Surgical resection for advanced bisphosphonate-related osteo
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Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse drug reaction represented by destruction and/or death of bone. Fibrous dysplasia (FD) is a rare bony disorder characterised by abnormal fibro-osseous tissue that has lowered resistance to infection. Effective treatments for BRONJ that follows FD are unclear.

A 69-year-old woman was referred to our hospital by a dentist at another hospital because of swelling in her left maxilla. There was the mobility of the left maxillary second premolar and first molar (FDI #25 and #26) and swelling of the surrounding gingiva. Computed tomography (CT) images revealed maxillary bone expansion with a ground glass appearance . The patient had begun steroid therapy for polymyalgia rheumatica 4.5 years earlier. Since then she had been taking alendronate, one of the oral BPs, for the prevention of glucocorticoid-induced osteoporosis.

The clinical diagnosis was acute periodontitis in #25 and #26 parts with FD of the left maxillary bone. After an administration of clarithromycin, #25 and #26 were extracted, and then small bone fragments were collected from the sockets for a histopathological examination. The finding of not FD but the sequestrum predicted the occurrence of BRONJ.

At 1 year after the extractions, a purulent discharge and exposed bone with gingival fistulas were observed in the extraction sites. CT images revealed separated sequestrums in the left maxilla and bone resorption in the periapical area of the left maxillary first premolar (FDI #24) . With the permission of the patient’s attending physicians, the alendronate was withdrawn. After exposed bone had been observed for 8 weeks, the patient was clinically diagnosed with Stage 2 BRONJ accompanying FD of the left maxillary bone. Under general anesthesia, we first performed extraction of #24 and sequestrectomy. We then performed a partial resection of the FD because necrotic-like bone fragments were collected by curettage of the marginal bone . Finally, the surgical wound was completely closed by sutures. The histopathological diagnosis was chronic osteomyelitis with FD . At 2.5 years after the operation, the healing is uneventful although residual FD bone exists . Although local conditions permit the resumption of alendronate, it remains discontinued at the attending physicians’ discretion.

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