Related Osteonecrosis of the TMJ: A Case Study

T. J. Hanson, MD; Mayo Clinic, Rochester, MN R. L. Redfern, DDS, PC; Colorado Springs, CO

Abstract Introduction Case Study Treatment 6 year follow up images (2012) Discussion References

1. Drake, M.T.; Clark, B. L.; et al. (2008). “: mechanism of action and role in clinical CASE DIAGNOSIS: 60-year-old woman treated The effect of bisphosphonates (BPH) on the • 60-year-old female with headache, ENT symptoms, neck and • BPH was discontinued Left TMJ Sagittal CBCT Coronal CBCT Bisphosphonates have been useful clinically to treat practice.” Mayo Clin Proc 83(9):1032-1045. with bisphosphonate for who developed and is well documented. However, the effect pain mediated loss due to , Paget’s • Occlusal treatments with 24/7 Mutually Protected Occlusion 2. Goncalves, D.A.; Camparis, C.M.; et al. (2011). “Temporomandibular disorders are differentially associated bisphosphonate related osteonecrosis of the jaw on the TMJ is not. Stage “0” (no open oral lesions) • History of clenching, TMJ dysfunction and nocturnal splint use disease of the bone, multiple myeloma, metastatic osseous with headache diagnoses: a controlled study.” Clin J Pain 27(7):611-615. splint 3. Hatcher, D.C.; Faulkner, M.G.. (1986). “Development of mechanical and mathematic models to study (BRONJ) affecting the temporomandibular is bisphosphonate related osteonecrosis of the jaw • Oral BPH (nitrogen-containing) use times two years disease, and hypercalcemia associated with malignancies. loading.” J Prosthet Dent 55(3):377-384. presented. (BRONJ) has been reported. Stage “0” BRONJ can • TMJ arthroscopic lavage Bisphosphonate related osteonecrosis of the jaw (BRONJ) 4. Isberg, Annika, ed.Temporomandibular Joint Dysfunction: A Practitioner’s Guide. Quintessence Publishing. • 1+ year history of mild pain, ENT symptoms, jaw “popping” Hanover Park, IL. include the TMJ. The TMJs are loaded synovial . was described in 2003 as an intraoral complication of BPH CASE DESCRIPTION: A 60-year-old woman was referred and headache • Physical therapy for joint mobility and myofascial pain 5. Jonasson, G.; Sundh V.; et al. (2011). “A prospective study of mandibular trabecular bone to predict fracture incidence in women: A low-cost screening tool in the dental clinic.” Bone 49(4):873-879. to clinic for evaluation of ENT symptoms, headache, Joint loading increases bone reactivity. Compromised • Sudden severe pain and collapse of the left TMJ condyle, use (nitrogen containing bisphosphonates). Stage “0” BRONJ joints are more reactive than normal joints under load • Diet modifi cation (soft diet) (no open oral lesions) was described in 2010. The jaw is 6. Laskin, DM; Greene, CS; Hylander, W.L., eds. (2006). Temporomandibular Disorders: An evidenced based neck and jaw pain. She had a 2-year history of orofacial pain, and abnormal jaw mechanics approach to diagnosis and treatment. Quintessence Publishing; Hanover Park, IL. bisphosphonate use for osteopenia. On examination she with more resultant stresses and remodeling. BPH is an area of increased risk for developing osteonecrosis with 7. Marx, RE, Sawatari, Y. (2005). BPH-induced bone of the : risk factors, recognition, prevention, and attracted to areas of bone reactivity. Stage “0” BRONJ Left TMJ Sagittal CBCT Coronal CBCT its high mechanical stress. BRONJ can affect the entire treatment. J Oral Maxillofac Surg 63:1567–1575. had pain with palpation over the masseter, temporalis, 8. McNeil, C, eds.Engineering Principles and Modeling Strategies/Raymond T. Mah, Steven P. McEvoy, David TMJ and nuchal musculature. She had pain with occurs within the bone. Osteonecrosis undermines the jaw and TMJ (including the external auditory canal). The C. Hatcher, M. Gary Faulkner. Quintessence Publishing, Hanover Park, IL. cortical layer which can to collapse of the cortex reported incidence of BRONJ is variable. A February 2012 9. Ott, S.M. “What is the optimal duration of bisphosphonate therapy?”, from www.ccjm.org/ jaw movements. Evaluation included Cone Beam CT 2 year follow up images (2008) content/78/9/619. of the mandibular condyles. This results in a change publication notes the prevalence of bisphosphonated related (CBCT), MRI and dental x-rays. She was diagnosed 10. Piper, M.A.; Chuong, R. (1991). Avascular of the mandibular condyle: histologic correlation with of articular dimension which will cause a change in osteonecrosis in patients with as high as 13.3%. MRI. American Society of Temporomandibular Joint Surgeons Annual Meeting. Palm Springs, CA. with stage 0 (no open oral lesions) bisphosphonate Sagittal and Coronal Cone Beam CT (CBCT) images of the Left TMJ demonstrate occlusion and biomechanics. This further need for Musculoskeletal symptoms are prevalent in BRONJ and TMJ 11. Reiskin, A.B. (1979). “Aseptic necrosis of the mandibular condyle: a common problem?” Quintessence Int related osteonecrosis of the jaw (BRONJ) affecting Left TMJ Sagittal CBCT Coronal CBCT continued improvement with recortication. Dent Dig 10(2):85-89. the TMJ. Treatment included discontinuation of the accommodation increases muscular activity, load patients. Patients with TMJ disorders have been reported to 12. Schellhas, K.P. (1989). “Unstable occlusion and temporomandibular joint disease.” J Clin Orthod on the injured joints, headache and cervicothoracic have increased fatiguability to the cervical extensor muscles. 23(5):332-337. bisphosphonate, referral to a dentist for fabrication of 13. Schellhas, K.P.; Piper, M.A.; et al. (1992). “Facial skeleton remodeling due to temporomandibular joint Mutually Protective Occlusion splints to reduce loading aggravation. The early recognition and proper management of BRONJ to degeneration: an imaging study of 100 patients.” Cranio 10(3):248-259. optimize patient outcome is essential. 14. Schellhas, K.P.; Wilkes, C.H.; et al. (1989). “MR of dissecans and of the of her TMJs, hyperactivity of the muscles of mastication mandibular condyle.” AJR Am J Roentgenol 152(3):551-560. 15. Sedghizadeh, P.P.; Stanley, K; et al. (2009). “Oral bisphosphonate use and the prevalence of osteonecrosis and to reduce recruitment and aggravation of the Case Study Outcome of the jaw.” J Am Dent Assoc 140(1):61-66. cervicothoracic musculature. Physical therapy was Severe erosive changes seen in condyle and fossa. Spires of cancelous bone 16. Travell, J.G.; Simons, D.G. Myofascial Pain and Dysfunction: The Trigger Point Manual; Vol. 1. The Upper implemented. She underwent TMJ debridement. Bone appear to “key” into the fossa. Half of Body. Lippincott, Williams, and Wilkins. • > 90% pain reduction (pain level reduced from 10/10 to 17. Wilkes, C.H.; Visscher, M.B.. (1975). “Some physiological aspects of pressure.” J Bone Joint quality was felt to be suboptimal for . Surg AM 57(1):49-57. Objective MRI T2 MRI Lft Sagittal T1 0-1/10) Conclusions Outcome included reduced pain, increased oral 18. Nalliah, R (2012). “Prevalence of bisphosphonate-related osteonecrosis in patients with cancer could be as high as 13.3 percent” Journal of the American Dental Association 143(2): 170-171. opening, improved quality of life, and improved BRONJ • Improved jaw range of motion 19. Armijo-Olivo, S; Silvestre, RA; Fuentes JP, et al (2012). “Patients with Temporomandibular Disorders Have status. • To increase physiatric awareness of bisphosphonate • Physiatrists need to be aware of the potential affects of Increased Fatigability of the Cervical Extensor Muscles” The Clinical Journal of Pain 28(1):55-64. related osteonecrosis of the jaw (BRONJ) • Improved jaw biomechanics BPH in patients with head and neck pain 20. Froelich, K; Radeloff, A; Kohler, C, et al. (2010). “Bisphosphonate-induced osteonecrosis of the external DISCUSSION: Bisphosphonates have been used ear canal: A retrospective study” Eur Arch Otorhinolaryngol 268:1219-1225. • Improved functional outcome (normal diet) clinically to treat osteoclast mediated bone loss due to • To demonstrate the role of advanced imaging for early • Osteonecrosis can affect the entire mandible (including the osteoporosis, Paget disease of bone, multiple myeloma, management of BRONJ Sagittal and Coronal Cone Beam CT (CBCT) images of the Left TMJ demonstrate • Improvement in BRONJ on imaging studies with recortication TMJ) improvement. metastatic osseous disease and hypercalcemia • To emphasize implementation of management • "Excellent" patient satisfaction with care • Advanced imaging is necessary for differential diagnosis associated with malignancies as well as other skeletal measures (including splints) to decrease the bone Example Patients with Advanced BRONJ diagnoses. Bisphosphonate related osteonecrosis of the reactivity in the TMJ, maxilla, and mandible MRI Lft Sagittal T1 • Coordination of care between medical and dental jaw (BRONJ) been reported, however, the impact on the specialities optimizes patient outcome TMJ is not well studied. A case study format is used to • Splint use reduces bone load and reactivity describe the clinical presentation, evaluation, diagnosis • MRI shows disruption of cortical 12 months later CBCT and management of a patient with BRONJ affecting the layers • Physical therapy is advantageous for range of motion and temporomandibular joint. • Mixed signal in medullary bone of myofascial pain components Methods condyle indicating OSN CONCLUSIONS: Patients frequently present for Left TMJ Sagittal T1 at • More research is required to understand BPH related 2 year follow-up physiatric evaluation with head, neck and jaw osteonecrosis of the jaw symptomatology. It is essential that the evaluating • A case study format is used. physiatrist be aware of the presentation, diagnosis and Imaging + clinical diagnosis consistent with Stage "0" management of bisphosphonate related osteonecrosis Two cases presenting with advanced BRONJ (non Stage "0" with open oral BRONJ (no open oral lesions) of the jaw (BRONJ) in patients with a history of lesions) with complex management issues bisphosphonate use.

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