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Lingual mandibular osteonecrosis after dental impressions for orthodontic study models
CLINICIAN'S CORNER
Lingual mandibular osteonecrosis after dental impressions for orthodontic study models Carmen Cerruto,a Alessandro Ugolini,b and Mauro Cozzanic Siena and Genova, Italy, and Smart City, Malta
A 43-year-old man sought orthodontic treatment to close anterior diastemas. During the impression procedure for routine documentation, the orthodontic assistant exerted excessive pressure on the metallic tray; 2 days later, the patient reported the detachment of a small piece of mucosa overlying the mylohyoid crest and was referred to a maxillofacial surgeon with a diagnosis of lingual mandibular osteonecrosis. The etiology of bony osteonecrosis is discussed, together with the anatomic variations that can be present in the basal bone and that must be carefully checked before an impression is taken. (Am J Orthod Dentofacial Orthop 2018;153:445-8)
L
ingual mandibular osteonecrosis is a clinical condition frequently associated with the use of bisphosphonates, antiresorptive medications (denosumab), and antiangiogenic therapies, as stated by the American Association of Oral and Maxillofacial Surgeons in a position paper on medication-related osteonecrosis of the jaw, updated 2014.1 It has been observed that, anatomically, these lesions are found more often in the mandible than in the maxilla (2:1 ratio), usually in areas where a thin mucosa overlies bony prominences (ie, tori, bony exostoses, mylohyoid ridge),2-4 and that they occur spontaneously, after damage to the mucous membrane, or after routine dental extractions, a clinical procedure that can occasionally cause the formation of a bony sequestration in the jaws.5-7 This case report describes the onset of lingual mandibular osteonecrosis in a 43-year-old man after dental impressions were taken for orthodontic study models.
a
Private practice, Siena, Italy. Orthodontic Section, Department of Sciences Integrated Surgical and Diagnostic, University of Genova, Genova, Italy. c Orthodontics UCM United Campus of Malta, Smart City, Malta. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Carmen Cerruto, Via Nino Bixio 20, Siena 53100, Italy; e-mail, [email protected]. Submitted, July 2016; revised and accepted, August 2017. 0889-5406/$36.00 Ó 2017 by the American Association of Orthodontists. All rights reserved. https://doi.org/10.1016/j.ajodo.2017.08.010 b
DIAGNOSIS AND ETIOLOGY
A 43-year-old man seeking improvement of his smile was referred by his general dentist to an orthodontist (C.C.) at his private practice in Almere in the Netherlands, to correct his malocclusion and allow for the placement of 6 veneers in the maxillary anterior area. He had a dental Class I malocclusion, mild skeletal Class III pattern, reduced overjet and overbite, and anterior spacing (Fig 1). The patient was a nonsmoker with asthma and high blood pressure, and had undergone gastric bypass surgery in 2013 for the treatment of obesity. After the bypass surgery, he began a daily regimen of pantoprazol (antacid) and hydrochlorothiazide (diuretic). His weight was normal, and he regularly played sports. Before the orthodontic consultation, the patient was regularly followed by a dental hygienist who controlled plaque and gingival inflammation and performed scaling and root planing in the area of the maxillary first and second molars and the mandibular right first and second molars. After 6 months of periodontal health and stability, he received a full-mouth bleeding score of less than 15% and a full-mouth plaque score of less than 15% and was deemed eligible for the orthodontic treatment.8 During the initial orthodontic consultation, intraoral and extraoral photos were taken, together with an orthopantomogram (Fig 2), a lateral teleradiograph (Fig 3), and alginate impressions for the orthodontic study models. 445
Cerruto, Ugolini, and Cozzani
446
Fig 1. Intraoral images of the patient.
Fig 2. Orthopantomogram.
The largest metallic trays were used for the impression (size 6 X-Large Upper [navy] and Lower [navy] Perma-Lock Stainless Steel Impression Trays; ASA DENTAL, Jericho, NY), but the lower tray was not sufficiently expanded or well adapted to the patient's anatomy; moreover, the assistant who took the impression had a robust physique and exerted excessive pressure during the procedure, causing pain in the area of the patient's mylohyoid ridge. Two days later, the patient reported the detachment of a piece of mucosa overlying the mylohyoid ridge, exposure of the underlying bone (Fig 4), pain, and a burning sensation, especially in association with certain foods (bread, spicy foods). Therefore, he was referred to the Department of Maxillofacial Surgery at Academisch Medisch Centrum in Amsterdam, The Netherlands for treatment of lingual mandibular osteonecrosis.
March 2018 Vol 153 Issue 3
Fig 3. Lateral head film. TREATMENT PLAN
The treatment protocol called for surgical debridement of the area, removal of the necrotic bone, and allowing the site to bleed to encourage rapid onset of the healing process.6-9 Surgical removal of the exposed and avascular bone was performed 2 weeks after the onset of osteonecrosis, at the initial maxillofacial consultation, to reduce the patient's discomfort. Surgical closure of the mucosa was unnecessary, since the second-intention healing process (characterized by the formation of granulation tissue and subsequent reepithelialization) occurred rapidly.10 Amoxicillin (500 mg; 3 times daily for 2 weeks) was
American Journal of Orthodontics and Dentofacial Orthopedics
Cerruto, Ugolini, and Cozzani
447
Fig 5. Lesion completely healed 2 weeks after surgery. Fig 4. Lingual mandibular osteonecrosis in the area of the right mylohyoid crest.
prescribed, together with 2 mg per milliliter of chlorhexidine mouthrinse twice daily until mucosal healing was completed. An alternative treatment option can be conservative and based on systemic antibiotic therapy and antimicrobial rinses until the sequestration of the avascular bone occurs and the sequestrum spontaneously exfoliates, but patient discomfort can last longer with this procedure. Two weeks after the surgical approach, the lesion was healed, and the patient reported no discomfort (Fig 5). Two months after the onset of the lesion, the maxillofacial surgeon gave his consent for the orthodontic treatment to begin. DISCUSSION
Exposure of necrotic bone is a rare complication after a dental impression and can cause pain and discomfort for the patient. It can be healed surgically (once the necrotic bone is removed and bleeding is promoted) or spontaneously after the formation and exfoliation of a bony sequestration, defined as a fragment of nonvital bone separated from adjacent bone as a result of focal bone necrosis and subsequent isolation and resorption of the site margins.11 Sequestration is usually associated with disruption of the blood supply to the bone as a response to various local or systemic factors. We correlated the onset of the necrotic condition with trauma that occurred during the taking of the dental impression, which, in turn, caused a reduced blood supply and an ischemic lesion of the area, as reported in the literature.5,6 The blood supply to the area is guaranteed by the inferior alveolar artery, which descends along the medial surface of the mandibular ramus and, before
entering the mandibular canal, gives origin to the mylohyoid artery, involved in the blood supply to the same muscle. Inside the mandibular canal, the inferior alveolar artery gives origin to small ramifications that contribute to the vascularization of the dental pulp, the periodontal ligaments, the dentoalveolar periosteum, the gingiva, and the mandibular bone.12,13 Specifically, at palpation, the patient exhibited a prominent mylohyoid crest that might have been a predisposing factor for an ischemic lesion (due to excessive pressure) in an area covered by a thin layer of keratinized mucosa.2-4,6 The literature has also reported tori and exostoses as areas susceptible to osteonecrosis because of the prominence of the bone covered by a thin layer of stretched and atrophic mucosa.2-4,6 With the same degree of trauma as occurring elsewhere in the mouth, these areas would be more predisposed to disruption of the blood supply, therefore leaving the bone exposed. The literature also defines patients in treatment with bisphosphonates or who undergo antiresorptive and antiangiogenic therapies as more susceptible to the onset of osteonecrosis,1 but the clinical history of our patient was negative for these medications. He followed a daily regimen of pantoprazol (after gastric bypass surgery in 2013) and hydrochlorothiazide (for the control of high blood pressure); he also suffered from asthma but took no medication for that. He was a nonsmoker and had not undergone any dental extractions before the impression was taken. A detailed search in PubMed was performed for reports of possible correlations between osteonecrosis and the daily use of these medications or gastric bypass surgery. To the best of our knowledge, no orthodontic journals have previously reported this complication,
American Journal of Orthodontics and Dentofacial Orthopedics
March 2018 Vol 153 Issue 3
Cerruto, Ugolini, and Cozzani
448
nor did the literature support any correlation between osteonecrosis of the bone and the intake of pantoprazol or hydrochlorothiazide, nor were correlations found between osteonecrosis and asthma, high blood pressure, and gastric bypass surgery. We therefore attributed the origin of this condition to a traumatic injury.
2.
3.
4.
CONCLUSIONS
The taking of conventional dental impressions rarely causes osteonecrosis in patients with predisposed anatomic sites; however, this case demonstrates that orthodontists and orthodontic assistants who take dental impressions (in the countries where they are permitted) should pay close attention to the anatomic conformation of the patient's basal bones, mainly in the mandible. If an anatomic variation is found, the tray should be modified accordingly, and the impression procedure should be gentle and careful. Alternatively, a plastic moldable tray or the recently introduced 3-dimensional intraoral scanners may be substituted for the metallic tray, thereby overcoming this complication effectively. With these clinical steps in mind, clinicians can minimize the risk of this rare and unexpected complication.
5. 6. 7.
8.
9.
10. 11.
REFERENCES
12.
1. 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 osteonecro-
March 2018 Vol 153 Issue 3
13.
sis of the jaw—2014 update. J Oral Maxillofac Surg 2014;72: 1938-56. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004;62:527-34. Estilo CL, Van Poznak CH, Williams T, Bohle GC, Lwin PT, Zhou Q, et al. Osteonecrosis of the maxilla and mandible in patients with advanced cancer treated with bisphosphonate therapy. Oncologist 2008;13:911-20. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonateinduced exposed bone (osteonecrosisyosteopetrosis) of the jaws: risk factors, recognition, prevention and treatment. J Oral Maxillofac Surg 2005;63:1567-75. De Visscher JG, Dietvorst DP, Van der Meij EH. Lingual mandibular osteonecrosis. Ned Tijdschr Tandheelkd 2013;120:189-93. Farah CS, Savage NW. Oral ulceration with bone sequestration. Aust Dent J 2003;48:61-4. Kharazmi M, Bj€ ornstad L, Hallberg P, Wanbro J, Carlsson AP, Habib S, et al. Mandibular bone exposure and osteonecrosis as a complication of general anesthesia. Ups J Med Sci 2015;120: 215-6. Lang NP, Tonetti MS. Periodontal diagnosis in treated parodontitis. Why, when and how to use clinical parameters. J Clin Periodontol 1996;23:240-50. Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, et al. Diagnosis and management of the osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015;30:3-23. Leaper DJ, Harding KG. Wounds, biology and management. Oxford, United Kingdom: Oxford University Press; 1998. Dorland W. Dorland’s illustrated medical dictionary. 29th ed. London, United Kingdom: W. B. Saunders; 2000. Fonzi L. Functional and clinical anatomy of the splanchnocranium. Milan, Italy: Edi-Ermes; 2000. (available only in Italian). Standring S. Gray's anatomy: the anatomical basis of clinical practice. 41st ed. London, United Kingdom: Elsevier; 2015.
American Journal of Orthodontics and Dentofacial Orthopedics
Lingual mandibular osteonecrosis after dental impressions for orthodontic study models Carmen Cerruto,a Alessandro Ugolini,b and Mauro Cozzanic Siena and Genova, Italy, and Smart City, Malta
A 43-year-old man sought orthodontic treatment to close anterior diastemas. During the impression procedure for routine documentation, the orthodontic assistant exerted excessive pressure on the metallic tray; 2 days later, the patient reported the detachment of a small piece of mucosa overlying the mylohyoid crest and was referred to a maxillofacial surgeon with a diagnosis of lingual mandibular osteonecrosis. The etiology of bony osteonecrosis is discussed, together with the anatomic variations that can be present in the basal bone and that must be carefully checked before an impression is taken. (Am J Orthod Dentofacial Orthop 2018;153:445-8)
L
ingual mandibular osteonecrosis is a clinical condition frequently associated with the use of bisphosphonates, antiresorptive medications (denosumab), and antiangiogenic therapies, as stated by the American Association of Oral and Maxillofacial Surgeons in a position paper on medication-related osteonecrosis of the jaw, updated 2014.1 It has been observed that, anatomically, these lesions are found more often in the mandible than in the maxilla (2:1 ratio), usually in areas where a thin mucosa overlies bony prominences (ie, tori, bony exostoses, mylohyoid ridge),2-4 and that they occur spontaneously, after damage to the mucous membrane, or after routine dental extractions, a clinical procedure that can occasionally cause the formation of a bony sequestration in the jaws.5-7 This case report describes the onset of lingual mandibular osteonecrosis in a 43-year-old man after dental impressions were taken for orthodontic study models.
a
Private practice, Siena, Italy. Orthodontic Section, Department of Sciences Integrated Surgical and Diagnostic, University of Genova, Genova, Italy. c Orthodontics UCM United Campus of Malta, Smart City, Malta. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Carmen Cerruto, Via Nino Bixio 20, Siena 53100, Italy; e-mail, [email protected]. Submitted, July 2016; revised and accepted, August 2017. 0889-5406/$36.00 Ó 2017 by the American Association of Orthodontists. All rights reserved. https://doi.org/10.1016/j.ajodo.2017.08.010 b
DIAGNOSIS AND ETIOLOGY
A 43-year-old man seeking improvement of his smile was referred by his general dentist to an orthodontist (C.C.) at his private practice in Almere in the Netherlands, to correct his malocclusion and allow for the placement of 6 veneers in the maxillary anterior area. He had a dental Class I malocclusion, mild skeletal Class III pattern, reduced overjet and overbite, and anterior spacing (Fig 1). The patient was a nonsmoker with asthma and high blood pressure, and had undergone gastric bypass surgery in 2013 for the treatment of obesity. After the bypass surgery, he began a daily regimen of pantoprazol (antacid) and hydrochlorothiazide (diuretic). His weight was normal, and he regularly played sports. Before the orthodontic consultation, the patient was regularly followed by a dental hygienist who controlled plaque and gingival inflammation and performed scaling and root planing in the area of the maxillary first and second molars and the mandibular right first and second molars. After 6 months of periodontal health and stability, he received a full-mouth bleeding score of less than 15% and a full-mouth plaque score of less than 15% and was deemed eligible for the orthodontic treatment.8 During the initial orthodontic consultation, intraoral and extraoral photos were taken, together with an orthopantomogram (Fig 2), a lateral teleradiograph (Fig 3), and alginate impressions for the orthodontic study models. 445
Cerruto, Ugolini, and Cozzani
446
Fig 1. Intraoral images of the patient.
Fig 2. Orthopantomogram.
The largest metallic trays were used for the impression (size 6 X-Large Upper [navy] and Lower [navy] Perma-Lock Stainless Steel Impression Trays; ASA DENTAL, Jericho, NY), but the lower tray was not sufficiently expanded or well adapted to the patient's anatomy; moreover, the assistant who took the impression had a robust physique and exerted excessive pressure during the procedure, causing pain in the area of the patient's mylohyoid ridge. Two days later, the patient reported the detachment of a piece of mucosa overlying the mylohyoid ridge, exposure of the underlying bone (Fig 4), pain, and a burning sensation, especially in association with certain foods (bread, spicy foods). Therefore, he was referred to the Department of Maxillofacial Surgery at Academisch Medisch Centrum in Amsterdam, The Netherlands for treatment of lingual mandibular osteonecrosis.
March 2018 Vol 153 Issue 3
Fig 3. Lateral head film. TREATMENT PLAN
The treatment protocol called for surgical debridement of the area, removal of the necrotic bone, and allowing the site to bleed to encourage rapid onset of the healing process.6-9 Surgical removal of the exposed and avascular bone was performed 2 weeks after the onset of osteonecrosis, at the initial maxillofacial consultation, to reduce the patient's discomfort. Surgical closure of the mucosa was unnecessary, since the second-intention healing process (characterized by the formation of granulation tissue and subsequent reepithelialization) occurred rapidly.10 Amoxicillin (500 mg; 3 times daily for 2 weeks) was
American Journal of Orthodontics and Dentofacial Orthopedics
Cerruto, Ugolini, and Cozzani
447
Fig 5. Lesion completely healed 2 weeks after surgery. Fig 4. Lingual mandibular osteonecrosis in the area of the right mylohyoid crest.
prescribed, together with 2 mg per milliliter of chlorhexidine mouthrinse twice daily until mucosal healing was completed. An alternative treatment option can be conservative and based on systemic antibiotic therapy and antimicrobial rinses until the sequestration of the avascular bone occurs and the sequestrum spontaneously exfoliates, but patient discomfort can last longer with this procedure. Two weeks after the surgical approach, the lesion was healed, and the patient reported no discomfort (Fig 5). Two months after the onset of the lesion, the maxillofacial surgeon gave his consent for the orthodontic treatment to begin. DISCUSSION
Exposure of necrotic bone is a rare complication after a dental impression and can cause pain and discomfort for the patient. It can be healed surgically (once the necrotic bone is removed and bleeding is promoted) or spontaneously after the formation and exfoliation of a bony sequestration, defined as a fragment of nonvital bone separated from adjacent bone as a result of focal bone necrosis and subsequent isolation and resorption of the site margins.11 Sequestration is usually associated with disruption of the blood supply to the bone as a response to various local or systemic factors. We correlated the onset of the necrotic condition with trauma that occurred during the taking of the dental impression, which, in turn, caused a reduced blood supply and an ischemic lesion of the area, as reported in the literature.5,6 The blood supply to the area is guaranteed by the inferior alveolar artery, which descends along the medial surface of the mandibular ramus and, before
entering the mandibular canal, gives origin to the mylohyoid artery, involved in the blood supply to the same muscle. Inside the mandibular canal, the inferior alveolar artery gives origin to small ramifications that contribute to the vascularization of the dental pulp, the periodontal ligaments, the dentoalveolar periosteum, the gingiva, and the mandibular bone.12,13 Specifically, at palpation, the patient exhibited a prominent mylohyoid crest that might have been a predisposing factor for an ischemic lesion (due to excessive pressure) in an area covered by a thin layer of keratinized mucosa.2-4,6 The literature has also reported tori and exostoses as areas susceptible to osteonecrosis because of the prominence of the bone covered by a thin layer of stretched and atrophic mucosa.2-4,6 With the same degree of trauma as occurring elsewhere in the mouth, these areas would be more predisposed to disruption of the blood supply, therefore leaving the bone exposed. The literature also defines patients in treatment with bisphosphonates or who undergo antiresorptive and antiangiogenic therapies as more susceptible to the onset of osteonecrosis,1 but the clinical history of our patient was negative for these medications. He followed a daily regimen of pantoprazol (after gastric bypass surgery in 2013) and hydrochlorothiazide (for the control of high blood pressure); he also suffered from asthma but took no medication for that. He was a nonsmoker and had not undergone any dental extractions before the impression was taken. A detailed search in PubMed was performed for reports of possible correlations between osteonecrosis and the daily use of these medications or gastric bypass surgery. To the best of our knowledge, no orthodontic journals have previously reported this complication,
American Journal of Orthodontics and Dentofacial Orthopedics
March 2018 Vol 153 Issue 3
Cerruto, Ugolini, and Cozzani
448
nor did the literature support any correlation between osteonecrosis of the bone and the intake of pantoprazol or hydrochlorothiazide, nor were correlations found between osteonecrosis and asthma, high blood pressure, and gastric bypass surgery. We therefore attributed the origin of this condition to a traumatic injury.
2.
3.
4.
CONCLUSIONS
The taking of conventional dental impressions rarely causes osteonecrosis in patients with predisposed anatomic sites; however, this case demonstrates that orthodontists and orthodontic assistants who take dental impressions (in the countries where they are permitted) should pay close attention to the anatomic conformation of the patient's basal bones, mainly in the mandible. If an anatomic variation is found, the tray should be modified accordingly, and the impression procedure should be gentle and careful. Alternatively, a plastic moldable tray or the recently introduced 3-dimensional intraoral scanners may be substituted for the metallic tray, thereby overcoming this complication effectively. With these clinical steps in mind, clinicians can minimize the risk of this rare and unexpected complication.
5. 6. 7.
8.
9.
10. 11.
REFERENCES
12.
1. 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 osteonecro-
March 2018 Vol 153 Issue 3
13.
sis of the jaw—2014 update. J Oral Maxillofac Surg 2014;72: 1938-56. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004;62:527-34. Estilo CL, Van Poznak CH, Williams T, Bohle GC, Lwin PT, Zhou Q, et al. Osteonecrosis of the maxilla and mandible in patients with advanced cancer treated with bisphosphonate therapy. Oncologist 2008;13:911-20. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonateinduced exposed bone (osteonecrosisyosteopetrosis) of the jaws: risk factors, recognition, prevention and treatment. J Oral Maxillofac Surg 2005;63:1567-75. De Visscher JG, Dietvorst DP, Van der Meij EH. Lingual mandibular osteonecrosis. Ned Tijdschr Tandheelkd 2013;120:189-93. Farah CS, Savage NW. Oral ulceration with bone sequestration. Aust Dent J 2003;48:61-4. Kharazmi M, Bj€ ornstad L, Hallberg P, Wanbro J, Carlsson AP, Habib S, et al. Mandibular bone exposure and osteonecrosis as a complication of general anesthesia. Ups J Med Sci 2015;120: 215-6. Lang NP, Tonetti MS. Periodontal diagnosis in treated parodontitis. Why, when and how to use clinical parameters. J Clin Periodontol 1996;23:240-50. Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, et al. Diagnosis and management of the osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015;30:3-23. Leaper DJ, Harding KG. Wounds, biology and management. Oxford, United Kingdom: Oxford University Press; 1998. Dorland W. Dorland’s illustrated medical dictionary. 29th ed. London, United Kingdom: W. B. Saunders; 2000. Fonzi L. Functional and clinical anatomy of the splanchnocranium. Milan, Italy: Edi-Ermes; 2000. (available only in Italian). Standring S. Gray's anatomy: the anatomical basis of clinical practice. 41st ed. London, United Kingdom: Elsevier; 2015.
American Journal of Orthodontics and Dentofacial Orthopedics