PMC8054499_01
Previously reported cases of tocilizumab-related osteonecrosis of the jaws (with or without co-treatment with bisphosphonates or other drugs)
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T1
An intraoral clinical examination revealed infected, dry alveolar sockets in the maxilla and mandible (regions #15-14, #11-27, #33-36 and #45-46) without signs of mucosal abscess or purulent discharge (Figure 1 (Fig. 1)).
Patient's clinical features 4 weeks after tooth extractions. Intraoral examination revealed persistent alveolar sockets and local nfection on the left side of the mandible (A). Necrotic bone exposure and persistent alveolar sockets on the right and left side of the maxilla (B). The lesion was classified as stage 2 medication-related osteonecrosis of the jaw according to the American Association of Oral and Maxillofacial Surgeons staging system [1].
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F1
A panoramic radiograph obtained on the day of her visit on March 2017 revealed regions of osteosclerosis, subperiosteal bone deposition at the extraction sites, and persistent unremodeled bone in the alveolar sockets surrounded by periapical hypermineralized lines (Figure 2 (Fig. 2)).
Panoramic radiograph examination (performed in March 2017) revealed osteonecrosis, osteolysis, and subperiosteal bone deposition. Arrows show persistent unremodeled extraction sockets at surgical sites in the mandible and maxilla.
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F2
A digital volume tomography in sagittal view showed persistent bony trabecular architecture and absence of bony lysis - the classical radiologic signs of "persistent dry alveolar sockets" (Figure 3 (Fig. 3)).
Digital volume tomography (performed in March 2017). Sagittal view shows persistent bony trabecular architecture without bony lysis, indicating classical radiologic signs of persistent dry alveolar sockets. Arrows indicate the unremodeled alveolar sockets.
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F3
The postoperative orthopantomograph showed reduced alveolar bone height without sequesters after surgical revision (Figure 4 (Fig. 4)).
Postoperative panoramic radiograph (performed in March 2017) after surgical decortication, showing diffuse bone resorption of the mandible in the region of alveolar exposure, and the remaining vital alveolar bone.
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F4
A postoperative orthopantomograph was performed in August 2017 after surgical decortication showed vital alveolar bone (Figure 5 (Fig. 5)).
Panoramic radiograph (performed in August 2017) after the second alveolar decortication, 5 months after first surgical approach, presenting the remaining vital alveolar bone of the mandible and maxilla.
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F5
The sagittal view of the digital volume tomography showed persistent bony trabecular architecture without signs of osteonecrosis (Figure 6 (Fig. 6)).
Sagittal view of the digital volume tomography (performed in August 2017) after surgical decortication. Arrows show persistent bony trabecular architecture without signs of osteonecrosis. Clinically, no signs of wound dehiscence or bone exposure were detected.
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F6
The histopathological analysis of the decalcified samples showed areas of bone necrosis with inflammatory cell infiltration, several basophilic bacterial colonies, empty Haversian canals without residual osteocytes/osteoblasts, and fewer Haversian blood vessels, thus confirming the clinical diagnosis of MRONJ (Figure 7 (Fig. 7)).