We want to congratulate the authors of the interesting Clinician’s Corner article, “Lingual mandibular osteonecrosis after dental impressions for orthodontic study models,” recently published in the AJO-DO . Indeed, it is important to be careful during dental impressions, especially when these are performed by orthodontic assistants. As described by the authors, osteonecrosis of the lingual mandibular region has been attributed to traumatic injury after excessive pressure during a dental impression. In this context, they referred to the position paper of the American Association of Oral and Maxillofacial Surgeons to define mandibular osteonecrosis when associated with medication-related osteonecrosis of the jaw. However, that paper states that 1 characteristic of medication-related osteonecrosis of the jaw is “exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region that has persisted for longer than 8 weeks.” In addition, the authors referred to an article in which 2 cases of mandibular osteonecrosis occurred 2 weeks after general anesthesia. These publicaions might be questionable in substantiating the Clinician’s Corner article because the lingual mandibular osteonecrosis occurred only 2 days after the dental impression. A recent systematic review on oral ulceration with bone sequestration qualitatively described a series of articles, and only 1 reported a minimum period of 5 days to develop an ulcer with bone sequestrum. Nevertheless, in Figure 4, the gingival borders and surrounding soft tissues of the bone ulcer seem to be keratinized; this is more compatible with chronic ulcers. In contrast, recent ulcers caused by trauma usually show erythematous margins, edema, and bleeding appearance. Moreover, the clinical aspect of cortical bone recently exposed by trauma is whitish, not the yellowish color observed in Figure 4.

Therefore, we would like respectfully to address to the authors the following questions. Is it possible that the osteonecrosis already existed before the dental impression was taken? Was a detailed intraoral examination done previously? We just suppose that the lingual mandibular osteonecrosis reported already existed before the dental impression was taken and was not previously identified because this region is difficult to evaluate appropriately during an intraoral examination. We take the opportunity to congratulate the authors once again.