SupplementPoster 760, Sprache: EnglischHenningsen, Anders
Introduction: Differential diagnostics of cystic cervical neoplasia is sometimes difficult. Genuine branchiogenic carcinoma, which means carcinoma in lateral cysts of the neck, are rare.
Case presentation: A 51 year old patient presented with a 4-week history of a progressive swelling postero-inferior to the right mandibular angle. Ultrasound of the neck showed a well defined, shmoothly shaped and homogenous cystic mass without hilus sign. A computed tomography scan of the head and neck revealed a 40mm hypodense mass in Level IIa, most likely a central necrotic lymph node metastasis. An 18FDG PET-CT scan revealed a rounded, metabolic active mass with central hypodensity in the right carotid triangle. There was no clinical or radiographic sign for any primary cancer. The mass was excised.
Result: Microscopic examination revealed a branchiogenic carcinoma. We applied a functional neck dissection on the right side and a bilateral tonsillectomy. The right tonsil contained a 2,2cm squamous cell carcinoma which infiltrated almost the whole tonsil (pT2, pN2a, M0).
Discussion and Conclusion: On assumption of a Cancer of unknown primary (CUP) we performed a PET-CT scan, which is clearly superior to single PET, CT or MRI. Despite the size of 2,2cm the primary cancer could not clearly be determined. First histologic examination revealed a branchiogenic carcinoma, which would be a rarity. Proof was given through diagnostic tonsillectomy, which is recommended for CUP of the head and neck but not in branchiogenic carcinoma. It has to be clarified whether branchiogenic carcinoma is a unique entity.
Schlagwörter: branchiogenic, carcinoma, metastasis, neck, tonsil
SupplementPoster 761, Sprache: EnglischAngermair, Johannes / Tschammler, Claudia / Heiligensetzer, Manuel / Linsenmann, Robert / Nolte, Dirk
Introduction: The clinical management of traumatic tooth loss in infant and adolescent denture poses a particular challenge for the surgical treatment due to the resulting local bone and soft tissue deficit. The "two-phase transplantation concept" (TPTX) has been developed to account for adequate recovery of aesthetics and function by reliably maintaining the growth of the youthful jaw up to early adulthood.
Material and Method: In the primary and early mixed dentitions (age 4 to 10) the not yet exfoliated primary canines are used as tooth substitutes for the upper lost permanent incisor (phase I). Exfoliation of the transplanted primary canines occurs either spontaneously or due to the growth of the adjacent erupting teeth. In phase II (> 10 years of age), premolar transplantation can be applied for long-term rehabilitation of the adolescent jaw.
Results: Autogenous transplantation (autoTX) of primary canines reliably stimulates the growth of local bone in the anterior upper jaw. Mean 5-year survival rate for primary canines autoTX assessed by Kaplan-Meier estimator was 87% (n=14). The survival rate of premolar autoTX is reported in the literature to be over 90% after 33 years which is supported by our own data (mean 3-year survival rate: 100%, n=24). Patient satisfaction, assessed by a questionnaire, resulted in excellent school grades for both primary canine (1.5) and premolar autotransplantation (1.7), respectively.
Conclusion: This biological therapeutic approach to dental trauma is new by basing on the natural exfoliation of the primary tooth transplant in the early phase I and, if necessary, on premolar autotransplantation in the later phase II of therapy, thus allowing the rapid rehabilitation of children and adolescents with avulsed upper central incisors.
Schlagwörter: Dental trauma, autogenous tooth transplantation, autogenous primary tooth transplantation, physiological resorption, mixed dentition, soft tissue management
SupplementPoster 762, Sprache: Deutsch, EnglischSchlabe, Jürgen / Thiele, Oliver / Struckmann, Victoria / Koilos, Leila / Hernekamp, Jan-Frederik / Kremer, Thomas / Kneser, Ulrich / Mischkowski, Robert Andreas
A polytrauma often needs an interdisciplinary team approach. Maxillofacial injuries such as maxillary or mandible fractures can occur in about 20% of cases. Injuries to the neck due to explosion injuries can cause severe and lifethreatening situations, especially in facial burn injuries. Airway management may be aggravated due to inhalation injuries.
Case report: a 19 year old fire fighter suffered a combination of a high velocity shrapnel injury and a severe facial burn. We show the successful management of an interdisciplinary team approach of plastic and maxillofacial surgery.
Schlagwörter: Facial burn, shrapnel injury, explosion injury, MASCAL
SupplementPoster 763, Sprache: EnglischTeiler, Anna Maria / Hoefer, Sebastian Herbert / Sader, Robert / Landes, Constantin
Background: Even today mycotic infection of the maxillary sinus is not a very rare disease. In most cases, Aspergillosis is the underlying pathogen and is associated with root canal filling - contains zinc oxide - that has been pressed into the maxillary sinus through the root tip. Most of the time aspergillosis remains non-invasive. However, the invasive form presents itself with a life-threatening condition due to potential destructive cranial progression. Often times diabetic or immunocompromised patients are affected.
Goals: The mycotic infection of paranasal sinuses requires thorough understanding of the underlying causes, possible surgical and anti-mycotic treatment options, and the willingness to work in an interdisciplinary setting with various clinics and sub-departments.
Methods: We exemplary choose 3 patients with a histopathological diagnosed mycosis of the maxillary sinus, we treated in our clinic.
Patient 1 (male, 68 years old) was transferred to us from the Department of Neurology after suffering from therapy-resistant headaches for two weeks and sudden paresis of the third cranial nerve.
A sinusitis maxillaris due to aspergillus fumigatus with affection of the left orbita and complete paralysis of the occulomotoric nerve could be diagnosed.
Patient 2 (male, 59 years old) presented himself with painless swelling of the cheek without dentogenic focus.
The underlying cause was right-sided rhinocerebral mucor-mycosis due to chronic sinusitis maxiallaris with subtotal destruction of the zygomatic bone.
Patient 3 (female, 80 years old) was transferred from the Department of Opthalmology due to left-sided periorbital swelling. The underlying cause was sinusitis due to aspergillosis infection.
Results: 2 out of 3 patients suffered from a predisposing condition: ulcerative colitis and renal insufficiency; as well as collagenous colitis.
2 out of 3 patients received prior root canal treatment.
In all cases surgical treatment (sanitization of the maxillary sinus and decortication) as well as systemic anti-mycotic therapy were applied.
2 out of 3 patients received additional local treatment via a drainage system.
Conclusion: Root canal treatment and persistent symptoms require early 3D-imaging of the perinasal sinuses (especially in the case of diabetic or immunocompromised patients).
The rapid confirmation of the diagnosis and the combined treatment (includiung surgical sanitation and systemic anti-mycotic therapy) are crucial for the outcome of the patient. Interdisciplinary treatment between Maxillofacial Surgeons and Infectious Disease Specialists leads to positive long-term results (follow-up duration of 18 months).
Schlagwörter: aspergillosis, sinuses, infection
SupplementPoster 764, Sprache: EnglischTeiler, Anna Maria / Hoefer, Sebastian Herbert / Sader, Robert / Landes, Constantin
Background: Highly acute oro-dentogenic infections with rapid dissemination - like in the case of necrotising fasziitis (NF) or a phlegmonous deep neck infection (DNI) occur very rarely. However, they require immediate therapeutic intervention. Especially in the case when the immune system is weakened (diabetes mellitus, immuno-suppressive pathologies,etc.) they correspond with high morbidity and mortality.
Goals: It is crucial to understand the disease progress and to be familiar with deep neck spaces and fascial planes. Despite advanced surgical treatment, deep neck infections and even more necrotising fasciitis can have poor outcome due to their common and potentially life-threatening complications: airway obstruction, descending mediastinitis and sepsis.
Knowledge about fast treatment, airway security, efficient drainage, debridement and appropriate antibiotics is essential.
Methods: Three exemplary cases were chosen to outline disease progression including life-threatening complications and therapeutic intervention.
Patient 1: DNI due to abscess with dental focus 37
Patient 2: NF due to necrotising cutaneous metastasis of a squamous cell carcinoma (SCC) originating at the bottom of the mouth.
Patient 3: NF with unclear focus in the head&neck region and immunosuppression due to DM type II.
Results: After being admitted to the emergency room all patients received full surgical therapeutic intervention (large scale debridement, airway security through tracheotomy, as well as extensive antiobiotic treatment).
Despite immediate referral to the intensive care unit 2 out of 3 patients passed away.
Conclusion: Even rapid and radical surgical intervention accompanied by antiobiotic treatment does not guarantee higher survival rates in case of NF and DNI. Early diagnosis is crucial. Despite this radical treatment the prognosis remains poor and has not improved significantly over the last 50 years.
No evidence-based proof exists regarding the effectiveness of further adjuvant therapy options such as hyperbaric oxygentherapy. However, if available, they should be administered as ultima ratio.
Schlagwörter: Infections, deep neck infection, necrotising fascitis, debridment
SupplementPoster 765, Sprache: EnglischHoefer, Sebastian Herbert / Teiler, Anna Maria / Ballon, Alexander / Sader, Robert / Landes, Constantin
Background: Soft tissue injuries with traumatic penetrations of foreign bodies occur fairly often and also known to involve the orbital region. Most of the time the trauma pattern is known or self-explanatory. In those cases, primary surgical removal of the foreign body is administered after diagnostic confirmation.
However, rare and exceptional cases occur where the patient history and conventional diagnostic methods are not effective. The following presents an example of an unambigious case as well as an intricate one.
Goals: Penetrating foreign bodies in the ocular orbit are a common injury to the face. These foreign bodies stem from diverse organic and non-organic compositions and require individual trauma management.
The goal of this poster was to present two cases similar in trauma pattern but with very different compositions of the penetrating foreign objects. As well as the challenges presented to the clinicians by a variety of possible foreign bodies.
Methods: A 5-year-old boy (Patient 1) is brought to our clinic after stabbing himself with a pencil in his right periorbital region while playing. He presents himself with an one-sided eyeglass haemorrhage and a tear injury to his right upper eye lid.
With low-dose CT the clinical suspicion is confirmed that a piece of the pencil remained within the orbita.
During endotracheal anaesthesia the foreign body is extracted without complications.
A 22-year-old male patient (Patient 2) presents himself to our clinic with a swollen upper left eye lid and ptosis of the same eye. According to his patient history he only states that he woke up intoxicated in a forest.
Since radiological diagnostics (first ultrasound examination, then CT, and finally a MRI) did not yield a specific cause and the clinical finding progressed steadily, surgircal exploration was performed.
During the exploration a small wooden branch was found. Afer surgical removal of the wooden foreign body the symptoms of the patient completely regressed.
Results: An exact patient history is essential for the further direction of treatment but the patient history can not always be correctly evaluated. In these cases, we would suggest a CT scan for bone and soft tissue with contrast agent as primary imaging technique. If this diagnostic tool is not available patients should be referred to an institution with better equipment. Only when there is a specific suspicion for a foreign wooden body we would suggest an MRI in the first line. Additionally an
ultrasound of the lid and orbit can be attempted but should be performed by an experienced examiner. Suspective facial wounds, specifically, should always be transferred to a specialized maxillofacial surgeon.
Conclusion: After trauma with possible penetration of a foreign body radiological diagnostic procedures are not 100% accurate. In conventional-diagnostic cases which are unclear the surgical exploration is an established diagnostic procedure, that - if successful - yields positive therapeutic effects at the same time.
Schlagwörter: Orbita trauma, foreign bodies of the orbit, foreign body treatment
SupplementPoster 766, Sprache: Deutsch, EnglischLautwein, Anke / Singh, Daman D. / Spitzer, Wolfgang J. / Holtmann, Henrik
A severe problem of clinical differential diagnosisOral squamous cell carcinomas (OSCC) around dental implants appear cumulated in patients who have still been diagnosed and have received therapy for oral squamous cell carcinomas. Ongoing cigarette consumption often combined with alcohol abuse also seems to be the main reason for their arising. However a preexisting dental implant induced tissue irritation/peri-implantitis without nicotine or alcohol cunsumption seems to promote the growth of oral malignoms for itself. The clinical problem in identifiying these tumours dues to its mimikry of peri-implant inflammation. In this poster we demonstrate three cases of patients with resected squamous cell carcinomas in the soft tissue of the lower jaw who got dental rehabilitation with implants after at least one year without recurrence of the tumours. In the controls after dental implantation new squamous cell carcinomas occured around these implants imitating peri-implant irritation. Extensive soft and hard tissue resection with explantation of the implants and local adjuvant radiation was proceeded. Up to now (more than two years) the three patients are presenting a relapse free disease process.
Schlagwörter: oral squamous cell carcinoma, OSCC, periimplantitis, periimplantary carcinoma, lower jaw
SupplementPoster 767, Sprache: Deutsch, EnglischGoetze, Elisabeth Johanna / Surjono, Stanley / Righesso, Leonardo / Koch, Felix / Wagner, Wilfried
Accuracy of guided drilling, a preclinical investigationAim: Reconstruction of large mandible defects can be done by using fibula grafts with one- or two stage implantation of dental implants. Preformated guided planning offers the opportunity to use a primary dental arch bar as a fixateure externe. This grounds on a precise guidance through a drilling template. The aim of this study was to determine the accuracy of such a preformed implant-drilling template.
Material/methods: In 4 stages 4 dental implants (Astra Dentsply 4,0x10mm) were placed in porcine bone (spongious and long bone) using a preformed drilling template for perpendicular implantation. Bone was not osteotomized. An dental arch bar (Astra ISUS) was screwed to the implants with 9 Ncm torque. Contact x-rays and conical digital volume tomography was done of the implants. The vertical distance between the inner thread and the conical connection was measured on both sides of the implant. Pivot of the implants was measured in two perpendicular planes. The gap difference and angulation of the inner implants were compared.
Results: The dental arch bar did not fit to all 4 implants in any stage. The outer implants could only be loaded on one side in 3 stages, in 1 stage none of the outer implants could be loaded. Pivot went up to 6,48° (1st plane) and 12,93° (2nd plane). The inner implants showed a gap difference of 0,56mm (± 0,37) resp. angulation difference of 1,47° (±0,22) - 1st plane/3,83° (±3,28) - 2nd plane - to each other.
Discussion/conclusion: Even with guided drilling implant and planned position are differing from each other. Special emphasis has to be set on the inner implants as osteotomy to the outer implants could compensate some deviation - regardless a variation in the position of the inner implants was present. This means primary use of a dental arch bar with four point fixation is limited. A resolution could be the use of a bar separated in the middle to compensate through the mobility of the osteomized segments. In conclusion the use primary dental arch bar is applicable.
Schlagwörter: fibula transplant, guided implantation, preformed transplantation, fibula, implantation
SupplementPoster 768, Sprache: Deutsch, EnglischMootz, Burkhard
Es gibt eine große Anzahl von Patienten, die gleichzeitig unter einer chronischen Rhinosinusitis und einer ästhetisch störenden Nasendeformität leiden. Von dieser Patientengruppe wird in zunehmender Zahl der Wunsch nach simultaner Sinuschirurgie und ästhetischer Nasenkorrektur geäußert.
Durch Fortschritte auf den Gebieten der rhinologischen Chirurgie und der endonasalen Sinuschirurgie (FESS) in den letzten 25 Jahren wurde das altehrwürdige Prinzip der zeitversetzten Rhinoplastik neu überdacht. Einige Chirurgen begannen, in geeigneten Fällen die Rhinoplastik mit der FESS zu kombinieren.
Den wenigen Veröffentlichungen zu diesem Thema ist zu entnehmen, dass die Infektions- und Komplikationsraten für beide Eingriffe, einzeln durchgeführt, gering sind und ferner bei einer Kombinationsoperation kein additives Risiko üblicher Komplikationen vorzuliegen scheint.
Wenn für eine Kombinationsoperation nur milde und moderate Formen einer chronischen Rhinosinusitis in Betracht gezogen werden und auf komplexe äußere Nasenrekonstruktionen verzichtet wird, dann ist in den Händen erfahrener und spezialisierter Chirurgen in einem multidisziplinären Team aus den Fachgebieten
der HNO-Heilkunde, der MKG-Chirurgie oder der Plastischen und Ästhetischen Chirurgie der Simultaneingriff FESS/Rhinoplastik ein vorhersehbarer, sicherer und effektiver Eingriff und kann zur Zufriedenheit der Patienten wesentlich beitragen.
Schlagwörter: ästhetische Septorhinoplastik, funktionelle endoskopische Nasennebenhöhlenchirurgie, Kombination, chronische Rhinosinusitis, Nasendeformität
SupplementPoster 769, Sprache: Deutsch, EnglischPabst, Andreas Max / Ziebart, Thomas / Krüger, Maximilian / Klein, Marcus Oliver / Walter, Christian
Introduction: Aim of this study is to analyze the influence of geranylgeraniol (GG) on cell viability, migration ability and apoptosis rate of endothelial progenitor cells (EPC) after bisphosphonate treatment in vitro.
Material and Methods: EPCs were isolated from human peripheral blood and cultured. The cells were incubated with different non nitrogen- and nitrogen-containing bisphosphonates (clodronate, ibandronate, pamidronate, zoledronate; 0, 5, 50 µM) and substituted with GG (10 µM). A second experimental series without GG served as controls. After 72 h, cell viability was analyzed by a MTT- and Presto Blue-assay. Migration ability was detected by a migration-assay and apoptosis rate of the EPCs was analyzed by a Tunel- and a Toxi Light-assay.
Results: Negative effects of the nitrogen-containing bisphosphonates on EPCs could be shown in the test lines without GG in all assays. In the GG test lines, EPC demonstrated a significantly increased cell viability (MTT/PrestoBlue: p each
Schlagwörter: bisphosphonate, geranylgeraniol, cell viability, EPC
SupplementPoster 770, Sprache: Deutsch, EnglischOlczak, Katarzyna / Sagheb, Keyvan / Krüger, Maximilian / Walter, Christian
Introduction: It was shown in cell cultures of different malignomas that chloroquine results in an increased apoptosis rate. Therefore current research evaluates this agent alone or in combination with other therapeutics for treatment of these malignant diseases. The aim of this study was to analyze the effect of chloroquine on the viability and apoptosis rate of squamous cell carcinoma (OSCC) in-vitro.
Materials and Methods: Cells of the tumor cell lines PCI1 and SCC68 were incubated for 24h with increasing concentrations (10, 30 and 50μg/ml) of chloroquine. Untreated tumors cells were used as controls. Apoptosis rate was evaluated by fluorometric determination of the activity of caspase 3 and 7. The viability of the tumor cells was checked by WST-assay. All tests were conducted at least five times. For statistical analysis a student's t-test was performed at a significance level of 5%.
Results: The in vitro study shows a dose -dependent degradation of the cell viability for both tumor cell lines: (PCI1: 0µg/ml: 100%; 10µg/ml: 77%; 30µg/ml: 65%; 50µg/ml: 60% [p=0,01, for control versus 50µg/ml]; SCC68: 0µg/ml: 100%; 10µg/ml: 62%; 30µg/ml: 39%; 50 µg/ml: 21% [p
Schlagwörter: Squamous cell carcinoma, therapy, chloroquine
SupplementPoster 771, Sprache: Deutsch, EnglischRahimi-Nedjat, Roman Kia / Sagheb, Keyvan / Kraft, Ina-Sophie / Sagheb, Kaweh / Al-Nawas, Bilal / Walter, Christian
Introduction: Oral squamous cell carcinoma (OSCC) of the buccal mucosa and the upper jaw are rare compared to other sites within the oral cavity and only few studies can be found concerning these localizations only. Therefore the impact of different factors on the recurrence of both tumors were analyzed retrospectively.
Material and methods: All patients with OSCC of the buccal mucosa and the upper jaw between 1988 and 2013 were analyzed and compared. Epidemiologic as well as risk factors and therapeutic strategies were investigated. Furthermore T-, N-, R- and G-classification and radiation were correlated to the incidence of recurrences.
Results: 113 patients (49% ♀, 51% ♂) with a median age of 65±13a (♀:68±14a,♂:58±11a) with buccal and 138 patients with maxillal OSCC with a mean age of 66±13a (♀:71±13a,♂:63±12a) were treated within the investigated period. Follow up was 48 months on average. 97% of buccal and 92% of maxillal OSCC were operated primarily. Comparison showed significantly higher recurrence rates for buccal OSCC for N0-, R0- and G1-classifications. Almost half of all buccal OSCC (49.6%) showed recurrence in the follow-up period, whereas OSCC of the upper jaw only recidivated in 26.1% of all cases. Within the radiated group 50% recurrence was observed for buccal OSCC and only 32.2% for the upper jaw. The median period until recurrence was observed was 11.5 (range 2-184) months for buccal and 13.5 (range 4-140) months for maxillal OSCC.
Discussion: OSCC of the buccal mucosa shows a very aggresive behaviour with early recurrence. Significant differences were observed in comparison to OSCC of the upper jaw.
Schlagwörter: oral squamous cell carcinoma, buccal mucosa, upper jaw, recurrence
SupplementPoster 772, Sprache: Deutsch, EnglischKoch, Felix Peter / Fuchs, Olaf / Götze, E. / Schulz, P. / Moergel, M. / Wentaschek, S. / Wegener, J. / Wagner, W.
Introduction: Large defects oft he human face regularly occur after Head&Neck trauma or cancer resection. They often cause esthetic as well as functional disorders, especially if the dental arch is affected. For a esthetic and functional reconstitution 2-4 operations are necessary. We present a new technique providing the reconstruction of the mandible combined with prothodontic rehabilitation by a single operation .
Methode: The 58years old patient presented with a near total defect oft he mandible after cancer resection and primary reconstruction by a titanium plate which perforated the skin within the first year.
Aiming a complete reconstruction oft he mandible, the gingiva and the deeth, a 3D model oft he skull was manufactured and upper as well as lower jaw protheses. Positioning the mandibular joints in the centre of the fossae, four dental implants have been planned to provide a quatrangular base for the lower jaw prothesis. The position oft he fibula segments as well as their angulation and lengths were adapted to the implant position. After, the molded fibula, bearing already the dental implants has been transformed into its natural straight appearance again to design the sawing splint and the implants drilling guide. To provide the correct angulation of the fibula segments a CAD/CAM dental archbar was manufactured from Titanium. This new approach of an prefabrictaed archbar fulfills three function: 1. It bears the prothethis 2. It stabilizes the molded fibula as a fixateur externe 3 it positions the complete fibula with rhe prothesis in a correct relation to the upper jaw, indicated by the protheses.
Conclusion: This innovative approach of an prothodontic and reconstructive rehabilitation could shorten total reconstruction/rehabilitation time.
Schlagwörter: CAD/CAM, microvascular fibula, cancer, reconstruction, 3D print
SupplementPoster 773, Sprache: Deutsch, EnglischWalter, Christian / Ziebart, Thomas / Pabst, Andreas Max / Hagelauer, Nadine
Einleitung: Stickstoffhaltige Bisphosphonate inhibieren die Farnesylpyrophosphat Synthetase des Mevalonatstoffwechselweges resultierend in einer Erschöpfung des zellulären Geranylgeranylpools. Weitere Arme von hier sind die Bildung des Squalenes z.B. für Cortison und die Prenylierung über Geranylgeranylation und Farnesylation. Ziel der Studie war die Analyse des Einflusses unterschiedlicher Isoprenoide auf Funktionen von mit Bisphosphonat behandelten Zellen.
Material und Methoden: HUVEC, Fibroblasten und Osteoblasten wurden mit Zoledronat inkubiert und die Vitabilität mittels MTT-Test, die Migrationskapazität mittels des Scratch Wound Assay überprüft und die Zellmorphologie mittels Phallacidinfärbung dargestellt. Die zeitgleich zum Zoledronat hinzugegebenen Isoprenoide waren: Geranlygeraniol, Eugenol, Farnesol, R-Limonene, Menthol und Squalene. MTT-Test: Isoprenoidkonzentrationen 0, 10, 25, 50 und 100µM, Zoledronat 50µM, 72h Inkubation. Scratch Wound Assay und Zellmorphologie: Isoprenoidkonzentrationen: 0 und 10µM, Zoledronat 50µM, Beobachtung über bzw. Färbung nach 48h. 3-fache Durchführung der Tests; Statistik: AVOVA, post-hoc Tukey, Signifikanzniveau: p-Wert 0,05.
Ergebnisse: Nur Geranylgeraniol konnte die Zellfunktionen und die Zellmorphologie von mit Zoledronat behandelten Zellen wieder herstellen. Trotz der strukturellen Verwandtheit waren die anderen Isoprenoide hierzu nicht in der Lage, so dass anhand des Ansatzpunktes der einzelnen Isoprenoide im Mevalonatstoffwechsel primär von einer Hemmung der Geranylgeranylation ausgegangen werden muss, da die anderen Isoprenoide, die an anderer Stelle im Mevalonatstoffwechsel ansetzen keinen Effekt aufwiesen.
Schlussfolgerung: Unter den eingesetzten Isoprenoiden ist nur das Geranylgeraniol in der Lage den negativen Effekt der Bisphosponate auf Vitabilität, Migrationsfähigkeit und Morphologie von HUVECs, Fibroblasten und Osteoblasten aufzuheben, so dass ein therapeutischer Effekt nur vom Geranylgeraniol zu erwarten ist.
Schlagwörter: Bisphosphonat, Bisphosphonat assoziierte Osteonekrose, Isoprenoid, Geranylgeraniol
SupplementPoster 774, Sprache: Deutsch, EnglischWalter, Christian / Engel, Christina / Thomas, Christian
Einleitung: Die Bisphosphonat assoziierte Osteonekrose (BP-ONJ) hat bei Hochrisikogruppen in älterer Literatur Prävalenzen von bis zu 20%. Ziel der Studie war es die Prävalenz bei Prostata-Ca-Patienten (PCa) neu zu evaluieren. In der Urologie Uni Mainz wurden im Jahr 2008 eine identische Studie durchgeführt mit einer BP-ONJ Prävalenz von 18,6% (8 von 43), die nach Etablierung eines Präventionsprogram 3 Jahre später evaluiert werden sollte.
Patienten und Methoden: Einschlusskriterien waren ein PCa und Bisphosphonattherapie (BP-Th) Die Studie wurde in der 2. Jahreshälfte 2011 durchgeführt. Patienten aus der Vorgängerstudie wurden nicht eingeschlossen. Zielkriterium war das Vorliegen einer BP-ONJ.
Ergebnisse: Von 26 Patienten hatten 2 eine BP-ONJ (8%), die nach durchschnittlich 25 Monaten BP-Th auftrat gegenüber 12 Monaten BP-Th-Dauer in der Gruppe ohne Nekrose. Alle Patienten erhielten Zoledronat bis auf einen Patienten mit BP-ONJ, der zunächst Pamidronat erhielt. Alle Patienten wurden vor BP-Th zum Zahnarzt überwiesen, 20 der 26 PC-Patienten kamen dem nach. Dabei entwickelte 1 von 6 Patienten, die nicht durch einen Zahnarzt gesehen wurden (17%) und 1 von 20, die gesehen wurden (5%) eine BP-ONJ. Im Vergleich zur Vorgängerstudie bei der die Patienten vor Bisphosphonatgabe nicht explizit zum Zahnarzt überwiesen wurden, bedeutet dies eine Reduktion von 19 auf 8% bei Einbezug aller Patienten und von 19 auf 5% bei stattgehabter präventiver zahnärztlicher Vorstellung. Bei 5 der 26 (19%) wurde unter BP-Th aber antibiotischer Abschirmung und anschließender plastischer Deckung eine Zahnextraktion durchgeführt, 2 entwickelten im Folgezeitraum eine BP-ONJ. In der Vorstudie war bei 33% eine Zahnextraktion unter BP-Th notwendig.
Schlussfolgerung: Obwohl statistisch nicht signifikant ergibt die Untersuchung doch klinische Hinweise, dass durch die Präventivmaßnahmen eine deutliche Reduktion der Prävalenz der BP-ONJ bei Patienten mit Prostatakarzinom erzielt werden kann.
Schlagwörter: Bisphosphonat, Bisphosphonat assoziierte Osteonekrose, Prävalenz, Inzidenz
SupplementPoster 775, Sprache: Deutsch, EnglischKrüger, Maximilian / Moergel, Maximilian / Horke, Sven / Al-Nawas, Bilal
Background: In oral cancer apoptosis induction is a key mechanism of radiotherapy. Upregulation of antiapoptotic proteins inside the tumor leads to an advantage for survival under therapy. In vascular cells Paraoxonase-2 (PON-2) reduces overwhelming ROS-production with the potential to prevent endothelial cells to undergo mitochondrial induced apoptosis. Since irradiation typically induces elevated levels of ROS, PON-2 could also protect squamous cell carcinoma against oxidative stress. Further, some cancers (liver, oesophagus, lymphatic tissue) showed overexpression of PON-2. For today expression pattern and functional influence of PON-2 in squamous cell carcinoma of the head and neck has not been investigated.
Methods: Basal PON-2 expression was determined in vitro in four squamous cell carcinoma cell lines and in human specimen of five patients with oral cancer by western blot analysis. Induction of PON-2 protein expression after singular radiation with 7 Gray 24, 48 and 72 hours after irradiation was examined also. Simultaneously, activity of Caspase 3/7 was examined for apoptosis detection after singular irradiation and temporary PON-2 knockdown by siRNA treatment.
Results: A variable PON-2 expression pattern in vitro and in vivo was detected. Intriguingly, higher basal levels of PON-2 seem to protect cells against radiation-induced apoptosis., while singular irradiation leads to induction of PON-2. On the other hand, temporary PON-2 knockdown leads to elevated apoptosis after irradiation.
Discussion: While some tumors showed higher levels of basal PON-2 expression, other tumors upregulated PON-2 as response to therapy. Tumor cells with higher expression levels of PON-2 basal or as response to therapy may have a biological advantage to suppress irradiation induced apoptosis.
Schlagwörter: Oral cancer, ROS, PON-2, irradiation therapy
SupplementPoster 776, Sprache: Deutsch, EnglischKoch, Johanna / Schulz, Peter / Wagner, Wilfried
Fragestellung: Die Nutzung von Tablet Computern steigt im klinischen Alltag immer mehr an. Hierzu gehört unter anderem auch die digitale Erhebung der Anamnese. Mit dieser Studie wird der Frage nachgegangen welchen Einfluss die digitale Anamneseerhebung mit Tablet Computern (iPad®) auf den Patienten und die Anamneseerhebung selbst hat.
Methode: Zufällig ausgewählte Patienten der Ambulanz der Klinik für Mund-, Kiefer- und Gesichtschirurgie - plastische Operationen wurden neben der herkömmlichen schriftlichen Anamneseerhebung darum gebeten diese zusätzlich digital auf einem iPad® (Apple Inc., Cupertino) durchzuführen. Als Software wurde die digitale impDAT Anamneseerhebung (Kea Software GmbH, Pöcking) verwendet.
Neben diesem Vergleich wurde nach Abschluss der digitalen Anamneseerhebung eine kurze Evaluation durchgeführt. Gefragt wurde hier nach der Bedienerfreundlichkeit, der Einschätzung des Datenschutzes und dem Besitz eines privaten iPad's®.
Ergebnis: Es wurden insgesamt 100 Probanden, davon 53 männlich und 47 weiblich gebeten die zusätzliche digitale Anamnese durchzuführen. 20 Probanden verweigerten die digitale Anamneseerhebung, 80 füllten die Anamnese mit Fragebogen aus. Das Durchschnittsalter der teilnehmenden Probanden lag bei 47 Jahren, wobei der jüngste Proband 12 Jahre, der älteste Proband 77 Jahre war. Von diesen besitzen 20 Probanden privat ein iPad®, 60 Probanden besitzen keines.
38 Probanden füllten sowohl die schriftliche wie auch die digitale Anamnese aus. Dabei zeigten sich in den Antworten mit Freitext 68 unterschiedliche, bei den Antworten mit vorgegeben Text 64 unterschiedliche Angaben. Bei 31 Patienten stand nur die digitale Anamnese zur Verfügung, die restlichen 11 Personen hatten die digitale Anamnese nicht gespeichert.
Bei der Evaluation befanden 80% der Probanden die Bedienfreundlichkeit als sehr gut, 18,75% als gut und 1,75% als befriedigend. 80,25% der Probanden haben nach eigenen Angaben die digitale Anamnese sehr zufriedenstellend, 19,75% zufriedenstellend und 1,25% nicht zufriedenstellend ausfüllen können. Beim Datenschutz sahen 71,25% eine hohe, 21,25% eine mittlere und 7,5% eine niedrige Vertrauenswürdigkeit.
Schlussfolgerung: Die digitale Anamneseerhebung mit dem Tablet Computer wird insgesamt positiv von Patienten aufgenommen und wird in Zukunft sowohl in Kliniken wie auch in Praxisräumen immer mehr Einzug halten. Sowohl die Bedienerfreundlichkeit wie auch die Durchführung der Erhebung zeigt sich insgesamt als positiv bei den Patienten, obwohl es insgesamt Bedenken beim Datenschutz gibt. Die objektive Auswertung der digitalen gegenüber der schriftlichen Anamneseerhebung ergibt jedoch auch das Bild unterschiedlicher Antworten. Dies kann durchaus auf das neue Medium des Tablet Computers zurückgeführt werden wenngleich hier weitere Studien notwendig sind um dies weiter zu objektivieren.
Schlagwörter: Anamnese, Tablet, Tablet Computer, Anamneseerhebung
SupplementPoster 777, Sprache: Deutsch, EnglischSehhati-Chafai-Leuwer, Susanne / Geerling, Gerd / Hille, Konrad / Kübler, Norbert
Introduction: In patients with corneal opacity due to thermal and chemical burns , or other inflammatory disorders of the ocular surface, the risk of rejection of a corneal transplant is high due to strong vascularization and scarring of the cornea in such cases the use of an osteo- odonto - keratoprosthesis (OOKP) is a possible therapeutic alternative.
Materials and Methods: We describe a case of a patient who underwent OOKP-surgery, a method first published in 1963 by Strampelli. Our patient had a past history of Stevens-Johnson-Syndrome with subsequent corneal opacity. Multiple unsuccessful corneal transplants resulted in a corneal ulcerceration. The preoperative visual acuity was only hand movement. In January 2013, tooth number 13 along with its root and surrounding alveolar bone and periosteum was removed and cut along the canal of the dental pulp resulting in two halves.Afterwards a disc was prepared from this specimen.A PMMA cylinder was inserted into a transverse bore hole through the dentin and the adjacent alveolar bone. The graft consisting of the synthetic cylinder and its stable biological matrix was subcutaneously implantet into the lower lid for 3 months. In the meantime, the cornea was covered with buccal mucosa. Three months later, the OOKP was implanted into the center of the cornea with the protruding optical cylinder as a light bridge between the environment and the vitreous body. The biological graft was located between the cornea and the overlying oral mucosa.
Results: Sofar the follow-up was eight months. No operative complication did occured. The postoperative visual acuity is currently 0.4 which allows newspaper reading and participation in public life. A narrow angle glaucoma, which is a typical complication in about 50% of these cases may occur.
Conclusion: The OOKP is a validated, promising and demanding tool for the treatment of very severe corneal conditions .Due to the complex nature of the procedure,its use is restricted to few interdisciplinary centers.
Schlagwörter: corneal blindness, Steven-johnson-Syndrome, Osteo-Odonto-Keratoprothesis
SupplementPoster 778, Sprache: Deutsch, EnglischKoch, Felix Peter / Yuhasz, Mikell M. / Travieso, Rob / Wong, Kenneth / Clune, James / Zuang, Zhen W. / Houten, Joshua Van / Steinbacher, Derek M.
Background: Transport distraction osteogenesis (DO) can be used to autologously reconstitute calvarial defects. However, distraction gap biology in transport DO has not been adequately described. The purpose of this study is to histomorphologically interrogate osteogenic formation during cranial transport distraction using a novel device. We also evaluate the effect of fat grafting on the regenerate during distraction.
Methods: This study was approved by Yale IACUC (# 2011-11393). Ten male New Zealand white rabbits (3 months; 3.5kg) were used (8 treatment, 2 control). A 16x16mm defect was created abutted by a 10x16mm transport disc. The device was fixated anterioposteriorly. Four animals were fat-grafted using 2cc of subdermal intrascapular fat deposited along the distraction site. Latency (1d), active distraction (12-14d) (1.5 mm/day), and consolidation (4wks) followed. Calcein and xylene orange fluorochromes were injected subcutaneously during and post-distraction to mark sites of bone formation. Following sacrifice, osteogenesis was assessed using microCT, histology, and fluorescence.
Results: No perioperative complications were experienced. Treatment animals demonstrated regenerate bone between distracted segments on microCT. MicroCT analysis of fat-grafted and non-fat grafted animals revealed a mean density of 2271.95 mgHA/ccm and 2254.27 mgHA/ccm (p=0.967), respectively, and defect bone versus total volume (BV/TV) of 0.0999 and 0.0766 (p=0.5979), respectively. Controls had minimal reossification. Histologically, mean densities measured 43.63% and 8.19% for non-fat and fat grafted animals, respectively. Density ratios (regenerate:native bone) were 53.96% and 23.71%, respectively. Fluorescent microscopy revealed ossification from the callus as well as bone fronts emanating from dura and periosteum.
Conclusions: Transport distraction is effective to reconstruct critically-sized rabbit calvarial defects. Regenerate bone arises predominantly from the callus with contribution from surrounding dura and periosteum. Adipose grafting is well tolerated but does not enhance osseous regeneration.
Schlagwörter: Distractionosteogenesis, rabbit, in vivo, histology, fat transfer
SupplementPoster 779, Sprache: Deutsch, EnglischSchwaab, Philipp / Kreusch, Thomas
A rare extrainestinal manifestation of Crohn's DiseaseIntroduction: Pyoderma gangrenosum of the scalp is a extremely rare manifestation of Crohn's Disease in an atypical location. The disease is part of the neutrophilic dematoses. Diagnosis needs to be established histologically. It's longterm outcome is not predictable and pathogenesis is unknown. Potential differential diagnoses are basal cell carcinoma, spinal cell carcinoma, sarcoma, lymphoma as well as cutaneous manifestations of lymphoma. In general, immunosuppressive therapy is regarded as a prerequisite for surgical treatment.
Epicrisis: The diagnosis Pyoderma gangrenosum of the parietal scalp was established in an 80 year old female patient who suffered from an acute episode of Crohn's Disease. Further lesions of pyoderma gangrenosum were found at the mons pubis and the external auditory canal. Immunosupressive treatment with steroids, azathioprine and infliximab resulted in remission of the diarrhea with bloody and mucous constituents and progression of the Pyoderma gangrenosum could be prevented. Surgical necrosectomy and decortication at a maximal range of 13 x 10 cm of the exposed scull was performed. After sufficient granulation, supported by vacuum assisted closure therapy, the defect was covered by a split skin graft taken from the right thigh. The patient was followed up for 404 days from first examination and is being continually treated with low dose steroids and azathioprine. So far, there are no signs of relapse.
Results: The importance of immunosusppressive treatment of Pyoderma gangrenosum as a precondition for successive surgery was evinced in this course of disease. Vacuum assisted closure therapy seems to be an effective aid in supporting granulation and preventing wound infection. Granaulation tissue originating in the cancellous bone of the skull provided a sufficient basis for alimentation of split skin graft.
Schlagwörter: Crohn's Disaese, Pyoderma gangrenosum, exposed skull, immunosupressive therapie, steroids, azathioprin, infliximab, necrosectomy, decortication, granulation, vaccum assisted therapy, split skin graft
SupplementPoster 780, Sprache: Deutsch, EnglischKämmerer, Peer / Liese, Jan / Marciak, Paul / Al-Nawas, Bilal
Introduction: Orthopantomography is the radiological standard for evaluation of teeth and jaws. Though, presentation is limited to two-dimensional data. A three-dimensional demonstration via cone beam tomography is an additional analysis with higher exposure to radiation and costs. Aim of the study was a comparison of visibility and evaluation of pathologies of the maxillary sinus together with possible additional secondary diagnoses via orthopantomography and cone beam tomography.
Materials and Methods: Orthopantomographies and cone beam tomographies of patients with pathologies of the maxillary sinus were reviewed. Emphasis was laid on 1) visibility in both imaging physics and 2) number as well as significance of the additional secondary diagnosis.
Results: 31 cases (2006-2009) were reviewed. In 15%, the pathology was seen in the orthopantomography. In 85%, additional radiological methods were demanded. In cases of cone beam tomography, 35% new three-dimensional information were seen. 44% of the cone beams were seen to influence therapy and in 6%, cone beam tomography was seen to be mandatory. A mean of one additional secondary diagnose per patient was seen.
Discussion: This elucidates the clear and relevant advantages of the cone beam tomography for diagnostics of the maxillary sinus when compared to orthopantomography. The additional information is followed by a higher radiation exposure of the respective patients which is as high as if not less than a computed tomography.
Schlagwörter: Cone Beam Tomography, Radiology, Sinus maxillaris, Pathology, Comparison
SupplementPoster 781, Sprache: Deutsch, EnglischBaumgardt, Christoph
Hintergrund: Tumore der kleinen Speicheldrüsen im Kindesalter sind sehr seltene Entitäten. Trotz der niedrigen Inzidenz dieser Tumore zeigt sich jedoch mit über 50 % ein hoher Anteil an Malignomen, welche histologisch häufig einem Mukoepidermoidkarzinom (MEK) entsprechen. Unser Fallbericht soll dazu beitragen, weitere Erkenntnisse zum Verlauf und Prognose des MEK der kleinen Speicheldrüsen im Kindesalter zu erlangen.
Falldarstellung: Ein 5jähriges Mädchen wurde uns mit der histologisch gesicherten Diagnose eines MEK des linken Hartgaumens zugewiesen. Zuvor wurde eine Inzision zur Entlastung eines vermeintlichen dentogenen Abszesses und nachfolgend eine Biopsie alio loco durchgeführt. Das präoperative Staging ergab keinen Nachweis von locoregionären Metastasen oder Fernmetastasen, jedoch den Verdacht auf eine knöcherne Mitbeteiligung des harten Gaumens. Daraufhin erfolgte die Tumorresektion unter Mitnahme des anliegenden Knochens. Die histologische Aufarbeitung ergab zirkulär und zur Tiefe tumorfreie Ränder von 10 mm. Eine adjuvante Therapie war nicht notwendig. Der Resektionsdefekt wurde zunächst der sekundären Wundheilung überlassen. Sechs Monate nach der Tumorresektion und nach entsprechender Bildgebung zum Rezidivausschluß erfolgte die Deckung des Defektes mittels einer Schwenklappenplastik vom Gaumen. Über einen Nachuntersuchungszeitraum von einem Jahr ist die Patientin bis heute rezidivfrei.
Schlußfolgerung: Bei einer therapieresistenten Schwellung im Gaumenbereich darf als Differentialdiagnose ein MEK auch im Kindesalter nicht außer Acht gelassen werden. Nach bioptischer Sicherung und Resektion mit deutlichem Sicherheitsabstand können Rezidive vermieden werden. Persistierende Resektionsdefekte sollten sekundär verschlossen werden.
Schlagwörter: Mukoepidermoidkarzinom, Speicheldrüsentumor, Kinder
SupplementPoster 782, Sprache: EnglischStoetzer, Marcus / Stübner, M. / Rana, Majeed / Gellrich, Nils-Claudius / von See, Constantin
Introduction: The Bundeswehr Patient Evacuation Coordination Centre (PECC) is responsible for organising the evacuation of soldiers to Germany. The aim of this study is to collect and analyse the data of 166 Bundeswehr soldiers who had to be evacuated to Germany by air from the ISAF, KFOR, and EU NAVFOR-ATALANTA missions in recent years.
Methods: By the PECC, we selected patients based on diagnoses of diseases and injuries of the mouth, jaws and face. The data on evacuations was analysed using the SAS 9.3 statistics program.
Results: Priority levels were indicated when requests for evacuation from the country of deployment were made. They were distributed as follows.
Discussion: The rapid evacuation of even complex cases is an important factor in the medical care of soldiers and at the same time ensures high survival rates after attacks and incidents involving severe injuries. The time from the request for evacuation from the country of deployment to the arrival of the means of transport in Germany was the duration of evacuation.
Schlagwörter: medical treatment for evacuation, medical reports, repatriation
SupplementPoster 783, Sprache: Deutsch, EnglischHeinz, Maria Barbara / Ghassemi, Alireza / Gerressen, Marcus / Hölzle, Frank
Auricular ReconstructionAuricular defects often occur within the context of congenital anomalies, injuries and in particular after surgical excision of benign and malignant tumors. An optimal anatomical reconstruction of the external ear is essential for a successful surgical outcome and contributes significantly to the patient's psychosocial rehabilitation. To cover full thickness auricular defects, we developed the anterior pedicle retroauricular flap. The described flap represents a relatively simple technique for an aesthetically demanding reconstruction of the external ear.
Schlagwörter: anterior pedicled retroauricular flap, two step auricular reconstruction
SupplementPoster 814, Sprache: Deutsch, EnglischGassling, Volker / Detjen, Anna-Maria / Gerber, Wolf-Dieter / Kessler, Henrik / Limbrecht-Ecklundt, Kerstin / Traue, Harald C. / Wiltfang, Jörg
Einleitung: Die Lippen-Kiefer-Gaumenspalte (LKG-Spalte) ist die häufigste angeborene Fehlbildung des Mittelgesichts weltweit. Obwohl betroffene Patienten Unterschiede in der Gesichtsphysiognomie zeigen vermuten wir das Individuen mit LKG-Spalte keine abweichende Emotionsregulationsfähigkeit im Vergleich zu nicht betroffenen Kontrollpersonen zeigen. Der Grund hierfür liegt in der starken biologischen Basis der Gesichtsemotion und Emotionsexpression die angeboren ist und nur wenig durch externe Faktoren beeinflusst wird.
Material und Methoden: In der vorliegenden Studie wurden verschiedene Aspekte der Emotionsregulation bei 25 erwachsenen Patienten mit LKG-Spalte und einer gleichgroßen Kontrollgruppe untersucht. Die Studie gliederte sich in drei Teile. Erstens wurden verschiedene Emotionsregulations-strategien untersucht. Hier musste jeder Teilnehmer zwei Fragebögen beantworten (Emotion Regulation Questionnaire (ERQ) und Ambivalence over Emotional Expressiveness Questionnaire G 18 (AEQ-G18)). Zweitens wurde die individuelle Fähigkeit spezifische Basisemotionen zu erkennen untersucht (Facially expressed emotion labeling (FEEL) Test). Drittens wurde die Fähigkeit bestimmte Emotionen mit dem Gesicht auszudrücken untersucht (Facial Action Coding System (FACS)).
Ergebnisse: Die habituelle Emotionsregulation, gemessen durch ERQ und AEQ-G18 zeigte für alle Subskalen bei Patienten mit LKG-Spalte und Kontrollprobanden keine signifikanten Unterschiede. Die Erkennung von Basisemotionen zeigte gleiche Ergebnisse für beide Gruppen. Die Expression von spezifischen Emotionen durch das Gesicht zeigte ebenfalls keine Gruppenunterschiede.
Schlagwörter: Lippen-Kiefer-Gaumenspalte, EMotionsregulation, Gesichtsexpression
SupplementPoster 817, Sprache: Deutsch, EnglischLandes, Constantin / Hoefer, Sebastian Herbert / Teiler, Anna Maria / Blume, Maximilian / Ghanaati, Shahram / Sader, Robert
For all patients, the goal was to achieve significant improvement of function and asthetics via fibular "wrap-around" augmentation. Further advantage of this operation method is transoral positioning without profound submandibular incision lines. However, the method is very work-intensive regarding a non-compromised perfusion due to very narrow anatomical relationships. With limited cases - as a result of the rare occurence of the situation - transoral positioning is the therapy of choice (despite high work intensity). Sustainable augmentation is achieved. It may be suitable to combine the operation method with soft tissue augmentation - for example with fatty tissue aspiration or free SIEA micro-anastomotic tissue transplant.
Schlagwörter: augmentation, fibular transplantation, mandibular hypoplasia
SupplementPoster 818, Sprache: Deutsch, EnglischKretschmer, Frank-Hendric Peter / Eggerath, Jobst Werner / Moll, Christine / Draenert, Guy Florian / Heymann, Paul / Neff, Andreas
Denosumab is a novel antiresorptive agent used for the treatment of postmenopausal osteoporosis and bone metastases from malignant diseases. The indication is identical as for bisphosphonates, the effectiveness is comparable. Bisphosphonates can cause osteonecrosis of the jaw bone. Cases have been described both in patients with malignant diseases and in the treatment of osteoporosis. Denosumab can also cause osteonecrosis of the jaw. The clinical picture of necrosis is identical. So far, however, only cases of denosumab-related osteonecrosis of the jaw in patients with malignant diseases have been described. This report describes the case of a patient who was switched to denosumab because of gastrointestinal intolerance to bisphosphonates due to a treatment of osteoporosis. After dento-alveolar surgery osteonecrosis to the anterior mandible occured. It maybe assumed that the inhibition of osteoclasts by denosumab and the artificial dentoalveolar trauma triggered osteochemonecrosis in this patient.
The case described here is, to our knowledge, the first literature reported patient case of denosumab-related osteonecrosis of the jaw with continuous therapy because of osteoporosis and without the existence of an underlying malignant disease.
The authors recommend a dental treatment as recommended by the AAOMS and AWMF both before starting bisphosphonate therapy and before starting treatment with denosumab, regardless of the indication or underlying disease.
Schlagwörter: Denosumab, Bisphosphonate-related Osteonecrosis of the jaw, Denosumab-related osteonecrosis of the jaw, Osteoporosis, Osteochemonecrosis, BRONJ, ONJ