Case 5

“Aiming for the curb”

By: Neal Lehrman, DDS, MS

Sometimes its best NOT to shoot for the stars as it is not an option. It’s clear that we cannot always expect to fix everything in the course of  treating patients, and therefore our patients are best served with an eye towards more realistic outcomes.

A 76 year old female presented for evaluation and treatment of a long standing Bisphosphanate related osteo-necrosis of the jaw ( BRONJ )  lesion. She had been on Bis-phosphanates for almost a decade and approximately 3 yrs prior to presenting she developed an ONJ lesion post extraction #5. At the time of presentation, she reported being on amoxicillin tid, prescribed by her physician, for 3 yrs.  The patient had seen various dentists/surgeons and to a one, they did not want to get involved in treatment as the options were less than optimal. Looking through our lens.. how can we approach this not so unique problem?

Otherwise healthy, the sequestrum was removed from her maxilla and LANAP– hemostasis was performed to create a clot. At the same visit and subsequently for the next 3 weeks, biostimulation was performed without contacting the area itself. 500j at each of the three visits spaced approximately 7 days a apart.. and here is what happened.

 The result, while not perfect is actually remarkable in the fact that she is no longer on antibiotics and the area has been closed for over 1 year, thereby preventing re-introduction of infection. The films, particularly the final one, show excellent resolution of the lamina dura. Ideally, we would like to see bone growth with respect to height of osseous crest, but oftentimes that is not achievable. In its stead, the patient is thrilled to be “stable”. With appropriate expectations- management of these difficult situations can be routinely achieved.

Pre-[SPECIALIST]	Sequestrum removed
1 week post op	3 week post-op
immediate post-op	1 yr p.o. note the increased lamina dura.. only a small area from the original lesion remaining.. Perfect? definitely not… great result..absolutely….

mirror image of area @ 12 mos n.b. that is not bone but material alba was removed