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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">A case of mandible osteonecrosis after a severe periimplant infection</title><author><name sortKey="Grecchi, Francesco" sort="Grecchi, Francesco" uniqKey="Grecchi F" first="Francesco" last="Grecchi">Francesco Grecchi</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Zollino, Ilaria" sort="Zollino, Ilaria" uniqKey="Zollino I" first="Ilaria" last="Zollino">Ilaria Zollino</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author><author><name sortKey="Candotto, Valentina" sort="Candotto, Valentina" uniqKey="Candotto V" first="Valentina" last="Candotto">Valentina Candotto</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author><author><name sortKey="Gallo, Francesco" sort="Gallo, Francesco" uniqKey="Gallo F" first="Francesco" last="Gallo">Francesco Gallo</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Rubino, Giuseppe" sort="Rubino, Giuseppe" uniqKey="Rubino G" first="Giuseppe" last="Rubino">Giuseppe Rubino</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Giglio, Sara" sort="Giglio, Sara" uniqKey="Giglio S" first="Sara" last="Giglio">Sara Giglio</name><affiliation><nlm:aff id="aff3">Dental Clinic University of Milan, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Bianco, Raffaella" sort="Bianco, Raffaella" uniqKey="Bianco R" first="Raffaella" last="Bianco">Raffaella Bianco</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Carinci, Francesco" sort="Carinci, Francesco" uniqKey="Carinci F" first="Francesco" last="Carinci">Francesco Carinci</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23814591</idno><idno type="pmc">3692181</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692181</idno><idno type="RBID">PMC:3692181</idno><idno type="doi">10.4103/1735-3327.109768</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">001C53</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001C53</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">A case of mandible osteonecrosis after a severe periimplant infection</title><author><name sortKey="Grecchi, Francesco" sort="Grecchi, Francesco" uniqKey="Grecchi F" first="Francesco" last="Grecchi">Francesco Grecchi</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Zollino, Ilaria" sort="Zollino, Ilaria" uniqKey="Zollino I" first="Ilaria" last="Zollino">Ilaria Zollino</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author><author><name sortKey="Candotto, Valentina" sort="Candotto, Valentina" uniqKey="Candotto V" first="Valentina" last="Candotto">Valentina Candotto</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author><author><name sortKey="Gallo, Francesco" sort="Gallo, Francesco" uniqKey="Gallo F" first="Francesco" last="Gallo">Francesco Gallo</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Rubino, Giuseppe" sort="Rubino, Giuseppe" uniqKey="Rubino G" first="Giuseppe" last="Rubino">Giuseppe Rubino</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Giglio, Sara" sort="Giglio, Sara" uniqKey="Giglio S" first="Sara" last="Giglio">Sara Giglio</name><affiliation><nlm:aff id="aff3">Dental Clinic University of Milan, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Bianco, Raffaella" sort="Bianco, Raffaella" uniqKey="Bianco R" first="Raffaella" last="Bianco">Raffaella Bianco</name><affiliation><nlm:aff id="aff1">Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</nlm:aff></affiliation></author><author><name sortKey="Carinci, Francesco" sort="Carinci, Francesco" uniqKey="Carinci F" first="Francesco" last="Carinci">Francesco Carinci</name><affiliation><nlm:aff id="aff2">Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</nlm:aff></affiliation></author></analytic><series><title level="j">Dental Research Journal</title><idno type="ISSN">1735-3327</idno><idno type="eISSN">2008-0255</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>The term osteonecrosis has been applied to describe the presence of a persistent inflammation of the mouth, osteomyelitis, delayed healing of extraction sockets, development of sequestra or presence of fistulae from the mouth to the lower skin. Here, we document a case of mandible osteonecrosis that developed in a patient after a severe periimplant infection. Osteonecrosis, severe inflammatory osteolysis, and heavy bacterial colonization were found. Surgical toilette and hyperbaric oxygen therapy permitted complete healing of the case. No complication was recorded in the post-operative period and no further surgery was performed. The clinical follow up and the imaging after one year showed a complete ‘<italic>restitution ad integrum</italic>’ of the mandible. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="iso-abbrev">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="publisher-id">DRJ</journal-id><journal-title-group><journal-title>Dental Research Journal</journal-title></journal-title-group><issn pub-type="ppub">1735-3327</issn><issn pub-type="epub">2008-0255</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23814591</article-id><article-id pub-id-type="pmc">3692181</article-id><article-id pub-id-type="publisher-id">DRJ-9-233</article-id><article-id pub-id-type="doi">10.4103/1735-3327.109768</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>A case of mandible osteonecrosis after a severe periimplant infection</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Grecchi</surname><given-names>Francesco</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Zollino</surname><given-names>Ilaria</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Candotto</surname><given-names>Valentina</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Gallo</surname><given-names>Francesco</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Rubino</surname><given-names>Giuseppe</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Giglio</surname><given-names>Sara</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Bianco</surname><given-names>Raffaella</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Carinci</surname><given-names>Francesco</given-names></name><xref ref-type="aff" rid="aff2">2</xref><xref ref-type="corresp" rid="cor1"></xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy</aff><aff id="aff2"><label>2</label>Department of Medical-Surgical Sciences of Communication and Behavior, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Ferrara, Italy</aff><aff id="aff3"><label>3</label>Dental Clinic University of Milan, Milan, Italy</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Prof. Francesco Carinci, Department of D.M.C.C.C., Section of Maxillofacial and Plastic Surgery, University of Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy. <bold>E-mail:</bold><email xlink:href="crc@unife.it">crc@unife.it</email></corresp></author-notes><pub-date pub-type="ppub"><month>12</month><year>2012</year></pub-date><volume>9</volume><issue>Suppl 2</issue><fpage>S233</fpage><lpage>S236</lpage><history><date date-type="received"><month>6</month><year>2012</year></date><date date-type="accepted"><month>11</month><year>2012</year></date></history><permissions><copyright-statement>Copyright: © Dental Research Journal</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>The term osteonecrosis has been applied to describe the presence of a persistent inflammation of the mouth, osteomyelitis, delayed healing of extraction sockets, development of sequestra or presence of fistulae from the mouth to the lower skin. Here, we document a case of mandible osteonecrosis that developed in a patient after a severe periimplant infection. Osteonecrosis, severe inflammatory osteolysis, and heavy bacterial colonization were found. Surgical toilette and hyperbaric oxygen therapy permitted complete healing of the case. No complication was recorded in the post-operative period and no further surgery was performed. The clinical follow up and the imaging after one year showed a complete ‘<italic>restitution ad integrum</italic>’ of the mandible. Although the risk of developing osteonecrosis of the jaw for oral implants is low, the devastating complications still require caution.</p></abstract><kwd-group><kwd>Hyperbaric oxygen therapy</kwd><kwd>jaw osteonecrosis</kwd><kwd>periimplant infection</kwd><kwd>surgical toilette</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>INTRODUCTION</title><p>Osteonecrosis is still not completely understood at present. Probably the disease should be considered a consequence of a metabolic decrease and a tissue homeostatic disturbance.[<xref ref-type="bibr" rid="ref1">1</xref>] From the pathological point of view, the term “necrosis” refers to a retrograde change, meaning the death of a tissue. It is induced because of injury factors, which (either directly or indirectly) inhibit blood supply to the tissues.[<xref ref-type="bibr" rid="ref2">2</xref>] Necrosis can affect different tissues and when it affects osseous tissues, it is called ‘osteonecrosis’. Osteonecrosis frequently affects bones in the stomatognatic system, mainly the lower or the upper jaw (ONJ).[<xref ref-type="bibr" rid="ref3">3</xref>] It usually comprises of three stages:[<xref ref-type="bibr" rid="ref4">4</xref>]</p><p><list list-type="order"><list-item><p>Oral mucosa defect with bone exposure; in this case the lesion does not give any symptom and no infection is observed,</p></list-item><list-item><p>The lesion is painful with clinical features of infection, and</p></list-item><list-item><p>The lesion is similar to that of stage 2 but, additionally pathological bone fraction or fistula or extensive osteolysis occurs.</p></list-item></list></p><p>Many causes can be associated with this kind of disease but the most important are:</p><p><list list-type="order"><list-item><p>Radiation of the head and neck</p></list-item><list-item><p>Osteomyelitis</p></list-item><list-item><p>Bisphosfonates</p></list-item></list></p><p>However, other risk factors must be considered: Smoking and dental disease such as periodontitis, caries, poor oral hygiene and poorly fixed dentures. Infection is a constant component of ONJ (<italic>Actinomyces</italic> is typically identified). Periodontitis and above all, peri-implantitis are also observed in most patients with ONJ,[<xref ref-type="bibr" rid="ref5">5</xref><xref ref-type="bibr" rid="ref6">6</xref><xref ref-type="bibr" rid="ref7">7</xref>] while ONJ-associated delayed wound healing, as mentioned in the definition of this medical condition, encourages bacterial penetration into bone. The histological studies all show pronounced inflammatory changes, represented by a mixed cellular infiltration (neutrophils, lymphocytes, plasma cells), infection with bacterial debris, congested venules and bacterial infiltrate within the deep trabeculae, scarce quantity of osteoblasts and vascularization, and fibrosis of marrow spaces.[<xref ref-type="bibr" rid="ref8">8</xref>]</p><p>There is no universally accepted treatment for osteonecrosis of the jaws. The management of ONJ remains controversial; both radical and conservative treatment have been reported.[<xref ref-type="bibr" rid="ref9">9</xref>] Radical surgery is indicated in cases where conservative approaches are not successful and in symptomatic and rapidly progressive lesions.[<xref ref-type="bibr" rid="ref10">10</xref>]</p><p>Here, we document a case of mandible osteonecrosis that developed in a patient after a severe periimplant infection. Osteonecrosis, severe inflammatory osteolysis, and heavy bacterial colonization were found. Its treatment and the pertinent literature are discussed.</p></sec><sec id="sec1-2"><title>CASE REPORT</title><p>A-54-year old man presented to Maxillofacial Surgery, Galeazzi Hospital, Milan, Italy, in September 2009 for evaluation. He complained of pain, and the presence of a lesion about the submental region was observed. The anamnesis showed that the patient had undergone placement of two oral implants into the mandible a few months ago. The following month, the two implants were infected and were explanted by a dentist. However, the patient developed osteonecrosis at the chin symphysis and the wound had never healed, persisting for more than two months.</p><p>In the first clinical examination, the presence of two cutaneous fistulae at the submental region was noted [<xref ref-type="fig" rid="F1">Figure 1</xref>]. The chin was extremely reddened and edematous, with areas of necrosis, especially in the medial part. In a computed tomography (CT) study, the chin symphysis presented a global osteolysis with a composed fracture along the sagittal plane [<xref ref-type="fig" rid="F2">Figure 2</xref>].</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>The reddened and edematous chin with two cutaneous fistulae</p></caption><graphic xlink:href="DRJ-9-233-g001"></graphic></fig><fig id="F2" position="float"><label>Figure 2</label><caption><p>Pre-surgical 3D computed tomography reconstruction</p></caption><graphic xlink:href="DRJ-9-233-g002"></graphic></fig><p>It was decided to submit the patient to a surgical toilette, in order to remove all necrotic areas. So, sequestra were removed, a primary closure was sutured, and proper antibiotic therapy was administered. The wound was finally under control. The hyperbaric oxygen therapy further permitted complete healing of the case.</p><p>No complication was recorded in the post-operative period and no further surgery was performed. The clinical follow up and the imaging [<xref ref-type="fig" rid="F3">Figure 3</xref>] after one year showed a complete ‘<italic>restitution ad integrum</italic>’ of the mandible.</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Post-surgical 3D computed tomography reconstruction</p></caption><graphic xlink:href="DRJ-9-233-g003"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title><p>The term osteonecrosis has been applied to describe the presence of a persistent inflammation of the mouth, osteomyelitis, delayed healing of extraction sockets, development of sequestra or presence of fistulae from the mouth to the lower skin. Several authors during the years focused on the importance of different characteristics of dental implants and their influence on survival of the same.[<xref ref-type="bibr" rid="ref11">11</xref><xref ref-type="bibr" rid="ref12">12</xref><xref ref-type="bibr" rid="ref13">13</xref><xref ref-type="bibr" rid="ref14">14</xref><xref ref-type="bibr" rid="ref15">15</xref><xref ref-type="bibr" rid="ref16">16</xref><xref ref-type="bibr" rid="ref17">17</xref>]</p><p>The initial approach to manage this disease should be conservative: Oral hygiene is essential, including use of 0.02% aqueous clorexidine mouthwash after meals;[<xref ref-type="bibr" rid="ref18">18</xref>] analgesics and anti-inflammatory drugs should be prescribed when judged necessary. Galler, <italic>et al</italic>.[<xref ref-type="bibr" rid="ref19">19</xref>] proposed even hyperbaric oxygen in the management of this disease.</p><p>The therapeutic value of hyperbaric oxygen (HBO) was originally observed in controlled <italic>in vivo</italic> experiments on burns, in which daily increases in the oxygen tension in hypoxic tissues were found to encourage capillary angiogenesis, proliferation of fibroblasts, and synthesis of collagen.[<xref ref-type="bibr" rid="ref20">20</xref>] Furthermore, HBO can also be bactericidal or bacteriostatic to many pathogens.[<xref ref-type="bibr" rid="ref21">21</xref>] Mainous, <italic>et al</italic>.[<xref ref-type="bibr" rid="ref22">22</xref>] was probably the first to suggest the use of HBO for the management of osteonecrosis of the jaw. However, the widespread use of HBO for the treatment of mandible osteonecrosis may be considered largely theoretical or anecdotal because of the paucity of controlled trials and the lack of any unified assessment of the improvement of symptoms.[<xref ref-type="bibr" rid="ref23">23</xref>]</p><p>The greatest advances in the surgical management of ONJ have been made in reconstructive surgery through the replacement of the necrotic bone with bone grafts and creation of a regional vascularized flap or insertion of free grafts capable of restoring mandible continuity with adequate bone volume and quality, sufficient crest height and integrity of the soft tissues.[<xref ref-type="bibr" rid="ref23">23</xref>]</p></sec><sec sec-type="conclusion" id="sec1-4"><title>CONCLUSION</title><p>Although the treatment of ONJ is complex, widely accepted criteria should be established to reduce the devastating complications of osteonecrosis and improve the quality of life of these patients.[<xref ref-type="bibr" rid="ref24">24</xref>]</p><p>Here, a case of mandible osteonecrosis after insertion of dental implants is reported. Although the risk of developing osteonecrosis of the jaw for oral implants is low, the devastating complications still require caution.</p></sec></body><back><ack><title>ACKNOWLEDGEMENTS</title><p>This work was supported by the University of Ferrara (F.C.), Ferrara, Italy and by PRIN 2008 (20089MANHH_004).</p></ack><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> This work was supported by the University of Ferrara (F.C.), Ferrara, Italy and by PRIN 2008 (20089MANHH_004)</p></fn><fn fn-type="conflict"><p><bold>Conflict of Interest:</bold> None declared</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Berger</surname><given-names>RP</given-names></name><name><surname>Symington</surname><given-names>JM</given-names></name></person-group><article-title>Long-term clinical manifestation of osteoradionecrosis of the mandible: Report 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