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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 17-20

Use of cone-beam computed tomography for evaluation of surgical specimen of medication-related osteonecrosis of the jaw


1 Radiology, The Nippon Dental University Niigata Hospital, Niigata, Japan
2 Department of Pathology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan

Date of Web Publication26-Apr-2018

Correspondence Address:
Ichiro Ogura
Radiology, The Nippon Dental University Niigata Hospital, 1-8 Hamaura-Cho, Chuo-Ku, Niigata, Niigata 951-8580
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_3_18

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  Abstract 


Cone-beam computed tomography (CBCT) provides accurate anatomical details in three-dimensional and multiplanar reformation images for diagnosis and treatment planning. We examined one surgical specimen of medication-related osteonecrosis of the jaw (MRONJ) by CBCT. CBCT images of the surgical specimen of MRONJ showed osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation. Furthermore, high-resolution mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time,16.8 s; field of view, 56 mm × 56 mm; thickness, 0.099 mm) was sharper than standard mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 16.8 s; field of view, 81 mm × 81 mm; thickness, 0.144 mm) and high-density mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 33.5 s; field of view, 81 mm × 81 mm; thickness, 0.144 mm). We showed that CBCT, especially the high-resolution mode, is useful for the evaluation of surgical specimen of the jaw, such as MRONJ. This report can be used for reference in future studies and in clinical settings.

Keywords: Cone-beam computed tomography, image quality, medication-related osteonecrosis of the jaw, osteonecrosis


How to cite this article:
Ogura I, Ono J, Okada Y. Use of cone-beam computed tomography for evaluation of surgical specimen of medication-related osteonecrosis of the jaw. J Oral Maxillofac Radiol 2018;6:17-20

How to cite this URL:
Ogura I, Ono J, Okada Y. Use of cone-beam computed tomography for evaluation of surgical specimen of medication-related osteonecrosis of the jaw. J Oral Maxillofac Radiol [serial online] 2018 [cited 2018 May 23];6:17-20. Available from: http://www.joomr.org/text.asp?2018/6/1/17/231360




  Introduction Top


Bisphosphonates are inhibitors of osteoclastic bone resorption and are effective in treating osteoporosis and other metabolic bone diseases and preventing skeletal events associated with metastatic neoplasms. Although bisphosphonates are an effective medication, they are also implicated in the development of medication-related osteonecrosis of the jaw (MRONJ).[1],[2]

Cone-beam computed tomography (CBCT) provides accurate anatomical details in three-dimensional (3D) and multiplanar reformation (MPR) images for diagnosis and treatment planning.[3] CBCT is superior to panoramic radiography in its ability to characterize the nature and extent of radiographic changes in bisphosphonate-associated osteonecrosis of the jaws.[4],[5],[6]

Surgical intervention should be considered in all MRONJ stages as it allows the histological confirmation of the diagnosis of MRONJ and is instrumental in the prevention of disease progression.[7] In recent years, usefulness of CBCT for evaluation of dissection specimens of mandibles [8],[9] and dry skull [10],[11] was reported. However, to the best of our knowledge, usefulness of CBCT for evaluation of surgical specimen of MRONJ. This study aimed to investigate usefulness of CBCT for evaluation of surgical specimen of the jaw, such as MRONJ.


  Case Report Top


One surgical specimen of MRONJ was examined by CBCT in this study. An 81-year-old man with rheumatism who received oral minodronate presented with left mandibular exposure of bone and paralytic symptoms, after the extraction of a left first molar of the mandible before 5 months.

Regarding preoperative imaging, panoramic radiograph was performed with a panoramic machine (Veraviewepocs; J MORITA MFG, Kyoto, Japan) using the maxillofacial protocol of our hospital as follows: tube voltage, 70 kV and tube current, 10 mA. Multidetector CT (MDCT) imaging was performed with a 16-MDCT scanner (Aquilion TSX-191A; Canon Medical Systems, Otawara, Japan) using the maxillofacial protocol of our hospital, as follows: tube voltage, 120 kV; tube current, 150 mA; field of view, 240 mm × 240 mm; and rotation time, 0.50 s. The protocol consisted of axial acquisition (0.50 mm) with axial, coronal, and sagittal MPR images. Bone scintigraphy was performed with an SNC-5100R (Shimadzu, Kyoto, Japan) and a Scintipack 24000 (Shimadzu) with a 512 × 512 matrix at 4 h after the injection; images were recorded on the computer at 5 min/frame. The radiopharmaceutical used in the patient was 99m Tc-labeled hydroxymethylene diphosphonate (Clear Bone Injection, Nihon Medi-Physics, Tokyo, Japan). The patient was administered the agent at 740 MBq with a rapid intravenous injection. The stored data were displayed on a screen for analysis. [Figure 1] showed multimodal imaging in the patient as preoperative examination. Panoramic radiography showed osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation [Figure 1]a. Axial bone tissue algorithm CT showed osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation [Figure 1]b. Bone scintigraphy shows increased uptake [Figure 1]c.
Figure 1: Multimodal imaging in an 81-year-old man with rheumatism who received oral minodronate as preoperative examination. Panoramic radiography (a) shows osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation (arrow). Axial bone tissue algorithm multidetector computed tomography (b) shows osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation (arrow). Bone scintigraphy (c) shows increased uptake (arrow)

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Segmental mandibulectomy in the patient was performed. Surgical specimen of MRONJ was fixed to the chinrest for CBCT [Figure 2]. Regarding evaluation of the surgical specimen, CBCT imaging was performed with a CBCT unit (Fine Cube; Yoshida, Tokyo, Japan) because of preparation of pathological specimen. The CBCT parameters were as follows: standard mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 16.8 s; field of view, 81 mm × 81 mm; thickness, 0.144 mm), high-density mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 33.5 s; field of view, 81 mm × 81 mm; thickness, 0.144 mm), and high-resolution mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 16.8 s; field of view, 56 mm × 56 mm; thickness, 0.099 mm), resulting in axial, coronal, and sagittal MPR images and 3D images. One oral and maxillofacial radiologist, with over 20 years of experience, reviewed all images.
Figure 2: Surgical specimen of medication-related osteonecrosis of the jaw fixed to the chinrest for cone-beam computed tomography

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[Figure 3] showed CBCT images of surgical specimen of MRONJ. CBCT indicated osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation. Furthermore, high-resolution mode [Figure 3]c and [Figure 3]f was sharper than standard mode [Figure 3]a and [Figure 3]d and high-density mode [Figure 3]b and [Figure 3]e.
Figure 3: Cone-beam computed tomography images of surgical specimen of medication-related osteonecrosis of the jaw by standard mode (a and d), high-density mode (b and e), and high-resolution mode (c and f). High-resolution mode was sharper than standard mode and high-density mode

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  Discussion Top


MRONJ continues to be a poorly understood disease regarding the underlying etiopathogenesis, risk factors, natural history, and optimal approaches to management.[4] Radiographic evaluation can be very useful in determining the extent of bony changes, the size and location of sequestra, proximity of changes to the inferior alveolar, and mental nerves. As the features and underlying pathophysiology of MRONJ continue to be defined, radiographic evaluation will likely play an increasing role in its diagnosis and management. Use of CBCT should be strongly considered when radiographic evaluations are included in prospective research investigations of MRONJ. Kämmerer et al.[6] demonstrate a significant advantage of CBCT over panoramic radiography for surgeons with regard to therapeutic planning for MRONJ. However, to the best of our knowledge, usefulness of CBCT for evaluation of surgical specimen of MRONJ. This study aimed to investigate usefulness of CBCT for evaluation of surgical specimen of the jaw, such as MRONJ.

Van Dessel et al.[8] investigated a comparative evaluation of CBCT and micro-CT on trabecular bone structures in the human mandible. The results demonstrated the potential of high-resolution CBCT imaging for in vivo applications of quantitative bone morphometry and bone quality assessment. Balasundaram et al.[9] investigated the correlation of the level of inferior alveolar canal with CBCT imaging. The results indicated that there is close correlation of the level of the inferior alveolar canal between cadaver specimens and CBCT images. In our surgical specimen of MRONJ, high-resolution mode was sharper than standard mode and high-density mode. Our results are in agreement with those of previous studies.

Wilde et al.[5] showed that cancellous bone destruction, cortical bone erosion, sequestration, and osteosclerosis can be seen across all stages, and prevalence seems to decrease with decreasing severity of MRONJ. In our study, CBCT images of the surgical specimen of MRONJ showed osteolytic changes in the jaws, sclerotic lesion, and sequestrum separation. Our results are in agreement with those of previous studies.

Even the several limitations, the relevance of this study is show up the importance of CBCT on diagnosis and reveal with more accuracy than the panoramic radiography. There were several limitations to this study. The sample was one case. Therefore, further study is necessary to validate these results.


  Conclusion Top


We showed that CBCT, especially the high-resolution mode, is useful for evaluation of surgical specimen of the jaw, such as MRONJ. This report can be used for reference in the future studies and in clinical settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ogura I, Sasaki Y, Kameta A, Sue M, Oda T. Characteristic multimodal imaging of medication-related osteonecrosis of the jaw: Comparison between oral and parenteral routes of medication administration. Pol J Radiol 2017;82:551-60.  Back to cited text no. 1
    
2.
Guo Y, Wang D, Wang Y, Peng X, Guo C. Imaging features of medicine-related osteonecrosis of the jaws: Comparison between panoramic radiography and computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122:e69-76.  Back to cited text no. 2
    
3.
Sue M, Oda T, Sasaki Y, Ogura I. Age-related changes in the pulp chamber of maxillary and mandibular molars on cone-beam computed tomography images. Oral Radiol 2017.  Back to cited text no. 3
    
4.
Treister NS, Friedland B, Woo SB. Use of cone-beam computerized tomography for evaluation of bisphosphonate-associated osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:753-64.  Back to cited text no. 4
    
5.
Wilde F, Heufelder M, Lorenz K, Liese S, Liese J, Helmrich J, et al. Prevalence of cone beam computed tomography imaging findings according to the clinical stage of bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:804-11.  Back to cited text no. 5
    
6.
Kämmerer PW, Thiem D, Eisenbeiß C, Dau M, Schulze RK, Al-Nawas B, et al. Surgical evaluation of panoramic radiography and cone beam computed tomography for therapy planning of bisphosphonate-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;121:419-24.  Back to cited text no. 6
    
7.
Ristow O, Otto S, Troeltzsch M, Hohlweg-Majert B, Pautke C. Treatment perspectives for medication-related osteonecrosis of the jaw (MRONJ). J Craniomaxillofac Surg 2015;43:290-3.  Back to cited text no. 7
    
8.
Van Dessel J, Huang Y, Depypere M, Rubira-Bullen I, Maes F, Jacobs R, et al. A comparative evaluation of cone beam CT and micro-CT on trabecular bone structures in the human mandible. Dentomaxillofac Radiol 2013;42:20130145.  Back to cited text no. 8
    
9.
Balasundaram A, Heir GM, Villegas FP, Ahmad M, Taher F.In vitro correlation of the level of inferior alveolar canal with CBCT imaging. Surg Radiol Anat 2015;37:591-7.  Back to cited text no. 9
    
10.
Kim JH, Jeong HG, Hwang JJ, Lee JH, Han SS. The impact of reorienting cone-beam computed tomographic images in varied head positions on the coordinates of anatomical landmarks. Imaging Sci Dent 2016;46:133-9.  Back to cited text no. 10
    
11.
Choi JW. Analysis of the priority of anatomic structures according to the diagnostic task in cone-beam computed tomographic images. Imaging Sci Dent 2016;46:245-9.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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