A technique for the treatment of oral–antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy

doi:10.1016/j.oooo.2016.03.015

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Volume 122, Issue 3, September 2016, Pages 287-291

The original abstract was presented at the American Association of Oral and Maxillofacial Surgeons Conference, 2013, Orlando, FL, in the Scientific Poster session.

https://doi.org/10.1016/j.oooo.2016.03.015 Get rights and content

Objective

Bisphosphonates and monoclonal antibodies directed at osteoclastic function are frequently used to treat postmenopausal and corticosteroid-induced osteoporosis. They are also used in the treatment of certain metastatic malignancies. However, osteonecrosis of the jaw has been reported after intravenous, subcutaneous, or oral use of these agents. More than 12 million Americans and another 20 million worldwide are thought to be taking a bisphosphonate. Exposed bone with oral–antral fistulas has been known to occur increasingly as a specific presentation of what is now termed medication-related osteonecrosis of the jaws (MRONJ) with a specific International Classification of Diseases, 10th revision (ICD-10) code. Oral–antral communications caused by bisphosphonate concomitant with secondary sinusitis represent a unique treatment challenge for the oral and maxillofacial surgeon. The purpose of this article is to demonstrate a simple but effective technique to treat oral–antral communications caused by MRONJ.

Study Design

With the review and approval of the University of Miami Internal Review Board, we identified 23 patients who had undergone this surgical procedure.

Results

We report a 100% resolution of osteonecrosis of the jaw (ONJ) and sinusitis with repneumatization.

Conclusions

The buccal fat pad and radical sinustomy can be used as an effective and predictable technique for the resolution of oral–antral fistulas caused by MRONJ.

Section snippets

Patients and Methods

Between 2008 and 2014, 321 cases of bisphosphonate-related osteonecrosis of the jaw were identified and treated and the University of Miami/Jackson Memorial Hospital Division of Oral and Maxillofacial Surgery. The majority of the exposed bone areas were in the mandible (68%) compared with the maxilla (28%). The majority of the exposures in the maxilla were confined to the posterior maxilla.

Twenty-three patients (3 men, 20 women; Table I) who presented with stage III MRONJ and sinusitis chose to

Results

We report a 100% resolution rate related to MRONJ, sinusitis, and OAF (Fig 7A). However, 2 patients developed more bone exposure after retreatment with a bisphosphonate. In both cases, the bone exposure occurred in an adjacent area of the maxilla. In one other patient, OAF recurred because of a failed bone grafting attempt, but resolution of the ONJ was retained. All radiographic studies of the patients showed repneumatization of the treated maxillary sinus.

Discussion

It is estimated that 12 million Americans and another 20 million people worldwide are taking either a bisphosphonate or denosumab. Increasingly, osteonecrosis of the maxilla with sinusitis and OAF have been known to occur as a specific presentation of MRONJ. Oral–antral communications caused by these drugs, concomitant with secondary sinusitis, represents a unique treatment challenge for the oral and maxillofacial surgeon.

The buccal fat pad was originally described as an anatomic structure

Conclusions

The surgical protocol of debridement of necrotic bone, radical sinusotomy, and transposition of buccal fat pad can be used as an effective and predictable technique for the resolution of OAF caused by bisphosphonate-induced osteonecrosis (Fig 8). However, this protocol does not prevent the development of more exposed bone in the future as a result of continued therapy with these drugs.

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There are more references available in the full text version of this article.

Cited by (21)

Is maxillary sinusitis and radiographic maxillary sinus opacification associated with an altered microbiology of MRONJ?
2024, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Maxillary sinusitis can be a sequela of medication-related osteonecrosis of the jaw (MRONJ). This study aims to characterize the microbiome of maxillary MRONJ with concurrent maxillary sinusitis and radiographic maxillary sinus opacification to determine if there is a relationship between the microbiome of MRONJ and sinus disease.
This retrospective case series was conducted using electronic health records from the University of Pennsylvania and affiliated hospitals. The target population was surgically managed maxillary MRONJ patients. The primary predictor variables were tissue culture results. The primary outcomes were maxillary sinusitis or maxillary sinus opacification. Statistical analysis was performed using chi-squared tests at the 95% confidence interval.
Thirty-nine subjects were selected: 25 had sinus opacification and 11 had sinusitis. Resident bacteria were present in 90% of subjects, nonresident bacteria in 74%, and opportunistic organisms in 15%. There were significantly more subjects with chronic sinusitis microbes (79%) than without. There were significantly more gram-positive anaerobes, specifically Propionibacterium, as well as the gram-negative facultative anaerobe, Capnocytophaga, in subjects with concurrent sinusitis.
Maxillary MRONJ with concurrent maxillary sinusitis may be associated with gram-positive anaerobic species, Propionibacterium, and Capnocytophaga colonization. Maxillary MRONJ patients may benefit from sinus evaluation and concurrent surgical intervention.
Combined approach to treatment of advanced stages of medication-related osteonecrosis of the jaw patients
2022, Brazilian Journal of Otorhinolaryngology
Increased incidence of localized osteonecrosis in the jaw bones caused by bisphosphanate use and reduced quality of life of the patients led researchers to diagnose the disease in the early period and to investigate the effective treatment modality.
Treatment of medication-related osteonecrosis of the jaw patients is based on individual protocols from clinical experience, as there are no definitive treatment guidelines. In view of the lack of consensus on the effectiveness of medication-related osteonecrosis of the jaw treatments in the literature, the aim of this study was to evaluate the surgical technique described in the treatment of advanced stages of medication-related osteonecrosis of the jaw patients.
Twenty-one patients affected by Stage 2–3 medication-related osteonecrosis of the jaw were treated with ultrasonic piezoelectric bone surgery for necrotic bone removing, leukocyte and platelet-rich fibrin concentrate obtained from the patient’s peripheral blood and Nd:YAG laser for biostimulation. Success was assessed as the maintenance of full mucosal coverage without signs of residual infection at 1-month (T1), 3-months (T2), 6-months (T3) and 1-year (T4) after surgery. Logistic regressions were used to evaluate the association between the different independent variables and treatment outcomes.
Two Stage 3 patients had delayed healing at 1 month after the operation. Complete mucosal healing was achieved in all patients at the third month. Multivariate analysis demonstrated that different variables were not significantly correlated with delayed healing (p > 0.05).
The surgical protocol presented in this study shows promising results for surgical management of advanced stages of medication-related osteonecrosis of the jaw patients.
Treatment and outcome of maxillary sinusitis associated with maxillary medication-related osteonecrosis
2021, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
Citation Excerpt :
On the other hand, Voss et al. [9] and Aljohani et al. [19] reported the effectiveness of surgical procedures, consisting of necrotic bone removal followed by closure with a mucoperiosteal flap, for treatment of maxillary MRONJ with maxillary sinusitis. Furthermore, Aljohani et al. [19] and Melville et al. [20] used buccal fat pad flaps successfully for closure of MRONJ-related oroantral communications. In recent years, ESS has been increasingly as a surgical treatment for maxillary sinusitis.
Medication-related osteonecrosis of the jaw (MRONJ) of the maxilla often accompanies maxillary sinusitis. This study aimed to investigate the treatment and outcome of maxillary sinusitis associated with maxillary MRONJ.
This is a retrospective observational study. Among 68 patients with MRONJ of the maxilla undergoing surgical treatment at two university hospitals between 2012 and 2018, 31 patients with accompanying maxillary sinusitis were enrolled in the study. The relationship between treatment method and outcome of maxillary sinusitis was analysed by one-way ANOVA and Fisher’s exact test, as well as multivariate logistic regression analysis.
All patients underwent resection of the necrotic bone. As for treatment of maxillary sinusitis, 12 patients underwent antral lavage, 4 patients underwent endoscopic sinus surgery (ESS), and 15 patients received no maxillary sinus surgery. All 4 patients who underwent ESS achieved healing, and of the 12 patients who underwent antral lavage, 4 were healed, and 6 improved. However, out of the 15 patients who underwent removal of necrotic bone, but no maxillary sinus surgery, 8 showed no change or became worse. Patients who underwent antral lavage or ESS showed significantly better treatment outcomes than those who underwent necrotic bone resection alone upon both univariate and multivariate analyses.
Our results show that better treatment outcomes might be achieved by performing sinus lavage or ESS for MRONJ-related maxillary sinusitis.
Inferior-based Nasolabial Flap for the Surgical Treatment of Stage 3 Medication-Related Osteonecrosis of the Maxilla: A Technical Note
2020, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
Citation Excerpt :
Based on recent retrospective studies, patients with advanced MRONJ should undergo surgical treatment rather than nonsurgical treatment to achieve good long-term results [2,3]. Maxillary sinusitis and oroantral communications associated with stage 3 MRONJ in the maxilla is a severe complication [4,5]. Shortly after surgery used a poorly-vascularized mucoperiosteal flap for wound closure, relapse and disease progression of osteonecrosis were frequently observed in the follow-up period [6,7].
Stage 3 medication-related osteonecrosis of the jaw (MRONJ) requires surgical treatment for resolution of the pathology. In the maxilla, removal of the necrotic bone and infected soft tissue leads to large defects with oroantral communications. It is essential to cover the exposed bone and close the communications by using well-vascularized soft tissue for good long-term results without a relapse of the osteonecrosis. Here, we evaluated the technical usefulness of the inferior-based nasolabial flap (IBNF) for covering the exposed bone and closing the oroantral communications in maxillary stage 3 MRONJ after complete decortication and sinusotomy. No problems were noted in the treated areas in four patients at 12 months postoperatively. Despite the limited number of cases, the IBNF may be a reliable and simple method for the reconstruction of relatively large defects and the closure of oroantral communications in maxillary stage 3 MRONJ without complications.
Algorithm for the treatment of oral and peri-oral defects through local flaps
2018, Journal of Cranio-Maxillofacial Surgery
Local flaps are currently considered the main reconstructive option for medium-size oral and peri-oral defects; however, their indications are sometimes challenging to select. The aim of this study was to critically analyse their selection and to propose a therapeutic algorithm.
We performed a search on PubMed regarding the medium-size oral and peri-oral defects reconstruction, and we collected data on the aetiology, the location of the defect, the type of flap used and postoperative complications. The final proposed treatment algorithm was the product of this analysis.
We found 111 articles and 2504 flaps (236 buccinator flaps, 60 masseter flaps, 466 facial artery myomucosal flaps, 285 tongue flaps, 95 palatal flap, 525 buccal fat pad flaps and 835 local lip flaps). The most frequent defect localizations included floor of mouth (203 flaps), cheek (242 flaps), anterior hard palate (418 flaps) and upper and lower lip (274 and 559 flaps). Partial flap necrosis and dehiscence occurred in 3% of cases whereas total necrosis in 1%.
Local flaps are a good option for oral and perioral defect reconstruction. An appropriate choice of the flap to be used based on the location of the defect is essential for a correct reconstruction.
Prevalence, initiating factor, and treatment outcome of medication-related osteonecrosis of the jaw—a 4-year prospective study
2018, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Citation Excerpt :
Better healing with block resection than with sequestrectomy may be explained by the fact that all infected bone was removed. Even more radical surgical approaches with coverage of sinus communication after surgical removal of necrotic bone, along with the buccal fat pad,26 or, in the mandible, coverage with a myofascial flap27 might have resulted in the higher success rate when combined with block resection. However, in the present study none of the patients with unhealed lesions after surgery was interested in a second surgical intervention.
Medication-related osteonecrosis of the jaw (MRONJ) has a wide range of prevalence, and a standard therapy has not yet been established. The aim of this study was to analyze the prevalence and initiating factors of MRONJ and the outcomes of surgical therapy.
In a prospective cohort study, all patients diagnosed with MRONJ in the Region of Skåne, in Sweden, were included. Predictor variables (comorbidity, site, stage, gender) and initiating factors (tooth extraction, periodontitis) were recorded. Surgical treatment was sequestrectomy or block resection, and the outcome variable was healing after 2 months. To estimate the prevalence, data on the use of bisphosphonate and denosumab were used.
Fifty-five patients with MRONJ were identified. The prevalence of MRONJ was 0.043% among patients treated with oral bisphosphonates, 1.03% among those on intravenous bisphosphonates and 3.64% in those on high-dose denosumab. Periodontal disease preceded development of MRONJ in 41 patients. Fifty patients were treated surgically and followed up for at least 2 months. Remission or healing occurred in 80% of patients treated with sequestrectomy and in 92.5% of patients treated with block resection.
The prevalence of MRONJ in Sweden is low. Periodontitis is the most common initiating factor. The outcome of treatment of MRONJ is healing in most patients treated surgically.

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Oral and maxillofacial surgeryA technique for the treatment of oral–antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy

Objective

Study Design

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Conclusions

J Oral Maxillofac Surg

J Oral Maxillofac Surg

American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws

J Oral Maxillofac Surg

What is a “failure” of bisphosphonate therapy for osteoporosis?

Cleve Clin J Med

Defining the epidemiology of bisphosphonate-associated osteonecrosis of the jaw: prior work and current challenges

Osteoporos Int

Bone remodeling in maxilla, and femur of young dogs

Anat Rec

Periodontal disease and bisphosphonates induced osteonecrosis of the jaws in the rat

J Bone Miner Res

Oral and maxillofacial surgery
A technique for the treatment of oral–antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy