백서 하악 골수염에서 감압술 효과

학위논문 (석사) -- 서울대학교 대학원 : 치의학대학원 치의과학과, 2021. 2. 김성민.연구의 배경 및 목적 턱의 골수염 (Osteomyelitis, OM) 은 대개 만성적인 치성 감염이나 턱뼈를 파괴하는 여러 가지 다른 이유로 인해 발생한다. 포도상구균(Staphylococcus aureus, S. aureus) 과 같은 미생물은 중요한 병원균이다. 악안면 낭포종에 드레인을 이용한 감압술은 신뢰할 수 있는 치료방법으로 낭포종 내벽에 배농을 위한 최소한의 배관을 뚫어 낭포종의 크기의 줄이고, 낭포종의 내압을 줄임으로써 주변으로부터 점진적인 뼈 성장을 가능하게 한다. 이 연구의 목적은 하악 골수염 백서 동물 모델에서 감압술의 효과에 대해서 알아보는 것이다. 연구방법 평균 몸무게 230.13±13.87의 8주 된 수컷 Sprague-Dawley 백서 14마리를 실험에 사용하였다. 하악에 직경 4 mm의 결손부를 만들어 1x107 CFU/ml 농도의 포도상구균 20ul를 결손부에 주입하여 골수염을 유발하였다. 백서는 치료방법에 따라 대조군은 치료하지 않은 그룹을 대조군 1 (control, C1), 소파술을 시행한 그룹을 대조군 2 (control, C2) 로 설정하였고, 실험군은 소파술, 드레인을 이용한 감압술을 시행한 그룹을 실험군 1 (experimental 1, E1), 소파술, 드레인을 이용한 감압술과 드레인을 통해 생리식염수로 세척을 시행한 그룹을 실험군 2 (experimental 2, E2) 로 설정하였다. 치료 후 4주에 백서를 희생하여 마이크로 단층촬영 (micro-CT), 헤마톡실린-에오신 (hematoxylin and eosin, H&E) 과 Masson’s trichrome 염색을 사용한 조직학적 분석을 시행하였고, 염증 관련 항체 IL-6와 TNF-α, 신생 혈관 관련 항체 VEGF-A와 TGF-β1, 골 형성 관련 항체 OPN와 ALP 항체를 사용해 면역화학적 분석을 시행하였다. 연구결과 백서 하악골 골수염 모델에서 포도상구균에 의해 골수염이 유발된 것을 임상과 실험적 결과로 확인하였다. 마이크로 단층촬영 (micro-CT) 에서 골 치유에 대한 대부분의 매개변수는 대조군 1 (C1) 과 대조군 2 (C2) 그룹에서 현저히 낮았다. 특히 실험군 2 (E2) 에서 대조군 1 (C1) 과 대조군 2 (C2) 에서 볼 수 있는 것 보다 골량 (bone volume) 과 골밀도 (bone mineral density, BMD) 가 크게 향상되었고, bone volume/volume of interest 가 유의미하게 높았다 (p < 0.05). 조직학적 분석에서 실험군 1 (E1) 과 실험군 2 (E2) 에서 결손부위에 발견되는 골세포 (osteocyte) 의 수가 현저히 많은 것으로 두드러진 골 치유를 보였다 (p < 0.05). 면역화학적 염색에서 실험군 2 (E2) 는 대조군 1 (C1) 에 비해 IL-6의 표현이 가장 약했고, TNF-α의 표현은 다른 그룹과 비교하여 실험군 1 (E1) 에서 강하게 착색되었다. VEGF-A의 표현은 실험군 2 (E2) 에 비해 대조군 1 (C1) 에서 가장 높았고, TGF-β1, ALP, OPN 표현은 실험군 1 (E1) 에서 현저하게 높았으며, 대조군 1 (C1) 에서는 다른 그룹과 비교했을 때 TGF-β1, ALP, OPN 표현이 없었다. 결론 마이크로 단층촬영 (micro-CT), 헤마톡실린-에오신 (hematoxylin and eosin, H&E)과 Masson`s trichrome 염색을 사용한 조직학적 분석 및 면역화학적 분석은 골수염 백서 모델에서 드레인을 이용한 감압술이 기존의 수술적 치료에 비해 이상적인 골 치유 결과를 보였음을 확인하였다. 이러한 결과를 바탕으로 임상의는 악안면 골수염 치료를 위해 배농 (drainage) 과 세척 (irrigation) 을 동반한 감압술을 사용하는 것을 권장할 수 있을 것으로 사료된다.Introduction Osteomyelitis (OM) of the jaw is usually caused by odontogenic infection or by a variety of other reasons which result in jaw bone destruction. Microorganisms such as Staphylococcus aureus (S. aureus) are known to be significant pathogens at the pathogenesis of OM. Decompression using a drain is a reliable technique, which releases the intraluminal pressure causing reduction of cyst and allows gradual bone regeneration from the periphery. The aim of this study was to analyze the effectiveness of decompression in an OM rat mandible model. Materials and methods A 4 mm diameter defect was made on the mandibles of 14 male Sprague-Dawley rats (8 weeks old with weight of 230.13+/-13.87 g) and 20 μl of 1x107 CFU/ml S. aureus was inoculated. Two weeks later, the animals were randomly divided into non-treatment control (C1), curettage only control (C2), curettage and decompression using drain (E1), and curettage and decompression using drain with normal saline irrigation (E2) groups. After four weeks, the animals were assessed with micro-computed tomography (micro-CT), histology stained with hematoxylin and eosin (H&E) and Masson's trichrome (MT), and immunohistochemistry (IHC) stained with inflammation-related IL-6 and TNF-α, angiogenesis-related VEGF-A and TGF-β1, and osteogenesis-related OPN and ALP antibodies, followed by statistical analysis. Results S. aureus infected osteomyelitis model was successfully created in a rat mandible. Most parameters showed significantly lower bone healing in the C1 and C2 groups in micro-CT analysis. Especially in the E2 group, bone mineral density with bone volume was significantly enhanced compared to that seen in the C1 or C2 groups, and bone volume/volume of interest parameter was significantly higher (p < 0.05) in the E2 group. In the histological analysis, the E1 and E2 groups showed the most prominent bone healing with a significantly high number of osteocytes found in the defect area (p < 0.05). In IHC staining, the E2 group had the weakest expression of IL-6 compared to that of the C1 group. The TNF-α antibody was stained strongly in the E1 group compared to that of other groups. The expression of VEGF-A was the highest in the C1 group compared to the E2 group. The TGF-β1, ALP, and OPN expressions were markedly high in the E1 group, while the C1 group had no TGF-β1, ALP, and OPN expression compared to that of the other groups. Conclusion The micro-CT, H&E, and MT stained histological analysis, and IHC analyses showed that decompression drains exhibited superior bone healing results compared with that of conventional surgical treatment alone in an OM rat mandible model. Based on these results, it is recommended that clinicians use decompression with drainage and irrigation to treat jaw OM.Contents I. Introduction 01 II. Materials and Methods 04 II.1. Establishment of an S. aureus-infected jaw 04 osteomyelitis model in rat II.2. Grouping and experimental design 07 II.3. The analysis of bone healing with micro-CT 08 II.4. The histological and immunohistochemical 09 analysis of OM healing II.5. Statistical analyses of micro-CT and histological 10 data of bone healing III. Results 11 III.1. Establishment of an S. aureus-infected jaw 11 osteomyelitis model in rat III.2. Clinical evaluation with blood test 11 III.3. Micro-CT results of bone healing 12 III.4. Histological and immunohistochemical results of OM healing 13 IV. Discussion 15 V. Conclusion 20 References 21 Tables 25 Figures and Figure legends 29 Abstract in Korean 47Maste

A 10-year survival rate of tapered self-tapping bone-level implants from medically compromised Korean patients at a maxillofacial surgical unit

Background The 10-year survival rate of dental implants in healthy subjects is 90–95%. While in healthy individuals, dental implants have become commonplace to solve problems of edentulism, whether dental implant treatment is optimal in patients with systemic disease remains unclear. The purpose of this study is to investigate the clinical outcomes of tapered, sand-blasted, and acid-etched internal submerged dental implants installed in medically compromised patients in our maxillofacial surgical unit. Methods A total of 1019 Luna® dental implants were placed in 333 patients at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. Kaplan–Meier survival estimates after 10 years of follow-up were computed for healthy vs. medically compromised patients. Results The 10-year follow-up survival rate of 1019 Luna® dental implants in the Korean maxillofacial surgical unit was 97.0% with a mean follow-up of 41.13 ± 35.13 months (0–120 months). The survival rate was 97.0%, in which 31 implants were failed during the follow-up. Cumulative 10-year implant survival rates were 99.4% in healthy individuals without systemic disease and 95.9% in patients with systemic disease. Conclusions Comparable success and survival rates were achieved with those of implants in healthy patients. Preoperative general health assessments including laboratory test results and checking the previous medication records are essential in diagnosing any unrecognized conditions for improved implant success rates in medically compromised patients

Decompressive effects of draining tube on suppurative and sclerosing osteomyelitis in the jaw

Background Osteomyelitis (OM) in the jaw is an inflammatory disease of osseous tissue that begins in the medullary space and progressively expands to the cortical portion of the bone, the Haversian system, the periosteum and the overlying soft tissue. Despite advances in dental and medical care, OM persists and is of important concern in modern medicine. Active negative pressure is known to prevent post-operative hematoma; decrease the number of bacterial pathogens, accumulation of toxins, and necrotic tissue; and promote osteogenesis and angiogenesis with the use of a draining tube such as the Jackson-Pratt (JP) or Hemovac. The purpose of this study was to assess the effectiveness of decompression for the treatment of OM in the jaw. Methods This retrospective study included a total of 130 patients, 55 patients with sclerosing OM and 75 patients with suppurative OM were included. The radiographic bone densities expressed as a grayscale values (GSVs), were measured using an easy digitalized panoramic analysis (EDPA) method, processed on the conditional inference tree, generated by the R program® 3.2.3 with a probability of 96.8%. Rectangle annotation analysis of INFINITT PACS® (INFINITT Healthcare, Seoul, Korea) of 50 mm2 was determined as the region of interest (ROI). Students t-test and ANOVA were used to determine significance (p < 0.05). Results Significant changes was observed between radiographic bone density in the sclerosing type with drain and without drain at the six-month and one-year follow-up (p < 0.05). Significant difference was demonstrated between the suppurative OM with drain and without drain groups at the one-year follow-up (p < 0.05). Conclusion The OM groups with drain exhibited more enhanced bone density compared to the groups without drain at the six-month and one-year follow-ups. The drain insertion for decompression is effective for the management of sclerosing and suppurative OM. It is recommended to implement it for the management of OM.This study was supported by grant no 03–2019-0043 from the SNUDH Research Fund and by Basic Science Research Program of NRF funded by the Ministry of Education (2017R1D1A1B04029339)

Adverse reaction to Coartem (artemether/lumefantrine) resulting in oculogyric crisis

Background Artemether/lumefantrine (AL), sold under the brand name Coartem, is the most common artemisinin-based combination therapy for the treatment of malaria. Drug-induced oculogyric crisis is a neurological disorder characterized by frequent upward deviations of the eye. In the literature, no cases of Coartem-induced oculogyric crisis have been reported in Ghana. Case presentation A 19-year-old male patient, who presented fever measuring 37.9 °C, general body pains, and weakness was prescribed with antimalarial therapy artemether/lumefantrine, Coartem®, from a local pharmacy. Just after initiation of treatment, the patient complained of double vision, involuntary upward eye deviation, and inability to close both eyes. The patient was diagnosed with Coartem-induced oculogyric crisis and was treated with the cessation of the causing agent and intramuscular injection of promethazine hydrochloride. Conclusions When a patient exhibits a neurological disorder, such as oculogyric crisis, with normal conscious state and normal vital signs, special attention should be given to obtaining a history of recently administered medications. Clinicians should recognize adverse reactions to drugs based on a thorough patient history and examination. The goal of this report was to present Coartem-induced oculogyric crisis.This research was supported by Basic Science Research Program funded by the Ministry of Education (2017R1D1A1B04029339) and by grant no 03-2019-0043 from the SNUDH Research Fund

Electron microscopic analysis of necrotic bone and failed implant surface in a patient with medication-related osteonecrosis of the jaw

Background Bisphosphonates (BP), a commonly used medication for various bone diseases, have been known to have severe complications such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). Failure of dental implants has also been found in patients with medication-related osteonecrosis of the jaw (MRONJ). In this study, we analyzed the necrotic bone tissues and the surface of the failed implants removed from the jaw in patients treated with BPs and antiresorptive agents. Results Chronic inflammatory cells with collagen and fibrous tissues and bone sequestrum were shown at 5.0 × , 10.0 × , 20.0 × , and 40.0 × magnified histologic sections in the bone and fibrotic scar tissues removed from patients with MRONJ due to osteonecrosis. Hardened bone tissues with microcracked bony resorbed lacunae were observed in SEM. Unlike the previously published comparative data where immune cells, such as dendritic cells, were found in the failed implant surface, these immune cells were not identified in the BRONJ-related peri-implantitis tissues through the TEM investigations. Furthermore, EDS revealed that in addition to the main titanium element, gold, carbon, oxygen, calcium, phosphorus, silicon, and sulfur elements were found. Conclusion Hardened bone tissues with microcracked bony resorbed lacunae were observed in the SEM findings, which were considered as the main characteristic of the osteonecrosis of the jaw. Immune cells, such as dendritic cells were not identified in the TEM. EDS showed that in addition to the main titanium element, gold, carbon, oxygen, calcium, phosphorus, and silicon elements were found. Furthermore, it was revealed that sulfur was found, which was considered to be one of the complicated causes of implant failure in patients with BRONJ

Clinical feasibility and benefits of a tapered, sand-blasted, and acid-etched surfaced tissue-level dental implant

Abstract Background It has been 50 years since Brånemark first introduced the concept of osseointegration. Since then, numerous ongoing research, developments, and optimization of implant properties have been conducted. Despite the high survival and success rates of dental implants, failures still occur in a small number of patients that are being rehabilitated by implants. The purpose of this study was to evaluate the survival and success rate of the Stella® implants that incorporate sand-blasted and acid-etched (S&E) surface treatment and tapered body design to confirm their clinical feasibility and benefits after placement. Methods We reviewed 61 partially and fully edentulous patients who underwent a tapered, S&E surfaced tissue-level implant placement between May 2013 and February 2016 in the Department of Oral and Maxillofacial Surgery in the Seoul National University Dental Hospital. Patient characteristics and treatment results were collected, and records of dental implants were analyzed clinically and radiologically. Results A total of 105 implant fixtures were placed in these patients. The mean age at the time of the surgery was 63.7 years with a range of 31 to 88 years. In total, 4.0-mm and 4.5-mm diameter implants were the most frequently used dental implants (40%, 49%) in this study. Implants 8.5 mm in length were predominantly used (60%). Seventy dental implants were placed in the mandible (70%), and only one dental implant was placed in the maxillary anterior region. At the end of the 5-year observation period, the success rate of the Stella® implants was 98.1%. Among the 105 implants placed, 2 were considered to be failures. Summarizing the clinical and radiographic results, the remaining 103 implants were considered successfully integrated. Conclusion The overall success rate was 98.1%. The tapered, S&E surfaced tissue-level implant system exhibited great performance in a variety of clinical situations including failed implant sites that enabled predictable and successful treatment outcomes. The effectives of a tapered design of tissue level, not a parallel design, are shown in this clinical report

Oral Manifestation of Unknown Hematopoietic Malignancy

Burkitt lymphoma is a highly aggressive type of hematopoietic malignancy that is comparatively common in chil dren and young people. It is important that Burkitt lymphoma be diagnosed as early as possible for prompt inter vention due to its rapidly progressive, high-grade malignant nature. Dentists, especially maxillofacial surgeons, can play a life-saving role in patients with such unknown malignancy as the first clinical or radiological manifestation might occur in the oral region.N

An accurate diagnosis of odontogenic cutaneous sinus tract by different computed tomography unit setting

Due to their rarity and the lack of associated dental symptoms, odontogenic cutaneous sinus tracts (OCSTs) are often misdiagnosed and confused with cutaneous lesions or non-odontogenic infections. It has been estimated that 50% of individuals affected by OCSTs are subjected to inappropriate treatments before the correct diagnosis is established. We describe the diagnosis and treatment of two cases of OCSTs. By using a computed tomography (CT) with soft tissue window setting, the extent of cortical bone destruction and the path of the sinus tract in the soft tissue was easily identified. Thus, we recommend the use of imaging techniques such as CT, which can confirm the odontogenic origin and the exact location of the OCST.Y

Odontogenic Keratocyst in the Masseter Muscle

Odontogenic keratocyst (OKC) arising from purely soft tissue other than the mucosa covering the jawbone is rare. A 57- year-old Korean female patient presented with a lump on her right cheek, which had been suspected as a fibrotic mass on the buccinator muscle by the local clinic. Magnetic resonance imaging showed an ovoid mass in the buccal space just before the right ramus with an enhancing component in the marginal area, and the interior of the mass revealed a fluid signal. Histopathologically, the lesion showed the typical features of OKC and the cyst wall contained some daughter cysts and the minor salivary gland, muscle, and fat tissues. The authors report a very unique case of OKC arising in the masseter muscle.N

Legal Liability of a Dentist: Inferior Alveolar Nerve Damage After Calcium Hydroxide Extrusion

During root canal treatments, calcium hydroxide can extrude through the apex causing chemical, mechanical, and/or thermal injuries to the inferior alveolar nerve, which can lead to neurological disorders. unfortunately, dental practitioner negligence can produce this potentially life-changing injury that can compromise the patient&apos;s life. The aim of this study is present a case of dental negligence by calcium hydroxide extrusion causing inferior alveolar nerve damage, discuss the methods of prevention, and characterize the medico-legal aspects of complication.N