The success of dental implants has long been considered to be dependent primarily on the quality and quantity of alveolar bone. Bone grafting allows patients with insufficient bone volume to obtain implant-supported prosthetic solutions for treatment of edentulism. While extensive bone grafting procedures have been commonly used to rehabilitate severely atrophic arches, they can be associated with long treatment times, unpredictability, and donor site morbidity. Nongrafting solutions have more recently been employed that maximally utilize the residual highly atrophic alveolar or extra-alveolar bone for implant therapy. With the use of modern diagnostic imaging and 3D printing technology, clinicians are able to provide individualized, subperiosteal implants that fully adapt to the patient's remaining alveolar bone. Other "graftless" implants, including zygomatic implants, utilize the patient's extraoral facial bone outside the alveolar process and have been shown to provide predictable results. This article discusses the rationale for graftless solutions in implant therapy and the data supporting the use of various graftless protocols as alternatives to grafting and conventional dental implant therapy.

Background: Temporomandibular joint disorder is a complex disease requiring multimodal treatment and often a delayed diagnosis. Purpose: The primary objective of this study is to evaluate the feasibility of simultaneously recording joint sounds while obtaining 3-tesla cine-magnetic resonance imaging (3T cine-MRI) of the temporomandibular joint (TMJ). A secondary objective pertains to optimization of a dynamic TMJ imaging protocol to maximize image quality and speed while maintaining synchronicity. Methods: Investigators enrolled four subjects (August 2018 to August 2019) eliciting audible joint sounds during continuous open-close jaw movements during clinical evaluation at the New York University College of Dentistry. A contact fiber-optic microphone (OptiRhythm 4130, Optoacoustics, Yehuda Israel) was utilized to record joint sounds elicited with functional movements during MR dynamic imaging at NYU Langone Health and all data was recorded appropriately. Results: Results of this feasibility study demonstrate the successful integration of audio and 3-Tesla MR imaging for the TMJ in all subjects. This protocol was shown to be well-tolerated by the subjects. A precise correlation of the movement of TMJ structures within cine-MRI images and with audible observations was achieved and assessed by an experienced oral and maxillofacial surgeon and an experienced radiologist. Conclusion: This protocol for simultaneous audio/cine-MRI is a viable tool for studying TMJ health and disease. In future studies, we anticipate this protocol will ultimately refine our understanding of TMJ sounds and their relation to anatomy, physiology, and pathology. In addition, we hope to establish a diagnostic aid to guide surgical and non-surgical decision-making more precisely.

For many decades the success of dental implants has been considered to be dependent predominantly on the quality and quantity of the patient's alveolar bone. Building on the high success rates of implants, bone grafting eventually was implemented, allowing patients with insufficient bone volume to obtain implant-supported prosthetic solutions for treatment of partial or complete edentulism. Extensive bone grafting procedures have been commonly used to rehabilitate severely atrophic arches but are associated with long treatment times, unpredictability, and donor site morbidity. More recently, nongrafting solutions that maximally utilize the residual highly atrophic alveolar or extra-alveolar bone for implant therapy have been reported to have success. The emergence of diagnostic imaging and 3D printing technology has allowed clinicians to provide individualized, subperiosteal implants that can adapt precisely to the patient's remaining alveolar bone. Furthermore, paranasal, pterygoid, and zygomatic implants that utilize the patient's extraoral facial bone outside the alveolar process can provide predictable and optimal results with no or minimal bone grafting with less treatment time. This article considers and evaluates the rationale for graftless solutions in implant therapy as well as the data supporting the use of various graftless protocols as alternatives to grafting and conventional dental implant therapy.

On March 15, 2020, routine dental care in New York State paused due to the COVID-19 pandemic. The pause lasted 10 weeks in part to preserve critical supplies of personal protective equipment (PPE). This interruption of access to dental care led to an overall deterioration of oral health, an increase in prescribing and use of antibiotics and analgesic medications, especially opiates, and a rise in visits to hospital emergency centers. New York University's College of Dentistry, an academic ambulatory dental center, normally sees over 1,000 patient visits per day. Most visits are patients who require urgent care or are in the process of treatment to restore debilitating oral health problems. NYU Dentistry responded to the State pause by creating a nascent teledentistry service that began operations on March 17, 2020.

Technological advancement and innovation in health care is ubiquitous and accelerating. Presently, oral and maxillofacial surgeons (OMSs) employ cutting-edge technologies on a routine basis in clinical practice. Advances in cone-beam computed tomography (CBCT) and computer-aided design/computer-aided milling (CAD/CAM) enable the OMS to fabricate custom surgical guides and to use video-guided navigation systems for both precise dental implant placement, as well as for planning and executing surgical procedures. In fact, it may have been the confluence of these 2 technologies that led to the development of a new and emerging technology: robotic assisted drilling systems (RADS). Though still in its nascent stages, robotic guidance systems continue to gain traction in various surgical specialties and in oral and maxillofacial surgery. As such, it may benefit the OMS to gain an understanding of and familiarity with this technology. The purpose of this communication is not to discuss the minutia of RADS, but rather to discuss RADS in the context of its preceding technology, its improvements and current limitations, and ultimately, where RADS may take oral and maxillofacial surgery in the near future.

Integrated care delivery is at the core of patient-centered medical homes (PCMHs). The extent of integration of dental services in PCMHs for adults is largely unknown. We first identified dental-medical integrating processes from the literature and then conducted a scoping review using PRISMA guidelines to evaluate their implementation among PCMHs. Processes were categorized into workforce, information-sharing, evidence-based care, and measuring and monitoring. After screening, 16 articles describing 21 PCMHs fulfilled the inclusion criteria. Overall, the implementation of integrating processes was limited. Less than half of the PCMHs reported processes for information exchange across medical and dental teams, referral tracking, and standardized protocols for oral health assessments by medical providers. Results highlight significant gaps in current implementation of adult dental integration in PCMHs, despite an increasing policy-level recognition of and support for dental-medical integration in primary care. Understanding and addressing associated barriers is important to achieve comprehensive patient-centered primary care.

The onset of the Coronavirus 2019 (COVID-19) pandemic has challenged the worldwide healthcare sector, including dentistry. The highly infectious nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and risk of transmission through aerosol generating procedures has profoundly impacted the delivery of dental care services globally. As dental practices with renewed infection control strategies and preventive measures are re-opening in the “new normal” period, it is the responsibility of healthcare professionals to constantly analyze new data and limit the spread of COVID-19 in dental care settings. In the light of new variants of SARS-CoV-2 rapidly emerging in different geographic locations, there is an urgent need to comply more than ever with the rigorous public health measures to mitigate COVID-19 transmission. The aim of this article is to provide dental clinicians with essential information regarding the spread of SARS-CoV-2 virus and protective measures against COVID-19 transmission in dental facilities. We complied and provided guidance and standard protocols recommended by credible national and international organizations. This review will serve as an aid to navigating through this unprecedented time with ease. Here we reviewed the available literature recommended for the best current practices that must be taken for a dental office to function safely and successfully.

BACKGROUNDFrom the earliest days of the COVID-19 pandemic, dental practitioners, organizations, educators, insurers, and manufacturers were concerned about the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on a panoply of issues, including transmission modes; personal protective equipment (PPE) supplies; aerosolization; office disinfection; patient confidence; and screening and testing protocols to determine the viral status of patients, clinicians, and staff members.The shared goals of dental clinicians were to treat patients as safely as possible through optimal use of PPE with disinfection and aerosol mitigation protocols to minimize the risk of viral transmission in the dental office or school clinic.Since initial state and federal pandemic efforts focused on treating the sickest patients, hospital capacity, mass testing, and the global PPE supply, a group of dental schools recognized that dental practices would benefit greatly from the ability to evaluate the viral status of their patients using officebased, point-of-care (POC) tests, ideally using sputum, saliva, and/or finger stick blood samples.Since private dental offices and most dental schools lack the analytic instrumentation and the Clinical Laboratory Improvement Amendment (CLIA) certifications to conduct the types of polymerase chain reaction (PCR) viral tests prevalent in

diagnoses statistical statistical Aims: The purpose of this small pilot study was to determine the type and initial management of relatively common radiolucent lesions that occur at the mandibular angle based on size of the lesion and its relation to the inferior alveolar nerve on panoramic radiograph. We also wanted to determine if useful information could be gained from the pattern of lesion expansion. Methods: A retrospective review of the panoramic images of patients from New York University 2018 angle was performed. (OKCs). A total of 63 patients met the inclusion criteria. The size of each lesion along with its distance from the superior border of the inferior alveolar nerve canal, both horizontally and vertically, was measured from the panoramic images. Formal statistical analysis was deemed unnecessary for this small pilot study. Results: Our data suggest that mandibular angle lesions which were smaller in size and further from the inferior alveolar nerve were more likely to be dentigerous cysts. Those mandibular angle lesions with larger size and less distance from the nerve canal were more likely to be OKCs or ameloblastomas. Furthermore, based on our data, ameloblastomas had the largest average lesion size, both horizontally and vertically. Our data also showed that dentigerous cysts appear to grow relatively symmetrically, while ameloblastomas and OKCs have an asymmetrical growth pattern. Conclusion: This study demonstrates how a surgeon can effectively utilize the panoramic radiograph to classify the lesion and thus guide initial surgical management of whether an immediate excisional biopsy can be definitive treatment or if the patient can benefit from immediate decompression therapy, thereby decreasing the necessity of further surgery.

Surgical extractions of mandibular third molars are among the most common procedures performed by oral and maxillofacial surgeons (OMSs). Injury to the inferior alveolar nerve (IAN) is a major consideration and can occur in up to 8% of cases overall; however, the risk has been significantly related statistically to the position of the third molar and the proximity of the neurovascular canal. Other risk factors include advanced patient age, difficulty of the procedure, and experience of the surgeon. The incidence of permanent or long-term damage to the IAN can approach 3.6% of cases.

e18268 Background: Antiresorptive medications are important in maintaining bone health for patients with osteoporosis, metastatic cancer and multiple myeloma. Medication-related osteonecrosis of the jaw (MRONJ) may compromise quality of life and treatment of the underlying disease. There are many controversies regarding the pathogenesis, risk and management of MRONJ. Evidence-based data that suggest osteonecrosis of the jaw (ONJ) is triggered by infection and reports of ONJ unrelated to antiresorptive therapy (ART) have confounded previous hypotheses that pathogenesis is directly attributed to ART by oversuppression of bone remodeling. The aim of this study is to determine the outcome for management of MRONJ based on eradication of infection. Methods: The investigators designed a retrospective cohort study for patients who underwent surgical management of MRONJ. Identification of infected and necrotic bone was achieved via nuclear imaging (i.e., technetium bone scan, positron emission tomography), computed tomography and/or cone beam computed tomography. Surgical techniques included bone resection (i.e., marginal, segmental), local flap, reconstruction with microvascular free flap, and/or autogenous platelet graft. Perioperative modalities included hyperbaric oxygen therapy and culture-guided antibiotic administration. We recorded medical history, location of the MRONJ lesion, type of antiresorptive therapy and duration of perioperative antiresorptive therapy. The outcome variable was postoperative healing defined by mucosal closure without signs of infection or exposed bone at the time of follow-up including cases with complications related to subsequent dental infection or treatment. Descriptive statistics were calculated for successful management, medical history and duration of perioperative antiresorptive therapy. We excluded cases treated by palliative intent, when surgery was limited or contraindicated, and/or inadequate follow-up. Results: A total of 54 patients with 59 MRONJ lesions were evaluated (40 with cancer and 14 with osteoporosis). All patients were successfully treated with 13 patients continuing ART after surgery (average follow-up 10 months) and 8 patients requiring more than 1 surgery for lesions associated with osteosclerosis. Conclusions: This study suggests that MRONJ is an infection-driven process that can be managed with various modalities to control diseased bone and facilitate healing. Patients may resume ART following successful management of MRONJ.

OBJECTIVE:Osteonecrosis of the jaw (ONJ) is commonly associated with antiresorptive therapy. There have been numerous reports of ONJ unrelated to antiresorptive therapy (ONJuat), confounding risk assessment. This study aimed to determine if ONJuat is associated with one or more particular comorbidities. STUDY DESIGN:This was a retrospective case-control study of patients with ONJuat and delayed healing (DH). Each case was matched for patient age and gender, as well as location of ONJuat or DH lesion to a control patient who had a history of dentoalveolar surgery with uneventful healing and no history of antiresorptive therapy. Comorbidity data included medical conditions and smoking. RESULTS:Of the 92 patients identified, 67 (73%) met the criteria for ONJuat and 25 (27%) for DH. The most common trigger for ONJ and DH was extraction (50%). The presence of any comorbidity (i.e., at least 1) was more prevalent in ONJuat than among controls (P = .04), and there were more comorbidities in patients with ONJuat and DH than in controls [M(SD) = 1.94 (1.2) and 2.0 (1.3) vs 1.26 (0.89); both P < .001]. CONCLUSIONS:ONJ and DH are not limited to patients with a history of antiresorptive therapy. More comorbidities may signal increased risk for ONJuat and DH.

Purpose: There is considerable controversy over the treatment of medication-related osteonecrosis of the jaw (MRONJ) and growing interest and debate related to the timing, type, technique, and goals of surgical intervention. The specific aim was to evaluate the predictive value of fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) on healing outcomes in patients undergoing surgery for MRONJ of the mandible.Materials and Methods: A retrospective cohort study of 31 patients with 33 MRONJ lesions of the mandible who had undergone surgery using FDG PET-CT was conducted. Data were collected on FDG uptake patterns, healing, follow-up, demographics, lesion characteristics, antiresorptive therapy, and adjunctive therapy. Panoramic and/or periapical radiographs were used to identify non-restorable teeth and PET-CT images were used to identify sequestra and FDG uptake. Above the mandibular canal, surgery consisted of marginal resection and/or debridement of clinically involved bone and exposure of clinically uninvolved bone identified by FDG uptake. Below the mandibular canal, mobile segments of bony sequestra were removed, but areas of clinically uninvolved bone with FDG uptake were not. Patients who did not heal underwent segmental resection and reconstruction with rigid fixation and a local or regional soft tissue flap or free fibular flap. The primary predictor variable was the FDG uptake pattern for each patient. The outcome variable was postoperative healing defined by mucosal closure without signs of infection or exposed bone at the time of evaluation.Results: Two risk groups were identified based on FDG uptake pattern. The low-risk group, type A, included 22 patients with activity limited to the alveolus, torus, and/or basal bone superior to the mandibular canal. The high-risk group, type B, included 11 patients with type A FDG activity with extension inferior to the mandibular canal. Treatment of type A MRONJ lesions was more successful than treatment of type B MRONJ lesions (100 vs 27%; P < .001). Seven of the type B failures were successfully retreated by segmental resection and reconstruction (1 patient refused further treatment).Conclusion: These results showed that low-risk FDG PET-CT findings predicted successful healing with surgery above the mandibular canal. In contrast, high-risk FDG findings were associated with a greater than 50% risk of failure for treatment that extended below the mandibular canal. Although these failures suggest that FDG uptake indicates infected tissue, further research is needed to identify which high-risk patients are most likely to benefit from a conservative treatment protocol. (C) 2016 American Association of Oral and Maxillofacial Surgeons

Biphasic calcium phosphate (BCP) bioceramics have been successfully applied in a broad variety of presentation forms and with different ratios of hydroxyapatite (HA) and β-tricalcium phosphate (β-TCP). BCPs have been loaded with stem cells from different origins for bone tissue engineering purposes, but evidence of stem cell behavior on different compositions (various HA/β-TCP ratios) and physical features of BCPs is limited. We compared the adhesion, proliferation, viability and osteogenic potential of human mesenchymal stem cells (MSCs) on granular BCPs with equal HA/β-TCP ratio of diverse particle sizes and on porous blocks which had different chemical compositions. In addition, the osteogenic differentiation of MSCs was compared to adipose-derived (ADSC) and dental pulp (DPSC) stem cells, as well as to pre-osteoblasts on a particulate BCP. MSCs growing on granular BCPs demonstrated increased number as compared to MSCs growing on blocks. Cells proliferated to a greater extent on small granular BCPs, while large granular BCPs and blocks promoted cell differentiation. Surprisingly, the expression of genes involved in osteogenesis was upregulated in MSCs on bioceramics in basal medium which indicates that BCPs may have osteoinductive potential. This was confirmed with the upregulation of osteochondrogenic markers, at different time points, when stem cells from various tissues were grown on the BCP. This study demonstrates that BCPs, depending on their physical features and chemical composition, modulate stem cell behavior, and that stem cells from different origins are inherently distinct in their gene expression profile and can be triggered toward osteochondrogenic fate by BCPs.

Purpose: Imaging is important to identify subclinical changes and for treatment planning in patients with osteonecrosis of the jaw (ONJ) exposed to antiresorptive therapy. The aim of this study was to compare the findings at radiography with those at fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) for patients with ONJ related to antiresorptive therapy.Materials and Methods: A cross-sectional retrospective analysis of patients with clinically identified ONJ lesions of the mandible was performed. Two imaging modalities were evaluated for each patient: plain radiography (ie, panoramic or periapical) and FDG PET/CT with 1-mm sections. Outcome variables for the radiographic findings were osteolytic and osteosclerotic bone changes. Outcome variables for FDG PET/CT images were localization of FDG uptake. Maximum standard uptake values (SUVmax) of abnormal FDG jaw uptake were recorded, in addition to the mean SUV of the contralateral normal mandible, and used to calculate the target-to-background ratio. Radiographic changes and FDG uptake were classified as local (ie, corresponding to exposed cortical bone) or diffuse (ie, local changes and changes extending beyond the margins of exposed bone) for each imaging technique. Local and diffuse changes detected by each imaging modality were described and the difference in detection was compared with the McNemar test.Results: Twenty-three patients with 25 clinically identified ONJ lesions were analyzed using radiography and FDG PET/CT. Differences were found in how radiography and FDG PET/CT detect local and diffuse changes associated with ONJ. Radiography showed local changes in 17 patients (68%), diffuse changes in 3 patients (12%), and no changes in 5 patients (20%), whereas FDG PET/CT imaging showed local changes in 17 patients (68%) and diffuse changes in 8 patients (32%). The McNemar test indicated that FDG PET/CT imaging was less likely to miss a lesion (P <.001). Mean SUVmax was 6.59, and the mean target-to-background ratio was 5.37.Conclusion: The results of this study show that FDG PET/CT detects local and diffuse metabolic changes that may not be represented by plain radiography for patients with ONJ related to antiresorptive therapy. The target-to-background ratio allowed the discrimination between ONJ lesions and background changes. Future studies are necessary to determine whether FDG PET/CT can determine risk and facilitate management of ONJ. (C) 2014 American Association of Oral and Maxillofacial Surgeons

Bacterial biofilms have emerged as potential critical triggers in the pathogenesis of bisphosphonate (BP)-related osteonecrosis of the jaw (ONJ) or BRONJ. BRONJ lesions have shown to be heavily colonized by oral bacteria, most of these difficult to cultivate and presents many clinical challenges. The purpose of this study was to characterize the bacterial diversity in BRONJ lesions and to determine host immune response. We examined tissue specimens from three cohorts (n=30); patients with periodontal disease without a history of BP therapy (Control, n=10), patients with periodontal disease having history of BP therapy but without ONJ (BP, n=5) and patients with BRONJ (BRONJ, n=15). Denaturing gradient gel electrophoresis of polymerase chain reaction (PCR)-amplified 16S rRNA gene fragments revealed less bacterial diversity in BRONJ than BP and Control cohorts. Sequence analysis detected six phyla with predominant affiliation to Firmicutes in BRONJ (71.6%), BP (70.3%) and Control (59.1%). Significant differences (P<0.05) in genera were observed, between Control/BP, Control/BRONJ and BP/BRONJ cohorts. Enzyme-linked immunosorbent assay (ELISA) results indicated that the levels of myeloperoxidase were significantly lower, whereas interleukin-6 and tumor necrosis factor-alpha levels were moderately elevated in BRONJ patients as compared to Controls. PCR array showed significant changes in BRONJ patients with downregulation of host genes, such as nucleotide-binding oligomerization domain containing protein 2, and cathepsin G, the key modulators for antibacterial response and upregulation of secretory leukocyte protease inhibitor, proteinase 3 and conserved helix-loop-helix ubiquitous kinase. The results suggest that colonization of unique bacterial communities coupled with deficient innate immune response is likely to impact the pathogenesis of ONJ.