FINAL Flashcards
Odontogenic Keratocyst (OKC) managmenet
- E&C with poten7al extrac7on
- If larger – consider staged marsupializa7on and E&C
pt presents with established MRONJ
Consult and Refer!!!
allograft and xenograft have what type of potential
Osteoconductive
Marsupializa*on • Disadvantages
– Cannot histologically examine the en7re cys7c wall
• Areas leI behind may be more aggressive than
piece removed
– Pa7ent inconvenience with home care
– Occasional secondary infec7ons
correct vertical periodontal defects
orthodontic eruption
Residual cyst management
Residual
• E&C
bone infection
osteomyelitis
removing a known aggressive cyst such
as an OKC (high recurrence) use what procedure
Enuclea*on & cure1age
3. Lateral periodontal cyst
managment
• Enuclea7on with preserva7on of tooth
Treatment of choice for cystic lesions
- Enucleation
three phases during distraction osteogenesis
latency
distraction
consolidation
A condition in which Irradiated bone becomes
exposed through a wound in the overlying
skin and/or mucosa and persist without
healing for 3 to 6 months
osteo-radio-necrosis
Known as “ decompression” technique
Staged marsupializa*on & enuclea*on
how to examine functional load in TMJ area
bite tongue blade between most
posterior teeth bilaterally and incisors
taking PO oral bisphosphonates
Informed consent/Medical
consult if considering drug holiday!
Asymptomatic patient receiving IV therapy
for bisphosphonates
§ Maintain oral hygiene § Avoid osseous injury
treatment sequence for internal derangement of TMJ
arthrocentesis
arthroscopy
open surgery
Member of the cytokine family of growth factors
BMP (Bone Morphogenic Protein)
Enuclea*on • Disadvantages
– Possible pathological fracture
– Devitaliza7on of teeth
– Injury to nerve
minimum distance between implant incisive canal
avoid midline maxilla
indications for arthrocentesis
• Acute closed lock • Acute trauma (hemarthrosis) • Capsulitis/synovitis
clinical stage 3 MRONJ treatment
§ Surgical debridement or
resection § Antibiotic therapy
A true cyst contains an
A true cyst contains an epithelial lining
what type of implants can be used to avoid the sinus
angled implants
surgically lengthen bone
distraction osteogenesis
New bone formation from differentiation of
osteoprogenitor cells, derived from mesenchymal
cells, into osteoblasts.
Osteoinduction
– Any cyst that can be removed in en7rety & safely
without harming adjacent structures should use what procedure
Indica7ons
Palpation – general principles
Light pressure over
Light pressure over lateral capsules: 5 lbs.
intraroral donor sites for block grafting
chin and ramus
two methods of horizontal augmentation
guided bone regeneration
block grafting
Tricks to detect guarding (excessive limitation
of ROM)
during TMJ exam
– Observe during interview, note interincisal ROM
– Look for tonsillar hypertrophy with tongue blade
performed through the implant osteotomy when you want to place an implant but need a few additional mm of bone
indirect sinus augmentation
increased risk of graft/membrane exposure
concern with vertical augmentation by grafting
vertical augmentation of the sinus predictable/non predictable
very predictable (posterior maxilla area)
everywhere else have to use distraction osteogeneiss or orthodontic eruption
Enucleation & Curettage of Jaw Tu m o r s
in what tumors specifically (4)
• Odontoma
• Ameloblas7c fibroma/
fibro-odontoma
- AOT
- Cementoblastoma
- Odontogenic fibrom
name a source of autograft that has no long term morbidity and has no issues on pt function right after
no long term morbidity, no issues walking right after, no gait disturbances, a little scar-anterior iliac crest
clinical stage 1 treatment
§ Oral antimicrobial rinses
(e.g. Peridex)
horizontal augmentation for small, well-defined, concave defects
guided bone regeneration
Staged marsupializa*on & enuclea*on • Lesion marsupialized and allowed time for:
– Bone cover of vital structures
– Increased strengthening of jaw
– Best for internal derangement, effusion
MR
Preauricular tenderness may be either
joint or muscle
finding
Aggressive lesions either by
histopath or clinical behavior
tx
Resection of Jaw Tumor
diseases associated with bone healing problems
drug related osteonecrosis of the jaws
osteo-radio-necrosis
osteomyelitis
like a catch, but stays that way for
minutes, hours, days, etc.
in TMJ area
Limited/Impaired movement
– Closed lock
BMP-2=Infuse® Not approved in
Not approved in children/skeletally immature
patients
Marsupializa*on • Indica7ons
– Adjacent vital structures at risk with enuclea7on
– Difficult surgical access to all por7ons of cyst
• Increases recurrence rate
– Medical compromise
Palpation – general principles
– Moderate pressure
Palpation – general principles
– Moderate pressure over masticatory muscles: 10 lbs.
controlled displacmeent of surgically created fractures
distraction osteogenesis
what happens during the latency stage of distraction osteogenesis
revasculariztion
osteoprogenitor cells accumulate
Does not actually produce bone – conducts bone
forming cells from host into/around the scaffolding.
Osteoconduction
full-thickness por7on removed resection technique
Segmental –
• Most odontogenic
tumors tumors tx
Enucleation & Curettage of Jaw Tu m o r s
Local removal of the tumor by instrumenta7on
or direct contact with the lesion
Enucleation & Curettage Surgical Te c h n i q u e
Removal of the disk
Meniscectomy=Discectomy:
how long does the conslidation phase occur in distraction osteogenesis
2-3 months
Enuclea*on & cure1age • Advantage
– Destroys any suspected epithelial remnants,
decreasing chance of recurrence
Total Joint Replacement • Indications
• Severe degeneration, usually mostly of the condyle
• foreign body giant cell reaction
• rheumatoid arthritis
• Juvenile Idiopathic Arthritis
• Idiopathic condylar resorption • Recurrent fibrous or bony ankylosis • Failure of other reconstructive procedure, e.g.
costochondral graft
PHASE I
Transplanted cellular bone in bone grafts produces new
Transplanted cellular bone produces new osteoid.
why does MRONJ happen in the jaws
¡ Increased bone turnover in the jaws
(Remodeling rate is 10 times more than long
bones )
¡ Thin overlying oral mucosa due to jaw
anatomy.
Removal of the en7re cys7c lesion without rupture
. Enuclea*on
requires a “good root” with a non-restorable crown
orthodontic eruption
minimum distance between implant and natural tooth
2mm
minimum distance between implant and mental nerve
5mm from anterior of bony foramen
Formation of new bone from either host-derived or
transplanted osteoprogenitor cells along a biologic
framework.
Osteoconduction
how to palpate the temporalis insertion
Palpate posterior maxillary vestibule
Posterior on ascending ramus
how long do you leave the cavity open with marsupialization
Un7l goals for choosing marsupializa7on have
been met
BMP (Bone Morphogenic Protein)
is higher in what type of bone
Higher in cortical bone vs. cancellous.
mechanical obsturction in TMJ area can mean
internal derangement
arthropathy
three things we are concerned about with jaw tumors
• Lesion behavior • Anatomic loca7on • Desired reconstruc7on
results
indicated for inadequate vertical dimension
sinus augmentation
Cadaver bone
Allografts/Homografts
Special Challenges to Advanced Implant Placement
Immediate Placement
Posterior mandible
Atrophic maxilla
Pathology ablation
minimum distance between implant and infeirior bordre of md
1mm
• Muscle palpation
in TMJ area
– Work from top down, starting at temporalis crest
• Temporalis, masseter • Repeat for SCMs, posterior neck/trapezius
how long for bony fill in enucleation
6-12 months
Inspection
clinically in TMJ area
– Facial asymmetry
– Swelling
– Asymmetric facial movement
– Masticatory muscle hyperplasia, hyperactivity
Resection of Jaw Tumors
name specific tumors
• Ameloblastoma • Myxoma • CEOT • Squamous odontogenic tumor
only _____ grafts are capable of osteogenesis
Osteogenesis
Consider __________in highly sensitive patients in TMJ area
Consider neuropathic pain (e.g. tactile allodynia,
hyperalgesia) in highly sensitive patients
new bone forms in gap
distraction osteogenesis
name 3 oral bisphosphonatets
¡ Fosamax (alendronate)
¡ Actonel (risedronate)
¡ Boniva (inandronate)
Synthetic analogs of inorganic pyrophosphate
bisphosphoantes
put a suture in the tissue and leave it open to the oral cavity and let it burst on its on
Marsupializa*on
__________grafting for replacement of TMJ
Costochondral grafting for replacement of TMJ
Localized involvement with involvement of cortical and medullary bone
treatment
stage 2 osteoradionecrosis
Conservative : Local debridement w,w/o HBO Chlorhexidine MW
• Cyst is enucleated first
• Mechanical (burs) cure]age is performed to remove
1-2mm of bone at the en7re periphery of the bony
cavity
- Enuclea*on & Cure1age (E&C)
soft tissue envelope expands
distraction osteogenesis
Ectomesenchymal
tumors
1. Odontogenic fibroma 2. Odontogenic myxoma 3. Cementoblastoma
allows our bones to repair from daily micro-trauma
bone remodeling
barrier isolates the defect from surrounding soft tissue
guided bone regeneration
asymptomatic pt still taking oral BP <4 years + risk factor (sterior/angiogenic meds)
stop BP therapy 2 months prior to treatment
clinical stage one MRONJ
§ Exposed/necrotic bone § Asymptomatic § No infectio
TMJ/MPD pain may trigger
migraines
Tumors that would be
difficult to remove in
en7rety by enuclea7on/
cure]age alone
tx
Resection of Jaw Tumors
what is tyrosine
anti-angiogenic medications
Initiates osteoinduction.
BMP (Bone Morphogenic Protein)
pathogenesis of osteoradionecrosis
¡ Hypoxia ¡ Hypovascularity ¡ Hypocellularity
minimum distance between implant and inferior alveolar canal
2mm from superior aspect of bony canal
does vertical or horizontal have a greater resorption rate
vertical
what muscles in the TMJ area are not are not directly palpable
Pterygoid muscles
inter-implant distance
3mm between outer edge of implants
Have osteoinductive and conductive properties.
Osteogenesis
what is really important before doing an extraction
Ta ke thorough medical history before performing teeth extraction !!!
Slow-growing, non-
aggressive tumors tx
Enucleation & Curettage of Jaw Tu m o r s
Determines quality of bone
Two-Phase Theory of Osteogenesis
PHASE II
what radiographic findings are seen with osteomyelitis
moth eaten appearance
radio opacities -? sequestra
Methods to restore lost tissue volume
Grafting
Distraction
Orthodontic Eruption
Types of Bone Grafts
Autograft
- Allograft
- Xenograft
- Alloplast
- Recombinate graft
Opening cyst to oral cavity
marsupializa7on
Name Developmental Cysts Developmental
Developmental
– Den7gerous Cyst
– Odontogenic Keratocyst (Tumor – WHO)
– Lateral Periodontal Cyst
– Glandular Odontogenic Cyst
– Calcifying Odontogenic Cysts (Gorlin’s Cyst)
Arthrocentesis Advantages
• Minimally invasive • Fast, simple procedure – usually done in office • Does not require general anesthetic • Highly effective at increasing joint mobility, reducing pain
BMP in young children can cause
cancer
Determines quantity of bone that the graft will form.
Two-Phase Theory of Osteogenesis
PHASE I
Provide only passive framework or “scaffolding.”
Osteoconduction
treatment for osteomyelitis
antibiotics-clindamycin
hospitization
Two-Phase Theory of Osteogenesis
PHASE I
is most active when
Most active within 4 weeks.
when is block grafting ready for implant placement
4-6 months
MANAGEMENT OF CYSTS (4)
- Enuclea7on
- Enuclea7on & cure]age (E&C)
- Marsupializa7on
4. Staged marsupializa7on & enuclea7on
(decompression technique)
General
– Posture, body habitus, mood, affect, insight
• Note distinctives, in TMJ evaluation
“poor eye contact, spoke through
clenched teeth throughout interview,” etc.
An inflammatory process of the bone marrow that involves cancellous and cortical bone with a tendency of progression.
osteomyelitis
drug holidays are effective for bisphosphonates T./F
false While there have been limited studies on drug holidays for treatment of MRONJ, currently there have yet to be studies to confirm drug holidays are effective in prevention of MRONJ without increasing the skeletally related risks of low bone mass.
correct uneven osseous/gingival levels
orthodontic eruption
Recominate Bone Morphogenic proteins (BMP-2 and
BMP-7 have FDA approval)
Recombinate Grafts
what is an all on four
2 angled parallel to sinus wall
2 in anterior
name a good mnemonic for evaluating TMJ in pain history
L Location of the symptom (finger vs. hand) I Intensity of the symptom (scale 1-10)
Q Quality of the symptom (e.g. burning, pulsating,
ache) O Onset of the symptom + precipitating factors R Radiation of the symptom (“show me where”)
A Associated symptoms (joint sounds, other
neurological oddities) A Alleviating factors (avoid jaw function, etc.) A Aggravating factors (chew, sing, talk a long time)
Staged marsupializa*on & enuclea*on • Advantages
– Develops a thickened cys7c lining
– Reduces morbidity and accelerates complete healing
– Same as for marsupializa7on
• Simple to perform • Can save vital structures • Completely resolves lesion or makes it smaller and easier to
treat and reconstruct
Formation of new bone from osteoprogenitor cells.
Osteogenesis
clinical stage 2 MRONJ treatment
§ Oral antimicrobial rinses § Antibiotic therapy
protrusion in TMJ translates
both joints
Epithelial
tumors (4)
- Ameloblastoma
- Adenomatoid odontogenic tumor
- Calcifying epithelial odontogenic tumor (Pindborg)
- Squamous odontogenic tumor
– A screen for gross joint pathology and other
potential problems for TMJ eval
Panoramic Film
Decreases intracys7c pressure
Marsupializa*on
three ways to vertically augment bone
distraction osteogenesis
orthodontic eruption
sinus augmentation
Superficial involvement, only Cortical bone exposed
treatment?
stage 1 osteoradionecrosis
Conservative : Chlorhexidine MW
dry socket shoud not last longer than what
Dry socket does not last for more than a
week. Think something else!!! - REFER (could be osteomyelitis)
Enuclea*on • Advantages
– Histopathologic examina7on of the en7re cys7c
wall
– Ini7al biopsy/treatment is cura7ve in certain
situa7ons
Mixed epithelial & ectomesenchymal
tumors
- Ameloblas7c fibroma
- Ameloblas7c fibro-odontoma
- Odontoma
Repair, revision, and/or
reconstruction of joint tissues (hard and soft)
Arthroplasty:
how much bone is produced in the distraction phase of distraction osteogensis
1mm per day
is horizontally augmentating ridges predictable or not predictable
• horizontally augmenting ridges: predictable
Staged marsupializa*on & enuclea*on • Indica7ons
– Concern for injury to adjacent anatomical
structures
– Size of lesion
– Marsupializa7on alone does not resolve lesion
– Need to examine en7re lesion histopathologically
BMP-2=Infuse® has been approved for
BMP-2=Infuse® has been approved for sinus floor augmentation and grafting of mandibular defects
name 3 IV bisphosphonates
¡ Aredia (pamidronate)
¡ Zometa (zolendronate)
¡ Reclast (zolendronate)
– Press upward from when palpating the muscles in the TMJ area
– Press upward from pterygomandibular sling, note
radiation or distant site of pain (e.g. TMJ area,
whole side of head)
what happens in the consolidation phase during distraction osteogenesis
active distraction complete
bony regenerate remodels into mature bone
clinical stage 3 MRONJ
§ Exposed/necrotic bone
§ Pain
§ Infection
§ One or more of the
following: ▪ Fracture, extra-oral fistula,
oro-nasal communication.
osteolysis
augment horizontal dimension of alveolus
block grafting
Open a cys7c lesion and maintain patency to an
adjacent cavity
Marsupializa*on
Extremely limited, unchanging ROM may indicate
in TMJ area
ankylosis
drugs associated with MRONJ
1) bisphosphonates
2) anti-resorptive agents
3) anti-angiogenic medicatiosn
kinase inhibitors and monoclonal antibodies
vertical augenting ridge predictable or non
nonpredictable
Differentiation is influenced by bone inductive
proteins from the bone matrix.
Osteoinduction
why is it difficult to obtain vertical augmentation
due to pressure from soft tissue envelope or a prosthesis
Calcifying odontogenic cyst (Gorlin’s) managmenet
• Enuclea7on and cure]age
Enuclea*on & cure1age Disadvantage
Damage to neurovascular bundle
– Dental pulps stripped
Allografts/Homografts
have what type of graft
Osteoconductive
extraoral donor site that provides a large quantity of bone
iliac crest
Staged marsupializa*on & enuclea*on • Disadvantages
Same as for marsupializa7on
• Pa7ent inconvenience • Occasional secondary infec7on • Cannot histologically examine the en7re cys7c wall
– However, secondary enuclea7on can remedy this concern
– maintains con7nuity at inferior
border resection technique
Marginal
Fibrous connec7ve 7ssue (CT) wall allows a cleavage
plane between lesion and bony cavity
- Enuclea*on
inadequate adaptation and/or fixation of the bone graft to recipient bed
concerns with vertical augmentation by grafting
how to palpate the masseter origin
Palpate posterior maxillary vestibule
• Lateral/posterior
Remodeling process continues indefinitely.
Two-Phase Theory of Osteogenesis
PHASE II
in enucleation use the largest curette that will allow
- Cleavage plane
- Concave surface toward bone
stage 2 MRONJ
§ Exposed/necrotic bone § Pain § Infection
zygomaticus implants are placed where
through the palatal aspect of the maxillary crest transantrally into the compact bone of the zygoma
iv indications for bisphosphonate rlated osteonecrosis of the jaws
IV ¡ Bone metastases associated with solid
tumors
¡ Hypercalcemia of malignancy
¡ Multiple myeloma
what is denosumab
anti-resorptive agent
Indications for Arthroscopy
Indications for Arthroscopy • Pain and dysfunction with the following conditions:
• Decreased condylar translation due to disk hypomobility • Anteriorly displaced disk with or without reduction • Closed lock • Traumatic injury
how should monitor after enculeation ( in general practitioner office)
May require close follow-up with periodic panoramic
radiograph (every 6 months)
general stiffness in TMJ area can mean
muscular influences
Opening cyst to oral cavity (marsupializa7on) and
surgical plan is to make the cyst smaller (decompression) for final E&C at a later date
Staged marsupializa*on & enuclea*on
• Second surgery after recurrence when 1st
surgery (enuclea7on) was deemed cura7ve use what procedure
Enuclea*on & cure1age
Two-Phase Theory of Osteogenesis
PHASE II
begins
Begins at 2 weeks and peaks around 6 weeks.
diagnosis of MRONJ
Ø Current or previous treatment with a
bisphosphonate
Ø Exposed bone in the maxillofacial region that
has persisted for more than Eight weeks
Ø No history of radiation therapy to the jaws
Inflammatory 1. Periapical
cyst management
- Remove underlying process – RCT or extrac7on
- Enucleate +/- cure]age
- An7bio7cs if necessary
bSynthetic analogs of inorganic pyrophosphate How do they work?
¡ High affinity ——–
¡ Inhibition of ——-
¡ May inhibit ———
Synthetic analogs of inorganic pyrophosphate How do they work?
¡ High affinity for Ca2+
¡ Inhibition of osteoclasts
¡ May inhibit capillary neo-angiogenesis
Name 2 Inflammatory cysts
– Periapical Cyst – Residual Cysts
Glandular odontogenic cyst
managmenet
- Enuclea7on and cure]age
- Some advocate more aggressive treatment (resec7on)
post-op care after bone grafting
diet mods
temporary prosthesis-non load bearing/limit wear
oral hygiene
oral indications for bisphosphonates
osteoporosis/osteopenia
paget’s disease
osteogenesis imperecta
Den7gerous cyst
managment
- Extrac7on of affected tooth + E&C
- If larger – consider staged marsupializa7on and E&C
what is enucleation good for
– Den7gerous cyst
– Periapical cyst
Two-Phase Theory of Osteogenesis
PHASE II
__________ is resorbed and replaced by __________. As the initial graft is resorbed, __________are released from the matrix.
Initial woven bone is resorbed and replaced by lamellar
bone. As the initial graft is resorbed, bone morphogenic proteins are released from the matrix.
receiving IV bisphosphonates
Avoid osseous surgery if
possible!
minimum required distance between implant and indicated struction for buccal + lingual plate
1mm
– Indirect load to lateral pterygoids
indicates what when examining the TMJ area
• Press chin area posteriorly and/or superiorly against
resistance with mouth half open (half of patient’s best
opening)
Note presence of pain in preauricular area (TMJs) or
deep under cheekbone (lateral pterygoid)
tx of tumors in medically compromised pts
Enucleation & Curettage of Jaw Tu m o r s
– Best for suspected bony abnormality, i.e.
ankylosis, severe arthritis
CT
Effusions in TMJ joint are strongly associated with
Effusions are strongly associated with ADD (+/-
reduction) and pain
Sole treatment (rarely) or as a preliminary step before defini7ve enuclea7on of the smaller cyst
Marsupializa*on
Asymptomatic patient taking oral BP > 4 years
: Drug holiday for 2 months.
In osteoinduction, host cells must be stimulated to differentiate into the _______ by ______ and ______.
Host cells must be stimulated to differentiate into the
osteoblasts by transplanted growth factors and
cytokines.
Incision into the joint
Arthrotomy:
Marsupializa*on • Advantages
– Simple to perform
– Can spare vital structures
– Either completely resolves lesion or makes it
much smaller and easier to treat and reconstruct
The Gold Standard
of grafts
Autografts
Two-Phase Theory of Osteogenesis
PHASE II
___________________ from the
graft bed begin after grafting, and________ from host connective tissue soon begins.
Angiogenesis and fibroblastic proliferation from the
graft bed begin after grafting, and osteogenesis from host connective tissue soon begins.
ADD is frequently found in asymptomatic control
populations what percent
(12-45%)
about to receive IV bisphosphonates
Get healthy before!
Does NOT demonstrate joint space reliably
Panoramic Film
Asymptomatic patient taking oral BP ¡ Sound recommendations are still lacking
§ <4 years
proceed with planned treatment
common reasons of compromised wound healing
medications
radiotherapy
infection
systemic disease
minimum distance between implant and mx sinus/ nose
1mm
Diffuse involvement including inferior border. Usually associated with pathologic fracture and possible osteo-cutaneous fistula
treatment
stage 3 osteoradionecrosis
Surgical resection and reconstruction
what happens during the distraction phase of distraction osteogenesis
osteoblast induction
woven bone formation
¡ Patients about to begin IV therapy
for bisphosphonates how to manage
¡ Patients about to begin IV therapy
§ Delay therapy, if systemic conditions permit
§ Optimize oral health prior to initiating therapy
§ Allow adequate osseous healing and wait until the
surgery sites become mucosalized (14-21 days)
Grafts transplanted between individuals of different
species (i.e. bovine bone/Bio-Oss)
Xenograft
indirect sinus augmentation yields how much bone
4mm of bone
BMP (Bone Morphogenic Protein)
acts on _______ to induce differntiation into
Acts on progenitor cells to induce differentiation into
osteoblasts.