Bevacizumab-Associated Implant Presence-Triggered Osteonecrosis: A Case Report and Literature Review
The effect of bevacizumab-related osteonecrosis of the jaw on previously osseointegrated dental implants has not been adequately studied. Here, we report a case of osteonecrosis of the jaw detected around dental implants placed before bevacizumab therapy. A 66-year-old woman undergoing bevacizumab therapy for metastatic triple-negative breast cancer developed malocclusion after buccal gingival swelling and pain in the #18, #19, and #20 tooth region. The patient visited a local dental clinic, where existing implants in relation to #19 and #20 were removed. Subsequently, the patient visited our department, and intraoral examination revealed necrotic bone in the region corresponding to #19 and #20. Radiographic examination showed a pathologic fracture in this region that was considered to result from osteonecrosis of the jaw. Bevacizumab therapy was suspended temporarily until the acute inflammation had subsided. In addition, treatment with antibacterial agents and conservative surgery was considered. Complete soft tissue coverage was observed 14 days after surgery. In recent years, the number of patients receiving bevacizumab treatment has increased. Because bevacizumab-related osteonecrosis of the jaw could occur around previously osseointegrated dental implants as well, this case report suggests an effective treatment regimen based on a combination of antibacterial agents and conservative surgery.
(a) Panoramic radiograph taken at the time of the patient's visit to the local dental clinic reveals pathologic fractures because of osteolysis and sequestrum, including the dental implants in #19 and #20 positions (arrowhead). (b) Necrotic bone sequestrated en bloc, including the dental implants.
(a) Intraoral view at the first consultation in our department. The lower jaw is displaced to the left, and a yellowish white bone is exposed (arrowhead) around the left lower molar. (b) The panoramic radiograph taken at the first visit revealed necrotic bone isolated in the region corresponding to #19 and # 20, from where the implants had been removed (arrowhead).
(a) Surgical specimen. Noninvasively removed, superficial isolated bone. (b) The histologic section shows that the bone fragments were surrounded by inflammatory cells and bacterial aggregates and were irregularly resorbed. Numerous empty osteocytic lacunae are observed, as are mosaic-pattern lines of bone remodeling (H&E, scale bars: 100 μm).
Localized findings. (a) Before conservative surgery. (b) Four weeks after surgery. (c) Six months after surgery.
Attachment of the maxillary twin rows splint.
The panoramic radiograph taken 2 months after surgery showed callus formation around the pathologic fracture site. Callus formation (arrowheads) was even more pronounced 6 months after surgery.
Seven months after surgery, 3-dimensional computed tomography reveals additional callus formation.
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