Faculty Bibliography

The onset of the Coronavirus 2019 (COVID-19) pandemic has challenged the worldwide healthcare sector, including dentistry. The highly infectious nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and risk of transmission through aerosol generating procedures has profoundly impacted the delivery of dental care services globally. As dental practices with renewed infection control strategies and preventive measures are re-opening in the "new normal" period, it is the responsibility of healthcare professionals to constantly analyze new data and limit the spread of COVID-19 in dental care settings. In the light of new variants of SARS-CoV-2 rapidly emerging in different geographic locations, there is an urgent need to comply more than ever with the rigorous public health measures to mitigate COVID-19 transmission. The aim of this article is to provide dental clinicians with essential information regarding the spread of SARS-CoV-2 virus and protective measures against COVID-19 transmission in dental facilities. We complied and provided guidance and standard protocols recommended by credible national and international organizations. This review will serve as an aid to navigating through this unprecedented time with ease. Here we reviewed the available literature recommended for the best current practices that must be taken for a dental office to function safely and successfully.

This report describes a case of needle breakage during a left-sided inferior alveolar nerve block to perform restorative dentistry on a 56-year-old male patient. The needle was removed in conjunction with interventional neuroradiology using biplanar fluoroscopy.

While bisphosphonates are the cornerstone for management of multiple myeloma, they are associated with medication-related osteonecrosis of the jaw (MRONJ). There are many controversies in the management of MRONJ in this patient population. In this article, we describe a representative case and, along with a literature review, we report the outcomes of our 3 cases with multiple myeloma who underwent mandible reconstruction with vascularized fibula bone grafts after segmental mandible resection for Stage 3 MRONJ over a 3-year period. All patients were male with a mean age of 59 years. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. All patients had pathologic mandible fractures associated with intraoral fistulae and exposed bone. Nonsurgical management was attempted in all patients. One patient also underwent debridement of the mandible without resolution of the disease. Mandible reconstruction with an osteocutaneous free fibula flap after segmental mandible resection was performed in all 3 cases without major complications or donor site morbidity. Different bacteria were isolated from the intraoperative tissue cultures in all cases. Computed tomographic imaging revealed bony union without hardware complications in all cases. Mean follow-up was 28 months. In conclusion, we demonstrated that patients with multiple myeloma and advanced MRONJ lesions of the mandible can be managed successfully and safely by segmental resection and reconstruction with vascularized fibula bone graft.

The definition of medication-related osteonecrosis of the jaw (MRONJ) includes a stage 0 presentation where exposed bone, the hallmark of this condition, is absent. Numerous management strategies have been recommended for MRONJ including hyperbaric oxygen (HBO2) therapy. This report describes a 64-year-old woman with stage 0 MRONJ of the bilateral mandible, refractory to clindamycin and local debridement, who was subsequently managed successfully with amoxicillin/clavulanate and HBO2 therapy. The authors also explore the current literature on the pathophysiology of MRONJ and the potential role of hyperbaric oxygen in its treatment.

OBJECTIVE:is associated with one or more particular comorbidities. STUDY DESIGN/METHODS:or DH lesion to a control patient who had a history of dentoalveolar surgery with uneventful healing and no history of antiresorptive therapy. Comorbidity data included medical conditions and smoking. RESULTS:and DH than in controls [M(SD) = 1.94 (1.2) and 2.0 (1.3) vs 1.26 (0.89); both P < .001]. CONCLUSIONS:and DH.

Background: Surgical management of medicationrelated osteonecrosis of the jaw (MRONJ) includes eliminating infected and necrotic tissue, establishing a wellvascularized wound bed, and soft tissue closure. Success is improved by multilayered primary closure1-3 with local flaps. In 1989 Bozola4 first described the buccinator flap based on the buccal artery to close oral mucosal defects, then modified in 1991 by Carstens5 who introduced the buccinator musculomucosal island pedicle flap based on the facial artery. Zhao in 19996 found that the buccinator flap can also be based on the posterior, inferior and anterior buccal branches of the facial artery and terminal branches of the posterosuperior alveolar artery. The authors modified previously described techniques by releasing the inferior border of the buccinator where it attaches to the lateral aspect of the alveolar process of the mandible, rather than using an island flap. The objective of this study was to determine the outcome for patients undergoing treatment of MRONJ using a modified buccinator flap. Methods: A retrospective cohort study of patients who underwent surgical management of mandibular MRONJ using a modified buccinator flap technique was conducted. Mandibular access is achieved via crestal incision and lateral mucoperiosteal flap. The buccinator is approached through subperiosteal dissection along the lateral border of the mandible and incision though the periosteum. The buccinator muscle is bluntly dissected from the underlying buccopharyngeal fascia, advanced over the mandibular defect and secured to the lingual cortex via trans-osseous suture. The mucoperiosteal flap lateral to the mandible is then advanced medially over the buccinator muscle, completing a 3-layered flap. The outcome variable was postoperative healing defined by mucosal closure without signs of infection or exposed bone. Descriptive statistics were used to assess successful management, antiresorptive therapy type, imaging used, and other surgical modalities. Results: Five patients met inclusion criteria. All were female, with an average age of 70.4 years. Four were previously treated with oral antiresorptive therapy for osteoporosis, and one was treated with denosumab for metastatic breast cancer. All underwent marginal resections of their lesions, with concomitant placement of platelet-rich plasma autograft in three patients. Primary closure was achieved using the described technique. Average follow-up duration was 6.7 months. All patients displayed successful outcomes without wound dehiscence, infection, or exposed bone. Conclusions: This pilot study demonstrates a novel approach for utilizing the buccinator muscle for surgical treatment of MRONJ. The modified buccinator flap is a convenient technique for soft tissue closure of the posterior mandible with minimal risk to the facial nerve and vascular supply. The authors will continue to examine the validity and reliability of this technique

Background: The treatment for medication-related osteonecrosis of the jaw (MRONJ) is controversial. Segmental resection of the mandible is recommended for extensive involvement of basal bone and orocutaneous fistula.1 When preservation of the inferior alveolar nerve (IAN) is not possible, functional problems may occur with concomitant resection of the inferior alveolar nerve.3 While allogeneic nerve grafting has been reported for the management of benign and malignant tumors and iatrogenic injury associated with third molar extraction, dental implant surgery, and bilateral sagittal split osteotomy,5 there is no data for patients with MRONJ. The objective of this study was to determine the neurosensory outcome for patients undergoing reconstructive nerve grafting during treatment for MRONJ. Methods: We conducted a retrospective cohort study of patients withMRONJ who underwent segmental resection followed by immediate reconstruction of the inferior alveolar nerve using an interpositional Avance allogeneic nerve graft. The primary outcome variable was objective and subjective neurosensory function. The neurosensory exam was conducted according to Zuniga et al that included brush stroke, contact detection and pain sensitivity.6 Subjective neurosensory function was determined by the patient's perception of overall return of sensation compared to the contralateral side and recorded as a percentage. Secondary variables include medical history and rationale for reconstruction (i.e., nerve transection, nerve attenuation, mandible fracture). Descriptive statistics were analyzed for all variables. Results: Three patients met inclusion criteria who were diagnosed with MRONJ and had underwent nerve grafting during mandibular resection. One patient was being treated with Xgeva (denosumab) for metastatic breast cancer and two were being treated with Zometa (zoledronic acid) for osteoporosis. Prior to surgical intervention, all patients experienced mandibular nerve paresthesia; one patient sustained a mandible fracture prior to treatment, but paresthesia was present prior to fracture. Average follow-up duration was 15.3 months. Post-operatively, two patients displayed 100% on objective neurosensory exam and 70% on subjective neurosensory function. The patient who presented with a mandible fracture prior to surgery had 0% on subjective neurosensory function and variable objective testing. In all three cases, preservation of the IAN was considered by transposition but not possible due to nerve attenuation (2 patients) and/or transection associated with mandible fracture (1patient). Conclusions: The use of allogenic nerve grafting materials has been well documented as an effective method of restoring nerve function in a variety of surgical contexts. This pilot study demonstrates successful subjective and objective outcomes following resection of patients with MRONJ. One factor that has been shown to hinder successful nerve reconstruction is previous mandible fracture. Previous studies have shown that fracture displacement of 5+mm and operator inexperience greatly contributed to worsening neurosensory scores.2,4 The authors will continue to examine the validity and reliability of this technique

The fibula microvascular free flap is widely used for mandible reconstruction including patients with medication- related osteonecrosis of the jaw(MRONJ) who are refractory to conservative management.1 In comparison with other free flaps used in mandible reconstruction, the fibula provides the greatest bone length and provides soft tissue replacement. While the fibula has little effect on bearing weight, it is an essential insertion for the biceps femoris muscle, one of the hamstrings, which assists in flexion of the knee as well as rotation of the leg. In addition, it is an attachment of the fibular collateral ligament, a structural component of the knee joint.2 There is a paucity of literature related to the feasibility of mandible reconstruction utilizing a microvascular free fibula flap in a patient with previous knee replacement surgery. Our patient is a 60-year-old female diagnosed with medication-related osteonecrosis of the jaw (MRONJ). She was refractory to multiple courses of antibiotic therapy and oral rinses. Upon physical examination, intraorally she has draining fistula at the right body of the mandible. Computed tomography of the mandible was significant for osteolytic bone destruction from at the body of the right mandible and nearing the inferior border. Her concerning surgical history included bilateral knee replacements which was taken into consideration during surgical planning. Due to the size of the planned defect, reconstruction with a fibula microvascular free flap was planned using virtual surgical planning (Medical Modeling Inc., Golden CO) and a prefabricated reconstruction plate (Stryker, Kalamazoo, MI). The surgical procedure included a tracheostomy, segmental resection of the right body of the mandible, rigid fixation, extraction of all teeth and microvascular fibular free flap reconstruction. The patient continued physical therapy and occupational therapy and became full weight bearing 12-days postoperatively. The patient was back to her preoperative ambulatory status one month after surgery. An English language search of three databases (PubMed, Science Direct, OvidMD) was performed to determine if a microvascular free fibula flap had been attempted in a patient with a history of knee replacement. The dearth of literature related to this concern lead to an interdisciplinary meeting between the Oral and Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery services to review the feasibility and risks for the proposed reconstruction in our patient. It was determined that as long as 10 cm of superior bone was to remain in place, the stability of the patient's knee should not be compromised. We conclude that microvascular fibular graft reconstruction of the mandible remains an option for patients with bilateral knee replacement

Radiation therapy (RT) is and essential treatment for many oral cavity and oropharynx tumors. However, radiation may cause significant long-term morbidity for survivors. A serious jaw complication from radiation includes osteoradionecrosis (ORN) requiring mandibulectomy and reconstruction, which has significant medical, economic, and quality of life implications for affected patients. Reconstructing ORN defects is challenging due to late effects of radiotherapy on bone and soft tissue tissues resulting in severe fibrosis and possibly infected wound environments. Microvascular free flaps (MVFF) are commonly used for mandibular reconstruction in ORN. When MVFF reconstructions are contraindicated, regional pedicle flaps combined with rigid fixation and autologous bone grafts are commonly reported options that can provide satisfactory functional and aesthetic outcomes. In the present case report we describe an osteomyocutaneous rotational flap using a rib to reconstruct a continuity defect due to ORN. The patient is a 64-year-old female with a history of successful simple surgical treatment for ORN of the left body of the mandible that included hyperbaric oxygen (HBO) therapy who developed ORN and pathologic fracture of the right body of the mandible. Another long-term concern was the prognosis for the clinically healed left mandible. Treatment options were presented to the patient including a microvascular osteocutaneous fibula free flap. However, the patient's ambulation and recovery time was a major concern and she preferred an osteomyocutaneous pectoralis major rib graft. The risks and benefits of both options were discussed. Three months postoperatively she developed an extraoral soft tissue dehiscence with exposure of the plate without infection. Computed tomography seven months postoperatively demonstrated a bone union of the rib at both the proximal and distal resection margins. She subsequently underwent examination of the graft which was found to be healed. The reconstruction plate was removed and the cutaneous defect was repaired using a full thickness skin graft to the right mandible. Reports on vascularized osteocutaneous rib grafts to reconstruct the mandible for ORN have been brief.1 Reconstruction of the mandible using rib has been reported primarily as a free bone graft.2,3 Additional considerations for our patient with a history of ORN of the left mandible include: the 25% failure rate associated with simple surgical treatment (i.e., sequestrectomy),4 the controversial efficacy of perioperative HBO therapy 5,6 and the increased risk of ORN over time.7An osteomyocutaneous pectoralis major rib graft was able to restore continuity of the right mandible and maintain the option for a microvascular fibula graft in the event of recurrent ORN in either or both sides of the mandible. The limitations for this option are the size of the defect and inability to place dental implants. The conclusion from this case report is that a rotational osteomyocutaneous rib graft may be an option for some patients with ORN