosis of the jaws: characteristics, risk factors, clinical features, localization and impact on oncological treatment. J Craniomaxillofac Surg 2012;40:303-9. 40. Otto S, Baumann S, Ehrenfeld M, Pautke C. Successful surgical management of osteonecrosis of the jaw due to RANK-ligand inhibitor treatment using fluorescence guided bone resection. J Craniomaxillofac Surg 2013;41:694-8. Corresponding author: Dr Matthias Troeltzsch University of Munich Lindwurmstrasse 2a 80337 Munich GERMANY Email: [email protected] Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Influence of two different machined-collar heights on crestal bone loss Herrero-Climent M, Romero Ruiz MM, Díaz-Castro CM, Bullón P, Ríos-Santos JV Int J Oral Maxillofac Implants. 2014 Nov-Dec;29(6):1374-9 Purpose. The purpose of this trial was to evaluate crestal bone level changes radiographically in a standardized fashion over a period of 12 months in humans for implants with a 0.7-mm machined collar (implant type A) versus type B implants with a 1.5-mm machined collar. Materials And Methods. Twenty-five patients with multiple missing teeth in posterior sectors were randomly assigned to one of the twogroups: A (0.7-mm machined-collar implants) or B (1.5-mm machined-collar implants). Changes at crestal bone level were assessed by measuring the shoulder-crest distance (SCD) on the mesial and distal aspects of each implant on customized periapical radiographs, which were taken on the day of surgery and 3, 6, and 12 months after surgery. Results. Eighty-one implants were included in the study. Mean SCD was 0.54 ± 0.53 mm at baseline and 1.49 ± 0.40 mm after 12 months. For 0.7-mm-collar implants, mean SCD was 1.40 ± 0.39 mm, while it was 1.56 ± 0.40 mm for 1.5mm-collar implants. Statistically significant differences were found only between the two types of implants for distal measurements at 3 and 12 months after placement. Conclusions. Both 0.7- and 1.5-mm machined-collar implants can be used with predictable results, as changes in periimplant crestal bone levels are similar for both implant types and do not seem to be significant from a clinical point of view. The SCD may well depend more on the location of the abutment-implant interface than on machined-collar height. Reprinted with permission of Quintessence Publishing.
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