Buccal Fat Pad Research Articles

TOPOGRAPHIC AND ANATOMICAL PECULIARITIES OF THE LATERAL REGION OF THE HEAD IN HUMAN FETUSES

HEAD IN HUMAN FETUSESAbstract. In order to clarify the topographical and anatomical peculiarities and variant anatomy of the structures of the lateral region of the head in the fetal period of human ontogenesis, 24 specimens of human fetuses aged from 4 to 10 months of intrauterine development were studied using a complex of morphological research methods (anthropometry, macroscopy, computer tomography, morphometry, reconstruction). We found anatomical variants of the masseter and temporal muscles in human fetuses. Thus, in a 5-month-old fetus, separate muscle bundles were found, which went from the right masseter to the right temporal muscle. In a 6-month-old fetus, the deep part of the left masseter muscle was fused to the left temporal muscle. In human fetuses, the temporal fascia in the direction of the zygomatic arch splits into two layers, between which there are accumulations of adipose tissue. In late fetuses, a formed sub-aponeurotic fi brous space was found. At the end of the fetal period, a deep fi brous space is observed between the periosteum and the inner edge of the temporal muscle. The cellular spaces of the temporal area in front are connected with the buccal fat pad, which creates the prerequisites for the spread of infl ammatory processes. The topographic and anatomical features of the temporal region of human fetuses are: weak development of the temporal muscle and small depth of the temporal fossa – in the middle part from 3.0 to 6.0 mm (depending on the age of the fetus); weakly developed tendinous part of the temporal muscle, which does not reach the temporal line of the parietal bone. The bony base of the temporal area is represented by the squamous part of the temporal bone, the greater wing of the sphenoid bone, part of the parietal and frontal bones, on the inner surface of which arterial grooves and impressions of cerebral gyri are hardly visible, and sometimes not at all clear or absent. Anatomical variants of the structure of the temporal and masticatory muscles, as well as the temporal fascia, can cause complications and errors during the diagnosis and surgical treatment of infl ammatory processes in the postnatal period of human ontogenesis.

CLINICAL FEATURES OF OROANTRAL COMMUNICATION MANAGEMENT USING BUCCAL FAT PAD BY TUNNEL METHOD

Background: Today, there is a wide variety of techniques for eliminating oroantral communication. One of them is the tunnel technique using a flap of the buccal fat pad. The introduction of this technique into clinical practice and the determination of the characteristics of the clinical course of the postoperative period in patients with the elimination of the oroantral communication using the tunnel method with the buccal fat pad determined the purpose of this work. Objectives: To determine the features of the clinical course of the postoperative period in patients with elimination of the oroantral communication using the tunnel method with the buccal fat pad. Materials and methods: In 30 patients aged from 35 to 72 years at the Department of Surgical Dentistry of ROSUNIMED was carried out the management of oroantral communication arising during the extraction of maxillary molars using the buccal fat pad by tunnel method. Results: In all cases of elimination of the oroantral communication after maxillary molars removal, the tunnel technique was used without completely covering the flap of the buccal fat pad with a vestibular flap. There was a general tendency for the severity of pain and swelling to increase on the 3rd day after treatment and decrease by the 7th day. During control examinations, no cases of recurrence of oroantral communication were detected. Complete epithelization of the postoperative area was observed in 29 patients (96.7%) on day 30. Conclusions: The emerging specific features of the postoperative period allow us to recommend the tunnel method of the oroantral communication management using the buccal fat pad.

Repositioning of herniated buccal fat pad following blunt trauma - Rare case report in pediatric patients

Herniation of the buccal fat pad in pediatric patients is a rare injury, occurring due to a breach in the buccinator muscle, often termed traumatic pseudolipoma in infants. This condition plays a crucial role in cheek contour in adults. Two case reports detailing the management of this rare injury in young children emphasize the importance of assessing mucosal perforation and considering previous trauma history for accurate diagnosis. These reports provide valuable insights for healthcare professionals, contributing to the understanding and management of uncommon medical conditions.

Free buccal fat pad graft for the bone defect filling of medication-related osteonecrosis of the jaws: A novel surgical approach

Surgical intervention for medication-related jaw osteonecrosis (MRONJ) is currently the main treatment method, offering a higher healing rate than conservative approaches. However, the management of bony defects after sequestrectomy remains a challenging issue due to poor vascularization from the drug effect. The use of pedicled buccal fat pad (PBFP) for filling bone defects has become common and effective but is limited to the posterior maxillary region. To add to the advantages of the buccal fat pad, we explored a novel treatment approach using a free buccal fat pad (FBFP) to fill bone defects other than the posterior maxilla. While the FBFP has been employed in oral defect reconstruction, currently published cases have been utilized in recipient sites with good blood supply. There has yet to be any usage in poor vascularization defects like MRONJ. This article describes that the FBFP was used to fill the surgical defects of 8 patients who were diagnosed with MRONJ and who underwent sequestrectomy and saucerization. During follow-up visits, there was excellent wound healing and no significant tissue depression. Based on successful treatment experiences, FBFP is a reliable therapeutic option for the management of poor vascularization defects like MRONJ treated through surgical intervention.

"Longitudinal Experience Using Pedicled Buccal Fat Pad Flaps in Cleft Palatoplasty: Mitigating Velopharyngeal Insufficiency Risk and Severity".

Cleft palatoplasty commonly results in denuded maxillary bone in the lateral gutter(s) and a posterior void between oral and nasal closures. Bony exposure of the anterior palate subjects the maxilla to scarring and growth restriction, while scar contracture of the posterior void may result in velopharyngeal insufficiency (VPI) and fistula formation. Utilization of the buccal fat pad flap (BFPF) at the time of palatoplasty provides vascularized tissue over these critical areas, thereby reducing the rate of secondary surgery for speech and fistula revision. A single-center, retrospective review identified patients who underwent palatoplasty with or without BFPF between 1995-2015. Data collected included cleft type, surgical technique, follow-up duration, and complications. Outcomes included rate of speech surgery and palatal fistula development. Veau phenotype index was computed on a scale of 2-4 as a weighted mean to reflect the frequency of cleft type (Veau II-IV) in BFPF and non-BFPF groups. Charts of 866 patients were reviewed; 212 met inclusion criteria. Of these, 101 received a BFPF. Mean follow-up duration was 11.4 years. Despite a selection bias for more severe clefts, the BFPF group had lower incidence of speech surgery (9.9% vs. 36.9%, p=0.0072). The BFPF group had more mild cases treatable with fat injection (7.9% vs. 2.7%, p=0.0346) and developed fewer fistulas (6.9% vs. 18.0%, p=0.0280). Despite the presence of more severe clefts, the BFPF group had a significantly lower rate of speech surgery. The BFPF is a valuable adjunct in primary palatoplasty, reducing VPI and fistula formation.

Effect of 980 nm photobiomodulation delivered by a handpiece with Gaussian vs. Flat-Top profiles on proliferation and differentiation of buccal fat pad stem cells.

The aim of this study was to compare the effectiveness of the Gaussian and Flat-Top profiles in proliferation and differentiation of mesenchymal stem cell of buccal fat pad. Based on the timing schedule and type of laser handpieces, the cells were assigned to a control group with no radiation, and two irradiation test groups (980 nm) with Flat-Top (F) (power of 1.1 W, beam area of 1 cm2 ) and standard Gaussian (G) (power of 0.7 W, beam area of 0.5 cm2 ) handpieces. Each test group was divided into three subgroups, receiving one time (60 J/cm2 ), two times (120 J/cm2 ), and three times (180 J/cm2 ) irradiation. 3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) and Annexin V tests were performed. The Alizarin Red staining and polymerase chain reaction tests were done both at the beginning and the end of the first and second weeks. The degree of mineralization and expression of osteogenic markers, RUNX2, OCN, and OPN were evaluated. Based on the MTT and Annexin V test results, both test groups outperformed the control group in degrees of cell proliferation during the first day of laser irradiation (p < 0.05). After one and two times irradiation, the expression of osteogenic markers in the test groups was significantly higher than the control group. PBM with Flat-Top and Gaussian handpieces can enhance ossification and cell differentiation regardless of the type of handpieces.

Buccal Mesenchymal Stromal Cells as a Source of Osseointegration of Titanium Implants.

We studied the interaction of human buccal mesenchymal stem cells (MSCs) and osteoblasts differentiated from them with the surface of titanium samples. MSCs were isolated by enzymatic method from buccal fat pads. The obtained cell culture was presented by MSCs, which was confirmed by flow cytometry and differentiation into adipocytes and osteoblasts. Culturing of buccal MSCs on titanium samples was accompanied by an increase in the number of cells for 15 days and the formation of a developed network of F-actin fibers in the cells. The viability of buccal MSCs decreased by 8 days, but was restored by 15 days. Culturing of osteoblasts obtained as a result of buccal MSC differentiation on the surface of titanium samples was accompanied by a decrease in their viability and proliferation. Thus, MSCs from buccal fat pads can be used to coat implants to improve osseointegration during bone reconstruction in craniofacial surgery and dentistry. To improve the integration of osteoblasts, modification of the surface of titanium samples is required.

Surgical Approach to Necrotizing Fasciitis in the Buccal Fat Pad

Cervicofacial necrotizing fasciitis (CNF) of the face is a rare and potentially life-threatening bacterial infection that requires immediate intervention. CNF involving the buccal fat pad particularly demands surgical drainage, with attention to the surrounding anatomical structures to prevent vascular or nerve damage. In this study, we reviewed the anatomy of buccal fat pads to suggest appropriate surgical approaches. A retrospective chart review was conducted on seven patients with CNF who had a buccal fat pad abscess requiring surgical incision and drainage between January 2022 and August 2023. Abscesses within the central buccal fat pad and its pterygoid extensions were drained via intraoral incisions. Abscesses in the temporal extension were addressed by the Dingman approach. All patients underwent our surgical drainage regimen combined with proper intravenous antibiotics, leading to successful treatment of CNF without significant functional sequelae, with an average stay of 18.71 days. The buccal fat pad, which corresponds to the deep space of the face, is surrounded by vital structures such as the facial artery, vein, nerve, and parotid duct. When treating abscesses in the buccal fat pad, it is important to understand the relationship of the fat pad to other vital structures for optimal outcomes.

Photobiomodulation Effect of Different Diode Wavelengths on the Proliferation of Human Buccal Fat Pad Mesenchymal Cells

This study aimed to determine the most effective wavelength for the proliferation of Human Buccal Fat Pad Mesenchymal Stem Cells (BFPMSCs) in cell culture. These cells can be used for different purposes such as regenerative periodontal procedures. Materials and Methods: The wells containing BFPMSCs were subjected to laser irradiation at 635, 660, 808, and 980 nm wavelengths with 1, 1.5, 2.5, and 4 J/cm2 energy densities. Cell proliferation and viability were evaluated after 1, 3, and 5 days with the methyl thiazolyl tetrazolium (MTT) assay. Result: The proliferation rate of human Buccal Fat Pad Mesenchymal Cells (BFPMSCs) was increased on the first and third days at a wavelength of 808 nm and day five at a wavelength of 980 nm in comparison to the control group. Our findings distinguished that PBMT with 635, 660, 808, and 980 nm wavelengths increased the proliferation of BFPMSCs. Conclusion: The best laser radiation setting, which led to the highest proliferation rate of the cells, included a wavelength of 808 nm with 2.5 J/cm2 energy density.

Microfragmented Fat and Biphasic Calcium Phosphates for Alveolar Cleft Repair: Protocol for a Prospective, Nonblinded, First-in-Human Clinical Study.

Biphasic calcium phosphates (BCP) may serve as off-the-shelf alternatives for iliac crest-derived autologous bone in alveolar cleft reconstructions. To add osteoinductivity to the osteoconductive BCPs to achieve similar regenerative capacity as autologous bone, a locally harvested buccal fat pad will be mechanically fractionated to generate microfragmented fat (MFAT), which has been shown to have high regenerative capacity due to high pericyte and mesenchymal stem cell content and a preserved perivascular niche. Our primary objectives will be to assess the feasibility and safety of the BCP-MFAT combination. The secondary objective will be efficacy, which will be evaluated using radiographic imaging and histological and histomorphometric evaluation of biopsies taken 6 months postoperatively, concomitant with dental implant placement. Eight patients with alveolar cleft (≥15 years) will be included in this prospective, nonblinded, first-in-human clinical study. MFAT will be prepared intraoperatively from the patient's own buccal fat pad. Regular blood tests and physical examinations will be conducted, and any adverse events (AEs) or serious EAs (SAEs) will be meticulously recorded. Radiographic imaging will be performed prior to surgery and at regular intervals after reconstruction of the alveolar cleft with the BCP-MFAT combination. Biopsies obtained after 6 months with a trephine drill used to prepare the implantation site will be assessed with histological and histomorphometric analyses after methylmethacrylate embedding and sectioning. The primary outcome parameter will be safety after 6 months' follow-up, as monitored closely using possible occurrences of SAEs based on radiographic imaging, blood tests, and physical examinations. For efficacy, radiographic imaging will be used for clinical grading of the bone construct using the Bergland scale. In addition, bone parameters such as bone volume, osteoid volume, graft volume, and number of osteoclasts will be histomorphometrically quantified. Recruitment started in November 2019, and the trial is currently in the follow-up stage. This protocol's current version is 1.0, dated September 15, 2019. In this first-in-human study, not only safety but also the histologically and radiographically assessed regenerative potential of the BCP-MFAT combination will be evaluated in an alveolar cleft model. When an SAE occurs, it will be concluded that the BCP-MFAT combination is not yet safe in the current setting. Regarding AEs, if they do not occur at a higher frequency than that in patients treated with standard care (autologous bone) or can be resolved by noninvasive conventional methods (eg, with analgesics or antibiotics), the BCP-MFAT combination will be considered safe. In all other cases, the BCP-MFAT combination will not yet be considered safe. Indonesia Clinical Trial Registry INA-EW74C1N; https://tinyurl.com/28tnrr64. DERR1-10.2196/42371.

Effects of Oral Cavity Stem Cell Sources and Serum-Free Cell Culture on Hydrogel Encapsulation of Mesenchymal Stem Cells for Bone Regeneration: An In Vitro Investigation.

To develop a stem cell delivery model and improve the safety of stem cell transplantation for bone regeneration, this study aimed to determine the effects of stem cell sources, serum-free cell culture, and hydrogel cell encapsulation on the growth and osteogenic differentiation of mesenchymal stem cells (MSCs) from the oral cavity. The study groups were categorized according to stem cell sources into buccal fat pad adipose (hBFP-ADSCs) (Groups 1, 4, and 7), periodontal ligament (hPDLSCs) (Groups 2, 5, and 8), and dental pulp-derived stem cells (hDPSCs) (Groups 3, 6, and 9). MSCs from each source were isolated and expanded in three types of sera: fetal bovine serum (FBS) (Groups 1-3), human serum (HS) (Groups 4-6), and synthetic serum (SS) (StemPro™ MSC SFM) (Groups 7-9) for monolayer (m) and hydrogel cell encapsulation cultures (e). Following this, the morphology, expression of MSC cell surface antigens, growth, and osteogenic differentiation potential of the MSCs, and the expression of adhesion molecules were analyzed and compared. SS decreased variations in the morphology and expression levels of cell surface antigens of MSCs from three cell sources (Groups 7m-9m). The levels of osteoblastic differentiation of the hPDLSCs and hBFP-ADSCs were increased in SS (Groups 8m and 7m) and the cell encapsulation model (Groups 1e, 4e, 7e-9e), but the promoting effects of SS were decreased in a cell encapsulation model (Groups 7e-9e). The expression levels of the alpha v beta 3 (ITG-αVβ3) and beta 1 (ITG-β1) integrins in the encapsulated cells in FBS (Group 1e) were higher than those in the SS (Group 7e). Human PDLSCs and BFP-ADSCs were the optimum stem cell source for stem cell encapsulation by using nanohydroxyapatite-calcium carbonate microcapsule-chitosan/collagen hydrogel in serum-free conditions.

Isolation of Human Adipose-Derived Stromal/Stem Cells from Lipoaspirates.

Adipose tissue is an abundant and accessible source of stem cells with multipotent properties suitable for tissue engineering and regenerative medical applications. Adipose-derived stromal/stem cells (ASCs) have been widely used in tissue engineering and cell therapy. In addition, the clinical application of ASCs in the treatment of inflammation and injury has been proven a success. Here, we describe methods from our own laboratory and the literature for the isolation and expansion of Adipose-derived stromal/stem cells (ASCs). We present a large-scale procedure suitable for processing >100mL volumes of lipoaspirate tissue specimens by collagenase digestion, a related procedure suitable for processing adipose tissue aspirates without digestion, and a procedure suitable for intact human adipose tissue, such as buccal fat pads in the maxillofacial region.

Which method is successful in closure of acute oroantral communication? A retrospective study.

This study's purpose is to retrospectively evaluate the success of surgical methods used in treating Oroantral Communication (OAC). This study was designed as a retrospective cohort study on patients who developed OAC after surgery maxillary posterior region. The records of patients previously treated with OAC were scanned through the hospital registry software. A data set was created by recording patients' age, gender, systemic disease, etiological reasons, and surgical methods. The primary predictor variable was the surgical method used to treat OAC. Other variables were age, gender, systemic disease and etiological reasons. The primary outcome was oroantral fistula development after the first surgical intervention. The patients who were positive in clinical examination and Valsalva test on control days were considered unsuccessful. One-way analysis of variance and Kruskal-Wallis tests were used for quantitative variables in more than two groups. Pearson chi-square test was used to compare categorical data. This retrospective cohort study was completed with 605 patients who met the study criteria among 95,883 patients who underwent surgery in the maxillary posterior region. The incidence of OAC was 0.63%. The patients consisted of 238 female and 367 male patients. The mean age was 41.06±14.48 years. Buccal flap and Buccal Fat Pad methods were used most frequently in the treatment. While treatment was completed with the first surgical intervention in 592 (97.85%) patients, OAF developed in 13 (2.15%) patients. No statistically significant relation existed between surgical technique and OAF development (p>0.005). The success rate of the Buccal Flap method was 98.7%, and the Buccal Fat Pad method was 95.8%. The results of this study showed that noninvasive methods in openings smaller than 5 mm and surgical treatment methods in openings larger than 5 mm have a high success rate with the limitations of present study.

Surgical Treatment of Stage 2 Bisphosphonates-Related Osteonecrosis of Mandible by Platelet-Rich Fibrin and Buccal Fat Pad Rotational Flap

Surgical Treatment of Stage 2 Bisphosphonates-Related Osteonecrosis of Mandible by Platelet-Rich Fibrin and Buccal Fat Pad Rotational Flap

Significance of the buccal fat pad in oral surgery

Significance of the buccal fat pad in oral surgery

Postoperative challenges in pedicled buccal fat pad grafts: MRI evaluation and the role of bone grafting for maxillary wall regeneration

Postoperative challenges in pedicled buccal fat pad grafts: MRI evaluation and the role of bone grafting for maxillary wall regeneration

Endoscopic maxillary sinus drainage combined with buccal fat pad flaps for repairing large oroantral fistulas in patients with odontogenic maxillary sinusitis

AbstractBackgroundOroantral fistula (OAF) is a pathological channel formed between the oral cavity and the maxillary sinus. A large size of OAF (≥5 mm) increases the risk of surgical failure, and an optimal surgical approach should be cautiously selected.ObjectiveThis study aims to characterize the application of nasal endoscopy and buccal fat pad (BFP) flaps to repair large OAFs in patients with odontogenic maxillary sinusitis (OMS).MethodsA total of 32 patients with large OAF combined with OMS after dental extraction who were treated in the Department of Otorhinolaryngology, Nanjing Renpin ENT Hospital from 2018 to 2022, were retrospectively recruited. A thorough preoperative evaluation was performed and all patients were first treated with nasal endoscopy, followed by the repair of OAFs using BFP flaps under general anesthesia. The cure rate and postoperative pain score were used as outcome indicators to evaluate the effectiveness of the procedure.ResultsAll patients completed a 12‐month follow‐up. The results showed that OFAs were cured in 25 (32 in total, 78.1%) patients by the second postoperative week. OFAs were healed in all patients at week 8 postoperatively. OMS was healed in 25 (32 in total, 78.1%) patients at the first postoperative week and all patients were healed by the disappearance of symptoms associated with OMS at week 8 postoperatively. At the second postoperative week, complete relief of pain symptoms was obtained in 18 (32 in total, 56.3%) patients (visual analog scale = 0 score), in 25 (32 in total, 78.1%) patients at the fourth postoperative week, and by the eighth postoperative week, all patients had complete resolution of pain symptoms.ConclusionsSecondary maxillary sinusitis is not a contraindication to the treatment of large OAFs. Large OAFs can be effectively closed using BFP flaps combined with endoscopic maxillary sinus drainage.

Palatal island flap with or without hinge flap for closure of oroantral or oronasal fistula: A technical note

ObjectiveThe study aimed to introduce the closure technique using palatal island flap with or without hinge flap for oroantral or oronasal fistula. We explained the surgical methods, assessed the efficacy of these techniques and compared with other closure methods. MethodsThis study included nine patients who were diagnosed with oroantral or oronasal fistula and underwent treatment; closure technique using palatal island flap with hinge flap (double flap closure) or that without hinge flap (single flap closure) between 2000 and 2022. Etiological factors included malignant tumors, benign tumors, cyst, and trauma. Double flap closure was performed in five cases, wherein primary closure was achieved with hinge flap created using surrounding palatal mucosa and secondary closure was achieved with palatal island flap. Single flap closure was performed in four cases. ResultsAll nine patients were treated successfully, and follow-up showed no evidence of flap necrosis or major postoperative complications. ConclusionsThe main advantages of this double flap closure technique include effective primary closure with hinge flap, which can prevent perforation into the nasal cavity and/or sinus even if the secondary flap (palatal island flap) becomes loose due to palatal mucosa irritation, and rich blood supply in the palatal island flap from the greater palatine artery. These factors confirm the validity of this technique. Secure closure with single palatal island flap was achieved; however, more secure closure can be achieved by using double flap closure technique. Therefore, it is important to choose single or double flap closure technique depending on the case.

Simultaneous management of chronic maxillary sinusitis from dental origin and the relevance of nasal septal deviation: A retrospective evaluation of 65 cases

PurposeDental origin constitutes most chronic unilateral maxillary sinusitis (CMS) and is referred to as dental chronic maxillary sinusitis (DCMS). Recently, dental implants and related surgical procedures have become more prevalent. We present an evaluation of the simultaneous treatment of DCMS. Materials and MethodsA retrospective review of records from 395 patients with CMS treated at our medical center from 2015 to 2020 found 65 patients diagnosed with DCMS. Statistical analyses were performed using the records data. ResultsFour patients were excluded. The final study population included 35 males and 26 females with a mean age of 55. 29 % were post-dental implant placement or related pre-prosthetic procedures. Presenting symptoms included middle meatus edema (72 %), pus in the middle meatus (70 %), and nasal secretion (39 %). Clinical findings included septal deviation (39 %), among them 87 % deviated toward the diseased sinus, OAF (49 %), and nasal polyposis (16 %). In 32 patients, the OAF was closed in one layer using a local mucoperiosteal flap. In 29 patients, the closure was done in two layers, including a buccal fat pad (BFP) regional flap. One patient had a reopened OAF, and five patients required revision surgery. 92 % of patients in this study had complete clinical and radiological resolution of the DCMS. ConclusionsRelevance of nasal septal deviation in association with DCMS is present. There is no distinct difference in the manner of OAF closure if it is done in a simultaneous procedure. One stage combined multidisciplinary surgical procedure is sufficient to treat DCMS.

Efficiency of Adjuvant Therapies in the Management of Medication-Related Osteonecrosis of the Jaws: A Case Series and a Literature Review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a challenging condition with no established gold standard treatment. This article presents a case series that explores a minimally invasive surgical protocol combined with various adjuvant treatments to manage MRONJ in oncologic patients. Patient and Methods: Seven patients diagnosed with MRONJ, with mandibular involvement at stages 2 and 3 were included in the case series. The treatment protocol consisted of pre-operative steps, including oral cavity sanitation, hygiene motivation, and pre-operative medical treatment. Using operative techniques, the surgical protocol involved fluorescence-guided bone debridement, curettage, and bone smoothing. Adjuvant treatments such as platelet-rich fibrin, buccal fat pad grafts, Pentoxifylline and tocopherol combination, and low-level laser therapy were used. Follow-up assessments were conducted at regular intervals, and the outcomes were evaluated. Result: Improved cicatrization and symptom relief in most cases, with complete healing achieved in all patients. Conclusion: The study highlights the outcome of the use of adjuvant therapies in the management of MRONJ, however, further research is needed in order to acknowledge the potential of adjuvant therapies for MRONJ treatment and establish a standardized protocol.