Rehabilitation after surgical interventions in bisphosphonate related lower jaw osteonecrosis

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Rehabilitation after the maxillofacial operations plays a significant role in dental practice as the surgical interventions can impair mastication, swallowing and speech. Rehabilitation creates a lot of difficulties not only from the side of restoring function and aesthetics, but it requires psychological care. Due to the fact that the chemical maxillofacial osteonecrosis are quite common this theme recently remains relevant.

The ethiopathogenesis and clinical aspects of the bisphosphonate related lower jaw osteonecrosis have been studied by us. 9 patients have been examined with this pathology, some certain conclusions about outpatient interventions for patients taking bisphosphonates medications, rehabilitation recommendations have been formed.

Competent rehabilitation aimed at close cooperation between the doctors of related specialties and also an active patient's participation are the pledge of a favorable prognosis in postoperative period.

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Relevance. Bisphosphonate osteonecrosis of the jaws is a complication of antiresorptive therapy characterized by necrosis and exposure of a bone area, which strictly affects the quality of life of patients, and can lead to disability [1].
In studies conducted by Brown et al. in 2013, it was found that the incidence of osteonecrosis of the jaw in patients receiving zolendronic acid therapy after tooth extraction is 86.4% [2].
A feature of the clinical manifestation of bisphosphonate osteonecrosis of the jaws is the chronic course and diffuse nature of the lesion, occurring with the exposure of bone tissue, its sluggish regeneration, the formation of sequestration and osteoporosis sites in the bone, and the low effectiveness of the treatment. The result of this process, as a rule, is the loss of teeth and bone tissue, which leads to a decrease, and, often, loss of chewing function, at the same time, the aesthetics of the maxillofacial region is disrupted, in addition, the patient who underwent treatment for cancer, and then BPH, needs psychological help help [3, 4]. It is worth noting that the determining factor in the rehabilitation of such patients is a high tendency to recurrence of the process.
Rehabilitation after such operations occupies one of the main roles in dental practice. In order to ensure an integrated approach to restoring the quality of life of such patients, joint participation of specialists of different profiles is necessary. Rehabilitation measures are planned by dental surgeons even before the operation and include

myogymnastics, physiotherapy, drug preparation, production of stereo models for surgery planning, temporary prostheses and special splints, if necessary, which will be fixed immediately after surgery [5-9]. With extensive operations, the functions of chewing, swallowing and breathing may be affected. Therefore, this topic remains relevant at the present time for specialists in many fields of medicine. Orthodontists and orthopedists play an important role in the recovery period. It is also necessary to remember that this is an aesthetically important area and the cosmetic effect strongly affects the quality of life of the patient.
The purpose of this work was to improve the quality of treatment of patients with chemical osteonecrosis of the maxillofacial skeleton through competent planning of surgical intervention and rehabilitation of patients aimed at close cooperation of doctors of related specialties, as well as the participation and motivation of the patient himself in this process.
Research materials and methods. In 2015-2023, 9 patients with bisphosphonate osteonecrosis of the mandible aged 40 to 65 years were examined and treated at the dental polyclinic of Ryazan State Medical University. All patients were first given a standard dental examination, after which an additional examination method was prescribed in the form of computed tomography. Based on the data of clinical and X-ray examination on pre-made stereo models, surgical treatment was planned, which consisted in subtotal resection of the mandible in a hospital under general anesthesia. At the preoperative stage, some patients were recommended to have a tooth removed on an outpatient basis and from that moment on, patients underwent psychological training, which continued in the postoperative period together with dentists of different profiles: orthopedists, orthodontists, outpatient surgeons.
The results obtained and their discussion. Based on clinical cases, we concluded that a feature of the clinical manifestation of bisphosphonate osteonecrosis of the jaw is the chronic course and diffuse nature of the lesion, and the determining factor in the rehabilitation of such patients is a high tendency to recurrence of the process, therefore, when removing a tooth on an outpatient basis, when taking zoledronic acid preparations, a complete suturing of the well of the removed tooth immediately after tooth extraction is desirable with a synthetic non-absorbable monofilament structure material.
After successful repeated outpatient surgical treatment, patients are admitted to the hospital for the treatment of BPH, where they undergo partial resection of the mandible, and rehabilitation is carried out again on an outpatient basis. In the dental clinic of Ryazan State Medical University, we rehabilitated patients after undergoing inpatient surgical treatment for

BFONCH. One of the main tasks of this period was the prevention of deformations in related areas by restoring the harmonious proportions of the face and the full function of the dental system. Dentists involved in rehabilitation need to take into account the peculiarities of blood supply and innervation of the maxillofacial region, to understand the peculiarities of behavior and psyche of patients. After all, these patients received this complication as a result of treatment for such a terrible disease as oncology, at the same time, the face is an aesthetically significant organ and the results of rehabilitation greatly affect the quality of life of such patients.
In practice, we have determined absolutely precisely that three specialists are always involved in the rehabilitation of this group of patients: a dental surgeon, an orthopedic dentist, and an orthodontist. During surgical care, pathologically altered tissues are excised, followed by restoration with transplants. The final stage of rehabilitation is orthopedic care, which allows you to restore lost functions and aesthetic harmony of the face.
In addition to rehabilitation therapy by dentists of various profiles, we paid great attention to myohymnastics. With increased muscle tone of the face and tongue, operations may not be successful. Therefore, it was necessary to teach the patient special exercises aimed at muscle relaxation before starting treatment.
We also believe that it is very important to follow a diet after surgery, therefore, after surgery, the following recommendations were identified for this patient: to refrain from taking spicy, fried and irritating food; when brushing teeth, choose a toothpaste without sodium lauryl sulfate, since it causes collagen denaturation; in the diet during rehabilitation - to reduce the content of simple carbohydrates, as they interfere with the synthesis of collagen, and therefore increase the healing period; during the recovery period, it is necessary to observe a rest regime, since growth hormone is synthesized at night and has a positive effect on tissue regeneration, healthy sleep is necessary, at least 8 hours; physiotherapy, since they increase the reactivity of the body, promote wound healing, improve tissue trophism, positively rebuild the nervous system; physical therapy according to Epifanov V.A., who defined the tasks of physical activity depending on the period of rehabilitation of the patient.
In the acute phase, immediately after the operation, exercises aimed at preventing complications and adapting the patient to basic household skills were prescribed. The author also distinguishes between subacute and recovery periods. Thus, in the second period, exercises were prescribed aimed at restoring the mobility of the temporomandibular joints, muscles, as well as at combating the development of contractures.

At the final stage, attention was paid to the restoration of full working capacity and impaired functions of the lower jaw.
Psychological rehabilitation of the patient played an important role. Ponomarenko G.N. points out the relationship between psychological balance and timely restoration of organs and tissues of the patient. The author emphasizes that untimely and incorrect provision of such assistance leads to self-medication, and this in turn has a detrimental effect on recovery. Psychotherapy was aimed at correcting inadequate emotional reactions, as well as at forming an active position of the rehabilitated patient in overcoming painful manifestations.
Thus, after the rehabilitation measures we carried out, according to an external examination 6 months after discharge, there is a moderate asymmetry of the face due to deformation of the soft tissues of the lower third of the face due to bone deficiency. In the submandibular region, a pale pink scar is visualized, with no visible discharge. With bimanual palpation, a densely elastic array of soft tissues is palpated during plate fixation. There are no areas of bone tissue exposure in the oral cavity.
Conclusions. The materials presented in the article reflect the need for close cooperation between specialists in related fields for the competent rehabilitation of patients with postoperative defects of the maxillofacial skeleton. Dental rehabilitation is aimed at maximum aesthetic and morphological recovery and begins already at the stages of preoperative preparation. Patients with this pathology need an individual approach. A detailed examination in the preoperative period using modern radiological methods makes it possible to remove pathologically altered tissues in full with maximum preservation of healthy tissues and accelerate the patient's adaptation and restoration of functions after surgery.
Rehabilitation should be aimed at improving the quality of life of patients, normalization of aesthetic and anatomical and morphological parameters. According to experts, the main attention should be paid to the first months of the postoperative period, to take timely action to restore the patient, to help him develop the habit of working on himself.
All of the above dictates the need to search for and improve methods for an objective assessment of the prevalence of necrosis, determining the optimal treatment tactics using high-tech methods and proper planning of patient rehabilitation, which ensures a favorable prognosis and a good quality of life in the postoperative period.


About the authors

Yuri A Medvedev

Federal State Budgetary Educational Institution of the Ryazan State Medical University of the Ministry of Health of Russia


MD, Professor, Professor of the Department of Surgical Dentistry and Maxillofacial Surgery with a course of ENT diseases

Russian Federation, Shevchenko str., 34, building 2, Ryazan

Lyubov B Filimonova

Federal State Budgetary Educational Institution of the Ryazan State Medical University of the Ministry of Health of Russia

Author for correspondence.
Russian Federation, ул. Шевченко, 34, корп. 2, г. Рязань

Alexander N Zhuravlev

Federal State Budgetary Educational Institution of the Ryazan State Medical University of the Ministry of Health of Russia


PhD, Associate Professor of the Department of Surgical Dentistry and Maxillofacial Surgery with a course of ENT diseases

Russian Federation, Shevchenko str., 34, building 2, Ryazan


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