A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible

Hyperbaric oxygen therapy as an adjunct treatment of periodontitis, MRONJ, and ONJ: a systematic literature review

OBJECTIVE

To review the available prospective literature on hyperbaric oxygen (HBO) therapy for periodontal conditions.

MATERIALS AND METHODS

A comprehensive electronic and manual search was performed to identify clinical studies on adult patients who underwent hyperbaric oxygen therapy for periodontal treatments. A systematic literature search was conducted in PubMed, Cochrane, and Dentistry Oral Sciences Source databases.

RESULTS

Fourteen articles were included in the final literature review, of which five were RCTs and 11 were prospective clinical studies. Four studies discussed HBO as an adjunct to nonsurgical treatment of periodontitis, eight reported on HBO and osteoradionecrosis, and one examined HBO in bisphosphonate-related necrosis of the jaws.

CONCLUSIONS

HBO has shown superior efficacy compared to antibiotics as a prophylactic measure in preventing osteoradionecrosis (ORN) in patients with a history of high mandibular irradiation. Clinicians should consider referring such patients for HBO therapy before and after tooth extractions. However, for the surgical excision of existing ORN lesions, HBO therapy does not yield significant benefits but does not negatively impact outcomes either. Regarding the treatment of periodontitis patients, the variability among studies prevents definitive conclusions. HBO therapy as an adjunct to SRP in periodontitis treatment produces mixed results.

CLINICAL RELEVANCE

This study's clinical relevance lies in its exploration of the potential benefits of HBO for periodontal conditions. Also, it provides clinicians with insights into when and how to integrate HBO therapy into their treatment approaches, particularly for patients with a history of irradiation and those undergoing complex dental procedures.

The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review

OBJECTIVES

Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.

STUDY DESIGN

A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.

RESULTS

Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.

CONCLUSIONS

Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

The Potential Therapeutic Role of Mesenchymal Stem Cells-Derived Exosomes in Osteoradionecrosis

As one of the most serious complications of radiotherapy, osteoradionecrosis (ORN) seriously affects the quality of life of patients and even leads to death. Vascular injury and immune disorders are the main causes of bone lesions. The traditional conservative treatment of ORN has a low cure rate and high recurrent. Exosomes are a type of extracellular bilayer lipid vesicles secreted by almost all cell types. It contains cytokines, proteins, mRNA, miRNA, and other bioactive cargos, which contribute to several distinct processes. The favorable biological functions of mesenchymal stem cells-derived exosomes (MSC exosomes) include angiogenesis, immunomodulation, bone regeneration, and ferroptosis regulation. Exploring the characteristic of ORN and MSC exosomes can promote bone regeneration therapies. In this review, we summarized the current knowledge of ORN and MSC exosomes and highlighted the potential application of MSC exosomes in ORN treatment.

Bacterial spectrum analysis and antimicrobial susceptibility study of osteoradionecrosis of the jaw in Southern China

OBJECTIVE

Osteoradionecrosis of the jaw (ORNJ) is one of the most common and serious complications after radiotherapy of head and neck malignancies due to the high incidence of nasopharyngeal cancer in Southern China. Clinicians lack understanding and consensus on anti-infective treatment in ORNJ lesions. This research aims to provide evidence for rational use of antibiotics by reviewing the bacterial spectrums and antimicrobial susceptibility test of ORNJ patients.

METHODS

We collected patient who was diagnosed with ORNJ from November 2012 to June 2019 in our hospital. Exudate or bone unexposed wound surface sampling, agar plates culturing, and susceptibility testing were analyzed. Descriptive statistics were used for data presentation.

RESULTS

A total of 219 samples were collected in our retrospective study. The most common cultured bacteria were Klebsiella pneumoniae (15.10%), Pseudomonas aeruginosa (13.54%), and Staphylococcus aureus (10.94%). Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 5.21% in the whole positive samples. Ticarcillin, Ofloxacin, Vancomycin, Tigecycline, and Meropenem were more susceptible than other antibiotics to treat uncontrollable infection.

CONCLUSIONS

Our research provided objective evidence for understanding the types of local bacterial flora and drug susceptibility in ORNJ lesions and gave a guiding reference for empirical antibiotics medication.

Chinese expert group consensus on diagnosis and clinical management of osteoradionecrosis of the mandible

Osteoradionecrosis of the mandible (MORN) is one of the most devastating complications caused by radiation therapy in the head and neck region. It is characterized by infection and chronic necrosis of the mandible as the main manifestation. Clinically, MORN-related symptoms include swelling, pain, dysphagia, trismus, masticatory or speech disorders, refractory orocutaneous fistula, bone exposure, and even pathological fracture. MORN has become a challenging clinical problem for oral and maxillofacial surgeons to deal with, but thus far, this problem has not been solved due to the lack of widely accepted treatment algorithms or guidelines. Because of the nonexistence of standardized treatment criteria, most clinical treatment against MORN nowadays is largely based on controversial empirical understandings, while recommendations on post-therapeutic evaluations are scarce. Therefore, to further unify and standardize the diagnosis and treatment of MORN, to decrease the huge waste of medical resources, and ultimately, to improve the wellbeing of the patients, the Chinese Society of Oral and Maxillofacial Surgery (CSOMS) convened an expert panel specialized in MORN from 16 domestic medical colleges and affiliated hospitals to discuss the spectrum of diagnosis and and formulate treatment. In addition, consensus recommendations were also revised with a comprehensive literature review of the previous treatment experiences and research pearls. This 'expert consensus statement on diagnosis and clinical management of MORN' is for clinical reference.

Effectiveness of Hyperbaric Oxygen Therapy for the Management of Chronic Osteomyelitis: A Systematic Review of the Literature

Hyperbaric oxygen has been used as an adjunctive measure in the treatment of chronic osteomyelitis. The aim of this systematic literature review was to analyze the outcome and the complications of hyperbaric oxygen for chronic osteomyelitis. Forty-five of 96 studies reporting the use of hyper-baric oxygen for 460 patients with chronic osteomyelitis met the inclusion criteria and were analyzed qualitatively. All patients previously received antibiotics and surgical debridement. Mixed bacterial flora was detected in most of the studies. Staphylococcus aureus was the isolated pathogen in 12 (60%) of the 20 cohort and in 4 (20%) of the 20 case studies. Adjuvant hyperbaric oxygen was effective in 16 (80%) of the 20 cohort and 19 (95%) of the 20 case studies. Overall, 308 (73.5%) of 419 patients with complete data had a successful outcome and no reported relapse. Available evidence supports a potentially beneficial role of adjunctive hyperbaric oxygen, especially in refractory cases of chronic osteomyelitis. [Orthopedics. 2018; 41(4):193-199.].

The Use of Hyperbaric Oxygen for the Prevention and Management of Osteoradionecrosis of the Jaw: A Dana-Farber/Brigham and Women's Cancer Center Multidisciplinary Guideline

BACKGROUND

Osteoradionecrosis of the jaw (ORN) is an infrequent yet potentially devastating complication of radiation therapy to the head and neck region. Treatment options include antimicrobial therapy, local sequestrectomy, resection, and the use of hyperbaric oxygen (HBO). Published data on ORN are difficult to compare because of the lack of a universally accepted classification and staging system, and the literature on the use of HBO to either prevent or successfully manage ORN is controversial and inconclusive. Therefore, we aimed to establish a standard approach for using HBO at our institution.

MATERIALS AND METHODS

A literature search was conducted of articles published in the English language between January 1980 and January 2016. Retrieved articles were evaluated by two independent reviewers. Isolated case reports, abstracts, case series, review articles, and cohort studies without a control group were excluded; summary data were extracted from the remaining studies. A panel of experts from Head and Neck Oncology and Oral Medicine from the Dana-Farber Cancer Institute and Brigham and Women's Hospital reviewed the summary data and established multidisciplinary guidelines on the use of HBO for the prevention and management of ORN.

RESULTS

Seven studies were evaluated and reviewed by the multidisciplinary panel. There was no consistent evidence in support of HBO for either the prevention or management of ORN.

CONCLUSION

Based on the available evidence and expert opinion, routine use of HBO for the prevention or management of ORN is not recommended and is rarely used at our institution. The Oncologist 2017;22:343-350 IMPLICATIONS FOR PRACTICE: The Division of Head and Neck Oncology of Dana-Farber/Brigham and Women's Cancer Center does not recommend the routine use of HBO for the prevention or management of ORN. Adjunctive HBO may be considered for use on a case-by-case basis in patients considered to be at exceptionally high risk who have failed conservative therapy and subsequent surgical resection.

A Pathological Fracture of the Mandible due to Osteomyelitis following a Full Dental Clearance

Orofacial infections following dental extractions are a common referral to an oral and maxillofacial department as an emergency, especially when combined with swelling and limited mouth opening. The case presented demonstrates a rare complication of chronic suppurative osteomyelitis with bilateral pathological fractures of the mandible, which occurred following a staged dental clearance. CPD/Clinical Relevance: Dental extractions are one of the most common treatments carried out by oral surgeons and general dental practitioners. This case highlights a rare but encountered complication of routine oral surgery and demonstrates when it is necessary to make an immediate referral to the local oral and maxillofacial surgery unit.

Fibular free flap reconstruction for the management of advanced bilateral mandibular osteoradionecrosis

Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis(ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction.Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN.

Primary Chronic Osteomyelitis of the Jaws in Children: An Update on Pathophysiology, Radiological Findings, Treatment Strategies, and Prospective Analysis of Two Cases

Objective. Primary chronic osteomyelitis (PCO) of the jaws in children is associated with pain, trismus, and swelling. In children, temporomandibular joint involvement is rare and few studies have been published due to the relatively low incidence. This paper presents two cases of mandibular PCO in children with the involvement of the collum mandibulae. In addition, a review of the literature regarding demographic data, histological, radiological, and laboratory findings, and treatment strategies of PCO was also performed. Material and Methods. Prospective analyses of two PCO cases. A PubMed search was used and the articles were sorted according to their corresponding key area of focus. Results. Review of the literature revealed twenty-four cases of PCO with two cases of mandibular condyle involvement. The mean age was 18 years; the male to female ratio was 1 : 3. Most of the patients were treated with anti-inflammatory drugs in combination with decortication. Clinical recurrence was seen in 7 cases. Conclusion. A combination of anti-inflammatory drugs and surgical intervention appears to be the first choice of treatment. However, surgical removal of necrotic tissue adjacent to collum mandibulae has its limitations in children. Further investigations are of utmost importance in order to increase our knowledge and understanding of this disease.

Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing

BACKGROUND

Osteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous flap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula flaps in flap survival, bony union, and postoperative complications.

PATIENTS AND METHODS

From 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n=108) or fibula flaps (n=45). Data collected for analysis included patient demographics, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use.

RESULTS

All patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac flap group and fibula flap group. In the group with iliac flap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac flap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P<0.01). In the group with fibula flap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac flap group (P=0.04). In the iliac flap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P=0.04 and 0.36, respectively).

CONCLUSIONS

For ORN patients, vascularized iliac bone flap provides more reliable results compared to fibula flap. The merits of vascularized iliac flap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.

Chronic suppurative osteomyelitis of posterior maxilla: A rare presentation

Thin cortical bone rich in vascularity makes the maxilla scarcely vulnerable to osteomyelitis as compared to mandible. Moreover, the introduction of newer antibiotics, understanding of pathogenesis and improved medical support lead to reduction in incidence of osteomyelitis. Local factors like continuous irritation, smoking and suppressed immune system contributes to the occurrence of suppurative osteomyelitis. We hereby, report an exceptional case of chronic suppurative osteomyelitis of posterior maxilla in a 42-year-old healthy male who was managed successfully by combination of antibiotics, surgical sequestrectomy and debridement.

Chronic suppurative osteomyelitis of subcondylar region: a case report

Chronic suppurative osteomyelitis (CSO) of the maxillofacial region is primarily caused by infections of odontogenic microorganisms. It may also arise as a complication of dental extractions, maxillofacial trauma, inadequate treatment of a fracture and irradiation to the mandible. This condition is characterized by areas of devitalized bone (sequestra) which serves as a nidus for recurrent episodes of infection. This case report describes a case of CSO in an untreated right subcondylar fracture of the mandible which was successfully treated with a combination of antibiotic therapy and surgical debridement in an 8-year-old boy. How to cite this article: Kumar GR, Syed BA, Prasad N, Praveen SP. Chronic Suppurative Osteomyelitis of Subcondylar Region: A Case Report. Int J Clin Pediatr Dent 2013;6(2): 119-123.

Mandibular osteomyelitis in children mimicking juvenile recurrent parotitis

OBJECTIVE

To describe pediatric cases with mandibular osteomyelitis initially diagnosed and treated as juvenile recurrent parotitis.

METHODS

We reviewed the patient data of all our pediatric patients treated at Helsinki University Central Hospital, a tertiary care hospital, between 1998 and 2010 who had the initial diagnosis of recurrent parotitis which in fact was osteomyelitis.

RESULTS

Over a period of 12 years, six children (aged 5-17 years, five girls) presented with mandibular osteomyelitis primarily diagnosed as recurrent parotitis. Diagnostic delay ranged from 1.5 months to 6.0 years before the final diagnosis of mandibular osteomyelitis confirmed in MRI. Of the six cases undergoing biopsies, bacterial culture showed Actinomyces or Streptococcus viridans in four cases. All patients received antimicrobial treatment. Two received hyperbaric oxygen therapy with no resolution of symptoms. Debridement was performed in these two cases as well, and in the second case persistent symptoms led to bisphosphonate treatment.

CONCLUSIONS

Juvenile parotitis is in most cases a clinical diagnosis, and treatment is symptomatic. In contrast, mandibular osteomyelitis is a severe disease requiring lengthy treatment. Because symptoms of these two entities may mimic each other, unclear cases require MRI.

Comparison of Er:YAG laser and piezoelectric osteotomy: An animal study in sheep

OBJECTIVES

It was the aim of this study to compare the feasibility of complete osteotomy of long bones in sheep using a newly designed variable square pulsed Er:YAG laser and piezoelectric surgery. In addition to uneventful bone healing after laser osteotomy, the goal was to assess the possibility to cut thick bony structures with both techniques in a surgically acceptable time frame of 2-3 minutes.

MATERIAL AND METHODS

A tibia midshaft osteotomy was performed in 24 sheep using either an Er:YAG laser (n = 12) or piezoelectric device (n = 12). Laser and piezoelectric groups were divided in two subgroups (n = 6) with sheep sacrificed after 2 and 3 months, respectively. A complete radiological, histological and histomorphometric analysis was performed to compare the course of bone/fracture healing and remodelling.

RESULTS

Laser and piezoelectric osteotomies of the sheep tibia up to a depth of 22 mm were possible without any thermal damage. Radiological and histological results after 2 months showed primary gap healing with distinct periosteal callus formation on the transcortex. After 3 months, radiological and histological analysis revealed less callus formation on the transcortex, with almost no visible osteotomy gap and a distinct formation of lamellar bone crossing the original osteotomy gap.

CONCLUSION

Er:YAG laser osteotomy can successfully be used in long bones with a depth of up to 22 mm, thus challenging the dogma of adverse effects of laser osteotomy due to thermal or other damages.

Osteoradionecrosis of the mandible: treatment outcomes and factors influencing the progress of osteoradionecrosis

PURPOSE

The present study was undertaken to evaluate our recent experience with mandibular osteoradionecrosis (ORN) and to identify factors that contribute to its progress.

PATIENTS AND METHODS

The medical records of 114 patients who had been treated for ORN during a 16-year period (1989 to 2004) were reviewed. The patients were then divided into 2 groups according to their response to conservative treatment. Group 1 consisted of patients whose ORN resolved with conservative treatment (n = 47). Group 2 consisted of patients whose ORN was unresolved with conservative treatment or who had required radical resection of the involved tissue (n = 67). The information was obtained from the medical records of the patients and analyzed.

RESULTS

The patients whose ORN was associated with an early-stage tumor or preirradiation extraction had a favorable response to conservative treatment. However, those who had an advanced primary tumor, had continued smoking and drinking after radiotherapy, had received palliative radiotherapy or a radiation dose of more than 6,000 rads, and who had an orocutaneous fistula, a pathologic fracture, swelling, or trismus had a poor response to conservative treatment. In these latter cases, radical resection of the involved tissue proved useful.

CONCLUSIONS

The results of the present study have indicated that several factors (ie, the stage of the primary tumor, signs of ORN) can influence the progress of ORN. Our results suggest that radical resection is a useful method for treating mandibular ORN that does not respond to conservative treatment.

Fibular free flaps in the management of osteomyelitis of the mandible

BACKGROUND

Fibular free flaps are an alternative method in the management of chronic osteomyelitis of the mandible without osteoradionecrosis.

METHODS

A prospective review of 2 cases of chronic osteomyelitis of the mandible managed with a fibular free flap was conducted. Patient satisfaction and aesthetic results were examined. Follow-up to 9 months was achieved and radiographic studies conducted. The current literature on the treatment of chronic osteomyelitis of the mandible and the use of free flaps in its management was reviewed.

RESULTS

The 2 patients with chronic osteomyelitis of the mandible whose conservative management failed were effectively treated with the use of a fibular free flap reconstruction.

CONCLUSION

Microvascular reconstruction with a fibular free flap should be considered as a treatment option in the management of chronic osteomyelitis of the mandible.

Patterns of treatment of osteoradionecrosis with hyperbaric oxygen therapy in the United Kingdom

We aimed to find out the number of patients with osteoradionecrosis (ORN) being treated by hyperbaric chambers in the UK during 2006-07, and the protocols that were being used. We did a telephone survey of 76 chambers to find out whether they treated patients with ORN, how many patients they treated in 2006-07, what chamber pressure they used, the duration of each session, and the total number of sessions/patient. A total of 25 chambers treated 273 patients with ORN in 2006-07; 10 were listed by the British Hyperbaric Association (BHA) and 15 were at multiple sclerosis (MS) centres. MS centres treated 23 (8%) of patients with ORN with a variable number of sessions of shorter duration and lower pressures than the chambers listed by the BHA. Most BHA chambers treated patients at 2.2 ATA for 90 min/session with 30 preoperative and 10 postoperative sessions/patient.

Effects of Hyperbaric Oxygen during Experimental Tooth Movement

Objective: To determine the effects of hyperbaric oxygen (HBO) on bone remodeling during orthodontic tooth movement.

Materials and Methods: Twenty-four male, adult Sprague Dawley rats were randomly divided into two groups. HBO was administered in the first group, and the second group served as a control. The mandibular first molars were moved mesially by means of Ni-Ti closed coil springs in all groups.

Results: Results were evaluated histomorphometrically and the parameters of trabecular bone volume (BV/TV), trabecular bone number (Tr.N), and trabecular separation (Tr.Sep) were evaluated at the interradicular bone area of the mandibular first molars. Increases in BV/TV and Tr.N and decreases in Tr.Sep revealed the osteoblastic activity of HBO. HBO application caused an increase in bone apposition and osteoblastic activity or a decrease in osteoclastic activity.

Conclusions: HBO enhanced the bone formation during experimental tooth movement. Therefore, the findings of this study support our hypothesis that osteoblastic activity might be modulated by changes in the environmental oxygen tension.

The influence of hyperbaric oxygen on the outcome of patients treated for osteoradionecrosis: 8 year study

This study was a retrospective review of treatment outcomes of osteoradionecrosis (ORN) of the mandible over an 8-year period, with specific reference to the role of hyperbaric oxygen therapy (HBOT). The presentation and management of 23 patients treated for ORN was studied by categorising them into three grades according to the severity of clinical and radiographic involvement. At presentation there were 13 patients with grade I ORN, six patients with grade II ORN and four patients with grade III ORN. HBOT was given to 10 patients in the grade I group, four patients in the grade II group and two patients in the grade III group. Overall eight patients (62%) with grade I, three patients (50%) with grade II and two patients (50%) with grade III were cured. In the patients who received HBOT the cure rate was 12.5% whilst in those without HBOT it was 86%. Although the cohort was small it seems that HBOT was of little benefit. HBOT is demanding for patients and has cost implications for the NHS; hence further clinical outcome data are urgently required with regard to its role in the management of ORN.

Cervicofacial Actinomycosis and Mandibular Osteomyelitis

Cervicofacial actinomycosis should be included in the differential diagnosis of any soft tissue swelling in the head and neck region, particularly if malignancy or a granulomatous disease is suspected. The diagnosis often is overlooked because of this entity's ability to mimic other conditions. Mandibular osteomyelitis also is underappreciated by many clinicians in their assessment of head and neck infections. Most cases are traced to an odontogenic source, with periapical tooth abscess and posttraumatic or surgical complication as key antecedent events.

Management of extensive osteoradionecrosis of the mandible with radical resection and immediate microvascular reconstruction

PURPOSE

Osteoradionecrosis (ORN) is a severe and devastating late complication of radiotherapy in patients with head and neck cancer. Management of ORN remains controversial and the current approach has been focused on debridement, systemic antibiotics, and eventually hyperbaric oxygen therapy for small and limited ORN. However, this conservative approach is ineffective in controlling extensive bone and soft-tissue necrosis. Microvascular composite flaps have been used in a variety of head and neck ablative surgeries but its use for the management of ORN has not been fully explored.

MATERIALS AND METHODS

From 1999 to 2002, 5 patients with refractory ORN of the mandible underwent radical resection and reconstruction with immediate microvascular-free fibular composite flap. All patients had been treated initially with conservative procedures and hyperbaric oxygen therapy.

RESULTS

All patients had initially successful vascularized reconstruction by clinical examination with minimal postoperative morbidity. One patient had complete flap loss at 20 days due to orocutaneous fistula and infection.

CONCLUSIONS

Radical resection followed by microvascular composite flap reconstruction is a reliable procedure in the management of patients with extensive ORN of the mandible.

Hyperbaric Oxygen for Adjuvant Therapy for Chronically Recurrent Mandibular Osteomyelitis in Childhood and Adolescence

PURPOSE

In this article, the question of whether adjuvant hyperbaric oxygen therapy (HBO) has a positive effect when treating chronically recurrent mandibular osteomyelitis in children and adolescents is discussed.

PATIENTS AND METHODS

Over a period of 5 years, 4 cases were observed, 3 of which were submitted to adjuvant HBO. Details on the modalities of this type of treatment and the simultaneous intravenous administration of high doses of antibiotics are reported.

RESULTS

All 3 patients have been free of any symptoms from 20 to 74 months (mean, 41 months) and therefore may most likely be regarded as healed.

CONCLUSION

The small number of cases does not allow a final statement on the extent to which HBO contributed to the positive outcome. However, in our opinion, HBO is a most promising therapeutic option. Finally, the problems involved in prospective randomized studies of this rare disease are discussed in detail.

The value of FDG-PET and bone scintigraphy with SPECT in the primary diagnosis and follow-up of patients with chronic osteomyelitis of the mandible

OBJECTIVE

To appraise the value of FDG-PET and bone scintigraphy using SPECT in the primary diagnosis and follow-up of patients with chronic osteomyelitis of the mandible (COM).

METHODS

In a prospective study the pattern of tracer uptake was investigated using 2 diagnostic methods in 42 patients. Results were compared with histology and radiographs as well as clinical and laboratory parameters.

RESULTS

The use of FDG-PET in the primary diagnosis of COM resulted in a sensitivity of 64% and a specificity of 77.7%. The sensitivity of SPECT was 84% and the specificity 33.3%. During the follow-up period of these patients the sensitivity of SPECT increased to 93.7%, while the specificity decreased (6.6%). The sensitivity and specificity of FDG-PET for this follow-up group were 62.5 and 80%, respectively.

CONCLUSION

Because of its high sensitivity, SPECT is vastly superior to other diagnostic methods in initiating treatment. In the follow-up period it might be replaced by FDG-PET, which reflects the disease course better and indicates the time of clinical remission.

Hyperbaric oxygen therapy in the treatment of radio-induced lesions in normal tissues: a literature review

Late complications are one of the major factors limiting radiotherapy treatment, and their treatment is not codified. Hyperbaric oxygen (HBO) has been used in combination with radiotherapy for over half a century, either to maximise its effectiveness or in an attempt to treat late complications. In this latter case, retrospective trials and case reports are prevailing in literature. This prompted European Society for Therapeutic Radiotherapy and Oncology and European Committee for Hyperbaric Medicine to organise a consensus conference in October 2001, dealing with the HBO indications on radiotherapy for the treatment and prevention of late complications. This updated literature review is part of the documents the jury based its opinion on. A systematic search was done on literature from 1960 to 2004, by only taking into account the articles that appeared in peer review journals. Hyperbaric oxygen treatment involving complications to the head and neck, pelvis and nervous system, and the prevention of complications after surgery in irradiated tissues have been studied. Despite the small number of controlled trials, it may be indicated for the treatment of mandibular osteoradionecrosis in combination with surgery, haemorrhagic cystitis resistant to conventional treatments and the prevention of osteoradionecrosis after dental extraction, whose level of evidence seems to be the most significant though randomised trials are still necessary. The other treatment methods are also outlined for each location.

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

Early detection of radiation-induced structural changes in rat trabecular bone

OBJECTIVE

Early detection of bone changes following radiotherapy is very important. The aim of this study is to establish a radiographic image analysis method for early detection of radiation-induced trabecular bone changes.

METHODS

Thirty-five Wistar rats were used for the experimental model of trabecular bone changes, which were induced by X-ray irradiation with 30 Gy to develop simulated osteomyelitis. Standardized 2.2 x direct magnification radiography was performed immediately prior to X-ray irradiation and once a week for 4 weeks following irradiation. The latent X-ray images were scanned using a computed radiography (CR) system. Mathematical morphological processing was then applied to the CR image data, which allowed the bone trabecular pattern features to be extracted as skeletal binary images. The sensitivity and specificity for detecting early trabecular bone changes in CR images and in skeletal binary images were evaluated. Quantitative analyses with quantum level value (QL value), skeletal pixel percentage (SKP) and star volume analysis (skeletal volume (Vsk), skeletal space volume (Vsp)) were performed. Histopathological examination was also conducted for confirmation of physical changes in the bone.

RESULTS

Visual observation of the skeletal binary images provided a higher sensitivity than the CR images. In the quantitative analysis, SKP, Vsk and Vsp values provided higher sensitivity than QL values.

CONCLUSION

The results of the present study suggest that a combined radiographic image analysis method using CR, mathematical morphological processing, SKP, Vsk and Vsp can be useful for the early detection of radiation-induced trabecular bone changes.

Management of advanced mandibular osteoradionecrosis with free flap reconstruction

BACKGROUND

The purpose of this study was to assess the effectiveness of free tissue transfer for treatment of advanced mandibular osteoradionecrosis (ORN) in head and neck cancer patients.

METHODS

We reviewed 29 patients who were treated for advanced mandibular ORN by radical resection and reconstruction with free flaps at our institution. All patients had either failed to respond to conservative treatment, including hyperbaric oxygen therapy and debridement or had pathological fracture due to ORN.

RESULTS

Twenty-four vascularized bone (17 fibula, five iliac, and two scapula), four rectus abdominis myocutaneous, and one radial forearm fasciocutaneous free flaps were used. The complications occurred in 6 of 29 patients (21%). A total of four flaps (14%) were lost. The mean follow-up was 2 years 9 months. All patients had complete resolution of ORN symptoms. No evidence of ORN recurrence was observed in any patient.

CONCLUSION

For advanced osteoradionecrosis of the mandible, radical resection followed by reconstruction using free flap provides a reliable means of obtaining good wound healing with acceptable aesthetic and functional results.

Possibilities of preventing osteoradionecrosis during complex therapy of tumors of the oral cavity

In recent years, there has been a dramatic increase in the number of tumors of the head and neck. Their successful treatment is one of the greatest challenges for physicians dealing with oncotherapy. An organic part of the complex therapy is preoperative or postoperative irradiation. Application of this is accompanied by a lower risk of recurrences, and by a higher proportion of cured patients. Unfortunately, irradiation also has a disadvantage: the development of osteoradionecrosis, a special form of osteomyelitis, in some patients (mainly in those cases where irradiation occurs after bone resection or after partial removal of the periosteum). Once the clinical picture of this irradiation complication has developed, its treatment is very difficult. A significant result or complete freedom from complaints can be attained only rarely. Attention must therefore be focussed primarily on prevention, and the oral surgeon, the oncoradiologist and the patient too can all do much to help prevent the occurrence of osteoradionecrosis. Through coupling of an up-to-date, functional surgical attitude with knowledge relating to modern radiology and radiation physics, the way may be opened to forestall this complication that is so difficult to cure.