Giuseppe Spinelli

Osteonecrosis from biphosfonates


Oral Surgery

Bisphosphonates are drugs used with relative Frequency range in various clinical forms, in particular in the treatment of osteoporosis. The use of intravenous bisphosphonates with some particularly powerful action is also indicated for the treatment of metastatic bone lesions or bone localization of myeloma and hypercalcemia secondary to malignancy.

The objective of the bisphosphonate therapy is the inhibition of osteoclastic activity with consequent strengthening of the trabecular bone.

In patients undergoing intravenous therapy with these drugs have been noted in all an incidence, not yet well defined, of osteonecrosis to the jaw. Since 2003, numerous reports have appeared in the literature on the relationship between intravenous bisphosphonates and osteonecrosis of paintings against the jaw (Wang et al 2003). The most affected site is the mandible (60%), compared to the jaw (40%) and sees implicated in 40% of cases, the pamidronate followed by zoledronic acid in 30% (Woo SB, Hellstein JW, Kalmar JR. Narrat. Ann Intern Med 2006).

In people taking bisphosphonates and.V. the incidence of osteonecrosis goes from ‘1% to 10% and the risk of developing bone necrosis becomes significant after 12 months of therapy (Durie BG, Katz M, N Engl J Med 2005).

The symptoms consist of pain and consequent inability in chewing and swallowing, oral abscesses and/or skin, pus and paresthesias. The typical clinical picture is presented as a single or multiple outbreak of bone exposure, fistula without bone exposure, cutaneous abscess and/or oral mucosa covered with erythematous, trismus, maxillary sinusitis, halitosis. From this extremely current was set up a study group of specialized experts from the Careggi hospital that proposes to carry out epidemiological studies, both retrospective and prospective in order to develop a critical awareness both in the world of dentists in the world of general practitioners . Dr. Giuseppe Spinelli makes his contribution in this study as a doctor specializing in maxillofacial surgery.

The approach proposed by Dr. Giuseppe Spinelli against bone necrosis by bisphosphonates is elective surgery.

In relation to the extent of the lesion and the performance status of patients can have different types of surgery:

  • Curettage alveolar.
  • Mandibular resection.
  • Resection and mandibular reconstruction with fibula free flap.

Can be done either under general anesthesia and conscious sedation.

The ‘intervention has a total duration of 40 minutes.

You are running an intraoral access and remove the necrotic tissue moving futher at least 1.5 cm in healthy tissue while maintaining the ‘integrity of the mandibular arch.

Required Exams: TC, OPT.


It is performed under general anesthesia.

The ‘intervention has a total length of 1.5 H…

You can either perform intraoral or extraoral access and removes necrotic tissue further at least 1.5 cm in healthy tissue going on breaking the continuity of the mandibular arch.

Required Exams: TC, OPT.


It is performed under general anesthesia.

The intervention of a total duration of 5-7 H.

This surgery is a viable therapeutic proposal in patients with good performance status in disease remission.

Intervention is divided into the following phases:

  • Extraoral mandibular resection with extraoral access reaching out further in healthy tissue for at least 1.5 cm from the lesion.
  • Dissection of the fibula with a lateral approach and isolation of the free flap with vascular pedicle.
  • Modeling of the flap.
  • Positioning of the flap at the recipient site and its revascularization with anastomosis to the branches of the external carotid artery.

Required Exams: TC, OPT, PET e ECODOPPLER.