Bisphosphonate-Related Osteonecrosis of the Jaw

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) adversely affects the quality of life and produces significant morbidity in afflicted patients. Oral and maxillofacial surgeons have been responsible for counseling, managing, and treating a majority of these patients. The strategies set forth in this position paper were developed by a Task Force appointed by the American Association of Oral and Maxillofacial Surgeons (AAOMS). The Task Force was composed of clinicians with extensive experience in caring for these patients, clinical epidemiologists, and basic science researchers offering a broad range of experience and background. The strategies are based on an analysis of the existing literature and the clinical observations of the expert Task Force members. AAOMS considers it vitally important that this information be disseminated to other dental and medical specialties. It is understood that the strategies and treatment algorithms outlined in this article are starting points based on our current understanding of BRONJ. As the knowledge base and experience in addressing BRONJ evolves, future modifications and refinements of the current strategies will necessarily be required.

Purpose

The purpose of this position paper is to provide:

• Perspectives on the risk of developing BRONJ and the risks and benefits of bisphosphonates in order to facilitate medical decision-making of both the treating physician and the patient;
• Guidance to clinicians regarding the differential diagnosis of BRONJ in patients with a history of treatment with intravenous (IV) or oral bisphosphonates; and
• Guidance to clinicians on possible BRONJ prevention measures and management of patients with BRONJ based on the presenting stage of the disease.

Neuromuscular Orthotic Treatment Plan

Cheek and tongue biting

Patient: RHONDA H

Chief complaint:

-Rhonda complains of biting the inside of her cheek on the left side and this annoys her. Cannot bite into an apple.

-Her husband says she has a somewhat “grumpy” appearance, lower lip in front of upper lip and biting upper lip

 

History of chief complaint:

-Sore mouth for approx 4 years, sometimes biting tongue as well

-Rhonda has sought 3 other opinions. Dr Calavassy was the first to come up with a definitive treatment plan

 

Rhonda would like to get rid of cheek and tongue biting and if we could eliminate “grumpy” look (partly due to lower jaw protrusion) it would be good

 

Medical History:

-Numerous joint replacement surgeries…both hips, both knees, both shoulders

-NO TMJ clicking, crepitus or pain

-Uses a walking stick

 

Extraoral examination:

-Class 111 skeletal with mandibular protrusion

-Mild deviation of mandible to right when viewed from the front

-Excessive submental fat

 

Intraoral examination:

-Class 111 malocclusion

-Numerous restorations (generally sound), 17 may need some attention

-Overcontoured restorations on distal of 34 and 45 (intentional)

-Generalised slacing lower arch

-Very slight forward functional shift of mandible CR to CO

-Negative overjet 1 mm in CR

-Signs of some wear/bruxing

 

Periodontal examination:

-Probing levels normal

-Marginal gingivitis 32, 44

-1-2 mm recession 34 44

 

Radiographic examination:

-Lateral Ceph: Mandibular prognathism

-OPG/bite wings/periapicals: Generally good

Intrusion v Crown Lengthening of Upper Anteriors

Janis McAloon
March 2005

Any time you do a crown you are getting rid of enamel so it is always going to be on dentine. I think this is an important issue and would like to tell you all a little story.

Imagine you had a central incisor crown that started life at 8mm x10mm but wore down to 8mm x 8mm then overerupted to compensate. So far it has escaped the dentist’s drill so it’s a nice tooth with an intact pulp. The patient still had a gummy smile and the (effective) incisal edge position was still about 1mm too long.

The roots were nice and long so you crown lengthened 3mm and decided to make a 10mm crown or veneer (8-1+3) so everything would like just perfect.

Either way you want a translucent incisal edge so you remove 3mm of tooth structure (1 to change the incisal edge + 2 for porcelain). That’s still a bit conservative from a porcelain point of view but you realise you are 5mm (2+1+2) from the original (unworn) incisal edge and you expect the pulp could be getting close.

The tooth structure you just removed? You did that keeping your bur parallel to the incisal table. It was 3mm wide (labio-palatally) when you started, its now 5mm wide. You would prefer not to have a really thick incisal edge. If it’s a crown you are doing, you decide to take quite a bit off the palatal to reduce this width (you have to anyway because your prep goes 3mm up the root). The palatal is looking a bit pink so you stop there.

Interproximally you give yourself a very fine margin because you know the pulp horns are close and you don’t want to deepen your margin as you go higher up because of this. Gerard Chiche has this in his book.

Thank goodness the technician is going to be overcontouring because you won’t be able to give her room for a nice porcelain shoulder and you certainly won’t want opacious porcelain on display (let alone a gold margin). So you keep a a shallow chamfer all around the tooth.

After you finish you look at your nice smooth preparation – you think to yourself how much smaller the preparation is than you usually do. You are glad you left a lot on the cingulum otherwise you wouldn’t have had any where near enough resistance form. Maybe a veneer would have been better. But maybe not…

If it’s a veneer you are doing, you have no choice but to accept the very thick incisal edge. You start reducing interproximally. You are doing the adjacent teeth and as you try to take your margins interproximally you notice the adjacent teeth are getting further and further apart.

You have to “slice” through the proximal because you want porcelain right up at the gingival margin on both sides. You seem to be running out of tooth structure and your margin is going more and more towards the palatal. There is no chamfer. The preparation almost looks like a crown preparation when viewed from the front, with knife-edged slices at the sides.

There is no enamel on the interproximal surfaces or up on the labial root surface (of course). Height wise, you have 5mm of enamel (8-1-2) to hold your 10mm veneer. That’s just in the centre of course. So its not just porcelain hanging off the edge, it’s hanging off the sides as well.

Thank goodness the tooth didn’t have any restorations, and thank goodness the patient isn’t a bruxer (you ignore the fact that it was tooth grinding that got you here in the first place). Nevertheless, you are worried, so you probably sit the patient up and suggest you convert to a crown preparation.

Sometimes when I am thinking of doing a procedure I go through and try to visualise it in as much detail as I can. That way I can make mistakes in my head without doing permanent damage to someone’s tooth. I hope you will all think just a bit more about this and whether it really is worth doing some intrusion first before cutting back a worn tooth.

Anterior Aesthetic Dilemmas

Introduction

• Age: 45 years old
• PMH: Arthritis (Celebrex)
• Chief Complaints:
  • 1. Unhappy with colour of upper front tooth.
  • 2. Would like something done about lower front teeth.
  • download full case

PDH:

• Tooth 21 underwent RCT 18mths ago after an accident.
• Missing tooth 31, lower anterior bridge made >20 years ago, most unhappy with the discolouration and display of metal.