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Dr. Hadi Munib
Oral and Maxillofacial Surgery Resident
Outline
 Synonyms
 Causes
 Staging
 Management
 References
Synonyms
 ONJ
 BRONJ
 MRONJ
Causes
 Antiresorptive (including bisphosphonates (BPs) and receptor activator of
nuclear factor kappa-B ligand [RANK-L] inhibitors)
 Antiangiogenic.
 BPs can be divided into Aminobisphosphonates (NBPs) and non-NBPs.
 NBPs are the one involved in the ONJ
Causes
 IV BPs are utilized to treat cancer, hypercalcemia of malignancy,
skeletal-related events with bone metastases and lytic lesion related to
multiple myeloma
 Oral BPs are used to treat osteoporosis, osteopenia or Paget’s disease and
osteogenesis imperfecta.
Why the jaws
 Inflammation or infection
 Microtrauma
 Altered bone remodeling
 Over suppression of bone resorption
 Angiogenesis inhibition
 Soft tissue BPs toxicity
 Terminal vascularization of the mandible
 Suppression of immunity
 Vitamin D deficiency.
Risk Factors
 Therapeutic indications
 Type of medication (BP and non-BP).
 The risk in patients treated with Zolendronate is 50–100 times superior to
placebo
 BRONJ occurs after a mean administration of 33 months IV or 48 months
Oral.
 DRONJ occurs early after treatment, independently of the number of
previous administrations.
Risk Factors
 52–61% of patients reported tooth extraction as a precipitating event.
 Mandible (73%)
 Maxilla (22.5%)
 Both 4.5% of the cases.
Definition
 Ongoing or antecedent treatment with antiangiogenic or antiresorptive
drugs
 No patient history of radiation therapy or manifest metastasis to the jaw
 Exposed bone or presence of an intraoral or extra-oral fistula in the
maxillofacial region persisting for more than 8 weeks. [Controversial]
Definition
 “Severe adverse drug reaction, consisting of progressive bone destruction
in the maxillofacial region of patients exposed to the treatment with
nitrogen-containing BPs, in the absence of a previous radiation treatment.”.
Prevention
 Proper Dental Assessment before therapy
 Drug Holiday; A myth or reality?
Treatment
 At risk category; Education
 Stage 0; Local Factors management
 Stage 1; Rinsed with antiseptic fluids and covered with an adhesive paste,
3 times a day.
 Stage 2; 2 weeks of medical therapy, surgical debridement, Antibiotic and
antiphlogistic treatments are administered.
 Stage 3 Marginal or segmental osteotomies are recommended for severe
cases
References
Osteonecrosis of the Jaws (BRONJ, MRONJ)

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Osteonecrosis of the Jaws (BRONJ, MRONJ)

  • 1. Dr. Hadi Munib Oral and Maxillofacial Surgery Resident
  • 2. Outline  Synonyms  Causes  Staging  Management  References
  • 4. Causes  Antiresorptive (including bisphosphonates (BPs) and receptor activator of nuclear factor kappa-B ligand [RANK-L] inhibitors)  Antiangiogenic.  BPs can be divided into Aminobisphosphonates (NBPs) and non-NBPs.  NBPs are the one involved in the ONJ
  • 5. Causes  IV BPs are utilized to treat cancer, hypercalcemia of malignancy, skeletal-related events with bone metastases and lytic lesion related to multiple myeloma  Oral BPs are used to treat osteoporosis, osteopenia or Paget’s disease and osteogenesis imperfecta.
  • 6.
  • 7. Why the jaws  Inflammation or infection  Microtrauma  Altered bone remodeling  Over suppression of bone resorption  Angiogenesis inhibition  Soft tissue BPs toxicity  Terminal vascularization of the mandible  Suppression of immunity  Vitamin D deficiency.
  • 8. Risk Factors  Therapeutic indications  Type of medication (BP and non-BP).  The risk in patients treated with Zolendronate is 50–100 times superior to placebo  BRONJ occurs after a mean administration of 33 months IV or 48 months Oral.  DRONJ occurs early after treatment, independently of the number of previous administrations.
  • 9. Risk Factors  52–61% of patients reported tooth extraction as a precipitating event.  Mandible (73%)  Maxilla (22.5%)  Both 4.5% of the cases.
  • 10.
  • 11. Definition  Ongoing or antecedent treatment with antiangiogenic or antiresorptive drugs  No patient history of radiation therapy or manifest metastasis to the jaw  Exposed bone or presence of an intraoral or extra-oral fistula in the maxillofacial region persisting for more than 8 weeks. [Controversial]
  • 12. Definition  “Severe adverse drug reaction, consisting of progressive bone destruction in the maxillofacial region of patients exposed to the treatment with nitrogen-containing BPs, in the absence of a previous radiation treatment.”.
  • 13.
  • 14. Prevention  Proper Dental Assessment before therapy  Drug Holiday; A myth or reality?
  • 15. Treatment  At risk category; Education  Stage 0; Local Factors management  Stage 1; Rinsed with antiseptic fluids and covered with an adhesive paste, 3 times a day.  Stage 2; 2 weeks of medical therapy, surgical debridement, Antibiotic and antiphlogistic treatments are administered.  Stage 3 Marginal or segmental osteotomies are recommended for severe cases
  • 16.
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  • 18.