Bisphosphonate related osteonecrosis of the jaws treated by surgical resection and immediate osseous microvascular reconstruction

A Systematic Review of Laser Photobiomodulation Dosimetry and Treatment Protocols in the Management of Medications-Related Osteonecrosis of the Jaws: A Rationalised Consensus for Future Randomised Controlled Clinical Trials

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating adverse effect of bisphosphates, antiresorptive therapy or antiangiogenic agents that can potentially increase oxidative stress, leading to progressive osteonecrosis of the jaws. Despite the large number of published systematic reviews, there is a lack of potential MRONJ treatment protocols utilising photobiomodulation (PBM) as a single or adjunct therapy for preventive or therapeutic oncology or non-oncology cohort. Hence, this systematic review aimed to evaluate PBM laser efficacy and its dosimetry as a monotherapy or combined with the standard treatments for preventive or therapeutic approach in MRONJ management. The objectives of the review were as follows: (1) to establish PBM dosimetry and treatment protocols for preventive, therapeutic or combined approaches in MRONJ management; (2) to highlight and bridge the literature gaps in MRONJ diagnostics and management; and (3) to suggest rationalised consensus recommendations for future randomised controlled trials (RCTs) through the available evidence-based literature. This review was conducted according to the PRISMA guidelines, and the protocol was registered at PROSPERO under the ID CRD42021238175. A multi-database search was performed to identify articles of clinical studies published from their earliest records until 15 December 2023. The data were extracted from the relevant papers and analysed according to the outcomes selected in this review. In total, 12 out of 126 studies met the eligibility criteria. The striking inconsistent conclusions made by the various authors of the included studies were due to the heterogeneity in the methodology, diagnostic criteria and assessment tools, as well as in the reported outcomes, made it impossible to conduct a meta-analysis. PBM as a single or adjunct treatment modality is effective for MRONJ preventive or therapeutic management, but it was inconclusive to establish a standardised and replicable protocol due to the high risk of bias in a majority of the studies, but it was possible to extrapolate the PBM dosimetry of two studies that were close to the WALT recommended parameters. In conclusion, the authors established suggested rationalised consensus recommendations for future well-designed robust RCTs, utilising PBM as a monotherapy or an adjunct in preventive or therapeutic approach of MRONJ in an oncology and non-oncology cohort. This would pave the path for standardised PBM dosimetry and treatment protocols in MRONJ management.

Mandible Reconstruction in a Rural Population: Comparison of Radial Forearm and Free Fibula Flap Outcomes

Comparison of microsurgical reconstructive options after mandible resection is limited in the literature. Fibula free flaps (FFFs) can be costly and have timing limitations, but dental restoration can be performed, with varied reported rates of completion. The radial forearm free flap (RFFF) with mandible plating may be an alternative in select populations. The purpose of this study was to determine if the RFFF has similar outcomes to the FFF for mandible reconstruction in a rural population. A retrospective review of patients who underwent mandibulectomy from 2017 to 2021 at a single tertiary-care academic institution was performed. Those with FFF or RFFF reconstruction were included. Mandible defects were classified using the Jewer-Boyd H-C-L system. Sixty-eight patients were included with 53 undergoing FFF and 15 undergoing RFFF. Immediate reconstruction was significantly more common with RFFF than FFF (100% versus 64.2%; P =0.01). Lateral mandible defects were most common among both groups (52.9% FFF versus 73.3% RFFF; P =0.04). Osseous defect length was similar (9.5 cm FFF versus 7.7 cm RFFF; P =0.07), but soft tissue defect size was significantly larger in the RFFF group (28.6 cm 2 versus 15.3 cm 2 ; P =0.01). Complication rates (47.1% FFF versus 46.7% RFFF; P =0.98) and disease-free status at last follow-up (96.2% FFF versus 80.0% RFFF; P =0.06) were similar. Dental restoration occurred in 21.3% of patients undergoing FFF. Patients undergoing RFFF or FFF reconstruction after mandibulectomy had similar surgical and disease outcomes, with a low rate of completed dental restoration after FFF. Our findings suggest RFFF is a reasonable alternative to FFF for mandible reconstruction in select patients.

MRONJ of the Mandible—From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap

Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.

Surgical treatment of 61 consecutive patients with maxillary stage 3 medication-related osteonecrosis of the jaws using a pedicled buccal fat pad

PURPOSE

Buccal fat pad (BFP) is used for the closure of large oroantral defects caused by surgical removal of the necrotic bone in patients with medication-related osteonecrosis of the jaw (MRONJ). This study aimed to evaluate the use of BFP for the closure of maxillary sinus defects in stage 3 MRONJ patients.

METHODS

This study recruited 61patients with large oroantral defects caused by MRONJ, including 49 patients with cancer and 12 patients with osteoporosis. Lesions were evaluated clinically and radiographically.

RESULTS

Among the 61 patients, 51 (83.6%) healed uneventfully, and 5 patients (8.2%) had local dehiscence and exposed bone; these 56 patients (91.8%) all healed after first or second operation. The Eastern Cooperative Oncology Group Performance Status was associated with being non-cured and might be an indicator for the healing process. All patients experienced a significant increase in body weight postoperatively.

CONCLUSIONS

This study suggest that block resection with removal of the necrotic bone combined with radical sinusotomy and closure of the defect with BFP is a reliable method to cure MRONJ lesions with a high success rate, and successful operation and prosthetic rehabilitation may improve body weight and the quality of life. The study was approved by the appropriate ethical approval for the Copenhagen ONJ Cohort (protocol no. H-6-2013-010) November 20, 2013.

Mandibular Reconstruction with Free Fibula Flap for Medication-related Osteonecrosis of the Jaw in Patients with Multiple Myeloma

While bisphosphonates are the cornerstone for management of multiple myeloma, they are associated with medication-related osteonecrosis of the jaw (MRONJ). There are many controversies in the management of MRONJ in this patient population. In this article, we describe a representative case and, along with a literature review, we report the outcomes of our 3 cases with multiple myeloma who underwent mandible reconstruction with vascularized fibula bone grafts after segmental mandible resection for Stage 3 MRONJ over a 3-year period. All patients were male with a mean age of 59 years. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. All patients had pathologic mandible fractures associated with intraoral fistulae and exposed bone. Nonsurgical management was attempted in all patients. One patient also underwent debridement of the mandible without resolution of the disease. Mandible reconstruction with an osteocutaneous free fibula flap after segmental mandible resection was performed in all 3 cases without major complications or donor site morbidity. Different bacteria were isolated from the intraoperative tissue cultures in all cases. Computed tomographic imaging revealed bony union without hardware complications in all cases. Mean follow-up was 28 months. In conclusion, we demonstrated that patients with multiple myeloma and advanced MRONJ lesions of the mandible can be managed successfully and safely by segmental resection and reconstruction with vascularized fibula bone graft.

Subtotal Mandible Reconstruction with a Free Fibula Flap and No Skin Incisions

Resection of large mandibular tumors followed by primary reconstruction using free tissue transfer is typically accomplished using transcutaneous cervical incisions, which provide access for ablation as well as inset of the osseous free flap. This approach offers wide exposure; however, it subjects the patient to potential facial scarring, marginal mandibular nerve injury, lip deformity/incompetence, formation of orocutaneous fistulae, as well as functional impairments to speech, mastication, and deglutition. To reduce morbidity and to preserve aesthetics, a transoral approach can be used in cases that do not require a neck dissection. This technique can be coupled with transoral dissection of the facial vessels for intraoral microanastomoses to avoid extraoral incisions altogether. We present a case of a large 17.2 cm subtotal mandibulectomy and 3-segment fibular free flap reconstruction using virtual surgical planning, with patient-specific cutting guides and reconstruction plate performed entirely transorally without any skin incisions. Although technically challenging, this is a safe and effective technique for large segmental mandibular defects, which provides superior cosmetic and functional outcomes.

Microsurgical Reconstruction of the Jaws Using Vascularised Free Flap Technique in Patients with Medication-Related Osteonecrosis: A Systematic Review

Background

Osteonecrosis of the jaw (ONJ) has been reported to be associated with patients receiving primarily bisphosphonate (BP) therapies. However, lately it has been documented that other medications, such as RANK ligand inhibitor (denosumab) and antiangiogenic drug, can cause ONJ. Micro-osseous-vascular reconstruction of the jaws in patients affected by medication-related osteonecrosis of the jaw represents a viable option of treatment for patients affected by stage III of the disease. However, there are still considerable doubts about the success of this procedure in the short, medium, and long term.

Material and Methods

A multidatabase (PubMed/MEDLINE, EMBASE, and CENTRAL) systematic search was performed. Any type of studies considering human patients treated with antiresorptive and antiangiogenic drugs was considered. The aim of the research is to primarily understand the success rate of micro-osseous-vascular reconstruction in the short, medium, and long period of time. This review has also the goal of better understanding any perioperative and postoperative complications resulting from the use of the reconstruction techniques.

Results

Eighteen studies resulted eligible for the study. Fibula free flap is the most commonly utilised vascularised free flap reconstruction technique (80.76%). Ten out of eighteen studies reported no complications. Recurrence of osteonecrosis was registered in five cases (6.41%) after free flap reconstruction. The overall free flap success rate was 96.16%.

Conclusions

Based on the limited data available in literature (Level 4 of the Oxford Evidence-based medicine scale), micro-osseous-vascular reconstruction of the jaws represents a valid treatment in patients with bisphosphonate-related osteonecrosis at stage III of the disease. However, additional data based on a larger cohort of patients are necessary to justify this type of intervention in patient affected by MRONJ.

Use of Leukocyte- and Platelet-Rich Fibrin in the Treatment of Medication-Related Osteonecrosis of the Jaws

Lesions associated with medication-related osteonecrosis of the jaws (MRONJ) are refractory to different treatment approaches. Hence, auxiliary approaches capable of improving patient outcomes should be explored. Leukocyte- and platelet-rich fibrin (LPRF) is a second-generation platelet concentrate (natural autologous fibrin matrix). It shows anti-infectious activity through immune regulation and accelerates the angiogenesis and multiplication of fibroblasts and osteoblasts; in consequence, it stimulates soft tissue healing and prevents exposure of the alveolar bone in the oral cavity. This report describes 2 cases involving women with breast cancer who were being treated with zoledronic acid and exhibited advanced MRONJ. In case 1, MRONJ developed in the maxilla after dental extraction; in case 2, it was assumed that MRONJ arose spontaneously in the mandible because no other risk factors could be detected. These cases were managed with surgical resection of the necrotic bone followed by placement of an LPRF membrane. Complete wound healing and intact mucosal cover were achieved. At clinical and tomographic follow-up after 2 years, there were no oral lesions or complaints. Therefore, this could be a noninvasive, quick, and alternative approach to manage bone exposure. The LPRF membrane contributes to a successful outcome and acts as a physical barrier against micro-organisms, thus preventing secondary infections.

Surgical resection and vascularized bone reconstruction in advanced stage medication-related osteonecrosis of the jaw

A retrospective review of all patients with stage 3 medication-related osteonecrosis of the jaw (MRONJ), treated by surgical resection and immediate vascularized bone reconstruction at a tertiary care medical center, was performed. Eleven patients were included, seven female and four male; their mean age was 65.8 years (range 56-73 years). Mean follow-up was 25 months. Ten patients had received intravenous bisphosphonates. The most common pathology was breast cancer (4/11). Pain (n=8) and pathological fracture (n=7) were the most common presenting symptoms. Microvascular free flaps consisted of seven fibula osteocutaneous flaps and four scapula osteocutaneous free flaps. All patients reported resolution of symptoms, with complete bone union identified radiographically (100%). Complications occurred in three patients (27%). One patient required removal of hardware at 8 months postoperative. Dental implant rehabilitation was completed in two patients. Ten patients are tolerating an oral diet. Ten patients are alive without evidence of MRONJ at any of the surgical sites. One patient died 28 months after surgery from progression of metastatic disease. Advanced MRONJ can be successfully treated in patients using vascularized tissue transfer, including those patients with significant peripheral vascular disease. Dental rehabilitation is a viable option for advanced MRONJ patients treated by vascularized flap reconstruction.

Bilateral Maxillary Reconstruction Using Fibular Flap in Bisphosphonate-related Osteonecrosis

Recent reports have shown successful transfer of vascularized fibular flap in bisphosphonate-induced mandibular osteonecrosis. We present a case of a 50-year-old patient who presented with bisphosphonate-related osteonecrosis of bilateral maxilla, which is reconstructed using a fibular flap.

Evaluation of surgical outcome and influencing risk factors in patients with medication-related osteonecrosis of the jaws

PURPOSE

Surgical treatment of the medication-related osteonecrosis of the jaw (MRONJ) is still challenging. We examined the outcome of the resection of osteonecrotic lesions and the influence of potential risk factors on the operative success.

METHODS

Seventy six surgical interventions on 40 patients were evaluated in a prospective design with a mean follow-up of 55 weeks. Primary endpoints were: (i) maintenance of the mucosal closure and (ii) decrease of MRONJ stage. Influential variables included preoperative duration, location and diameter of MRONJ, duration and change of antiresorptive therapy, presence of actinomyces species.

RESULTS

Only in 27.6% of cases long-term maintenance of the mucosal closure was achieved. However, stage II patients decreased to stage I in 81% after surgery (p < 0.01) and stage III patients improved in 83% of cases (OR = 8.08; p = 0.07). Stage I patients profited only in 38% by surgical intervention. MRONJ recurrence after surgery was associated with extended preoperative MRONJ duration (p = 0.015). There was no significance of further influential variables, but MRONJ of the upper jaw seems prognostically more favorable.

CONCLUSION

Advanced stages of MRONJ benefit from surgical treatment, whereas stage I diseases may also be treated conservatively. An early intervention reduces the risk of recurrence.

Resection and microvascular reconstruction of bisphosphonate-related osteonecrosis of the jaw: The role of microvascular reconstruction

BACKGROUND

Current treatment guidelines caution against osseous reconstruction using free flap tissue to treat bisphosphonate-related osteonecrosis of the jaw (BRONJ). The primary rationale for this stance is the theoretical risk of nonunion and recurrence of disease within the reconstruction. Emerging evidence suggests that these theoretical risks may be overestimated. We performed a literature review of this procedure for the treatment of advanced BRONJ. We also present a new case report of resection and microvascular reconstruction in a 58-year-old man with stage III BRONJ.

METHODS

A MEDLINE search was performed to gather all reports of maxillary and mandibular reconstruction using free tissue flap transfer for BRONJ. Inclusion criteria were confirmed stage II or III BRONJ, free tissue transfer and reconstruction, and reported complications. Articles were excluded if they contained only local flap reconstruction, wound closure without reconstruction, or osteoradionecrosis. Outcomes from our case report were added to the analysis.

RESULTS

We identified 10 articles that met criteria. Adding our case, we identified 40 cases of free flap reconstruction. The rate of nonunion was 5% (2 of 40). Fistulas formed in 4 cases (10%). BRONJ recurred in 2 cases (5%).

CONCLUSION

Complication rates after free flap microvascular reconstruction in BRONJ seem acceptable. Nonunion is relatively rare and should not be the sole reason to recommend against free flap reconstruction. A randomized clinical trial would help clarify the role of this procedure in refractory BRONJ; however, we believe that segmental resection and microvascular reconstruction is a viable option in select cases of BRONJ. © 2016 Wiley Periodicals, Inc. Head Neck 38:1278-1285, 2016.

The role of mylohyoid flap in the treatment of bisphosphonate-related osteonecrosis of the jaws

INTRODUCTION

Surgical treatment of bisphosphonate-related osteonecrosis of the jaws (BRONJ) combines excision of adequate damaged bone and watertight coverage by appropriate vascularized tissue. Local tissues are preferred when possible. This study compares local mucoperiosteal flaps with mylohyoid flaps with special emphasis on their influence on wound healing.

MATERIAL AND METHODS

A total of 195 patients with BRONJ in the mandible were included in this prospective study. The control group (n = 169) were treated with a mucoperiosteal flap, whereas patients of the study group (n = 26) received a mylohyoid flap.

RESULTS

Recurrence of BRONJ was significantly reduced (p = 0.023) as was extent of necrosis (p = 0.001) in patients with mylohyoid flaps.

DISCUSSION

This study demonstrates the importance of a sufficient mucosal coverage in surgical treatment of BRONJ. The mylohyoid flap provides an additional tissue coverage, which seems to account for the significantly reduced rate of disease recurrence.

CONCLUSION

The vascularized mylohyoid flap is an important tool in the complex and challenging surgical care of BRONJ.

Free flap reconstruction for patients with bisphosphonate related osteonecrosis of the jaws after mandibulectomy

INTRODUCTION

Bisphosphonate related osteonecrosis of the jaws (BRONJ) is a recognised unwanted effect of these drugs which affect bone remodelling. Treatment options range from conservative approaches through local bone debridement to free flap reconstruction following segmental resection. This current study aims to evaluate clinical outcomes after microvascular tissue transfer in BRONJ patients.

MATERIAL AND METHODS

A total of 212 BRONJ patients were included in this prospective investigation. Those who met defined inclusion criteria and received a surgical intervention were reviewed regularly during a follow-up period of at least 6 months.

RESULTS

Twenty-five patients (11.8%) received free flap reconstructions. A mean of 2.12 local debridements were performed before microvascular tissue transfer. A mean of 29.25% showed BRONJ recurrence after minimalist surgical intervention, compared to significantly less in patients after resection and free flap reconstruction. The postoperative fistula rate was significantly higher in patients, who received mucoperiosteal flaps.

DISCUSSION

This study underlines the importance and effectiveness radical resection and free flap reconstruction in the complex and challenging surgical treatment of BRONJ patients in a large patient cohort study. Nevertheless, all patients received radical intervention after failure of minimally invasive treatment. An individualized analysis and planning is necessary to identify appropriate patients for free flap reconstructions.

Microsurgical reconstruction for radiation- and bisphosphonate-induced mandible osteonecrosis based on patient-specific physiopathologic mechanisms

BACKGROUND

Radiation- and bisphosphonate-induced mandible osteonecrosis have distinct underlying physiopathologic mechanisms, but both can constitute a serious problem and lead to functional impairment and facial disfigurement.

METHODS AND RESULTS

We describe different clinical situations related to several grades of osteonecrosis, where different options of free transfer should be considered based on case-specific physiopathologic mechanisms. We propose a simple clinical grading system to predict the best treatment option.

CONCLUSIONS

For patients with advanced refractory disease, pathologic fracture, orocutaneous fistula, and severe osteolysis, resection associated with microvascular reconstruction seems to be a valid option that stops the underlying pathophysiology of overinfected avascular bone necrosis. Physicians who understand the specific physiopathologic mechanisms of each case can incorporate them into the assessment of the required reconstruction and treatment plans.

Successful long-term mandibular reconstruction and rehabilitation using non-vascularised autologous bone graft and recombinant human BMP-7 with subsequent endosseous implant in a patient with bisphosphonate-related osteonecrosis of the jaw

We describe a case of extensive osteonecrosis of the mandible after a dental extraction in a 71-year-old woman who was taking alendronic acid (Fosamax(®), Merck) for osteoporosis. Bone damaged by bisphosphonate-related osteonecrosis of the jaw (BRONJ), also now known as medication-related osteonecrosis of the jaw (MRONJ), can be regenerated and filled with endosseous implants using non-vascularised autologous grafts.

Intraindividual comparison of preoperative (99m)Tc-MDP SPECT/CT and intraoperative and histopathological findings in patients with bisphosphonate- or denosumab-related osteonecrosis of the jaw

PURPOSE

Bisphosphonate- or denosumab-related osteonecrosis of the jaw (BRONJ/DRONJ) requires reliable preoperative assessment of the extent of disease for surgical planning. The aim of this study was to compare the extent of BRONJ/DRONJ as detected by Tc-99m-methylene diphosphonate (MDP) bone scintigraphy with intraoperative and histopathological findings, and to assess the additional value of hybrid single photon emission computed tomography/computed tomography (SPECT/CT) for evaluation of disease.

MATERIAL AND METHODS

Twenty-one patients with BRONJ/DRONJ underwent three-phase bone scintigraphy including SPECT/CT. The diagnostic certainty using conventional SPECT or fused SPECT/CT imaging was compared. Location and extent of disease on scintigraphic imaging and pre- and intra-operative clinical assessment were compared. Intraoperative and histopathological findings served as reference standard.

RESULTS

A total of 29 sites of BRONJ/DRONJ were histopathologically confirmed in 21 patients. Bone scintigraphy demonstrated increased perfusion in 57.1% of patients, increased blood pool in 76.2%, and increased tracer accumulation at the metabolic phase in all patients. The intensity of tracer accumulation at the metabolic phase correlated significantly with clinical stage of disease (rs = 0.47, p = 0.03). Clinical examination (p < 0.0001), but not SPECT (p = 0.19), underestimated the extent of disease as determined by surgical evaluation. SPECT/CT offered a significantly higher diagnostic certainty (p < 0.0001).

CONCLUSION

In patients with BRONJ/DRONJ, the true extent of osseous lesions as determined by surgery is significantly underestimated by clinical examination. Tc-99m-MDP bone scintigraphy can reliably predict the extent of disease. Hybrid SPECT/CT may significantly increase the diagnostic certainty of anatomical localization.

Dramatic osteonecrosis of the jaw associated with oral bisphosphonates, periodontitis, and dental implant removal

INTRODUCTION

Osteoporosis affects millions of elderly patients, and anti-resorptive drugs (ARD) such as bisphosphonates (BP) represent the first-line therapy. Despite the benefits related to the use of these medications, osteonecrosis of the jaw is a significant complication in a subset of patients receiving these drugs.

CASE PRESENTATION

This report documents a case of dramatic bisphosphonate-related osteonecrosis associated with periodontitis and dental implant removal in an osteoporotic patient treated with per os bisphosphonates for an uninterrupted period of 15 years.

CONCLUSION

The aim of this report was to discuss the administration period of BP in the treatment of osteoporosis, the decision-making and clinical management of severe MRONJ and the indications for dental implant placement in these specific patients.

Surgical Therapy for Bisphosphonate-Related Osteonecrosis of the Jaw: Six-Year Experience of a Single Institution

PURPOSE

Bisphosphonates are drugs commonly used to treat osteoporosis, hypercalcemia of malignancy, and bone metastases. In some cases, its administration has been associated with osteonecrosis of the jaws. The management of medication-related osteonecrosis of the jaw (MRONJ) has not been completely elucidated, and its treatment can vary from no or limited surgery to more extensive surgery. The objective of the present study was to evaluate the efficacy of surgical therapy for patients presenting with MRONJ.

PATIENTS AND METHODS

A retrospective study was conducted that evaluated all MRONJ cases resulting from bisphosphonate use and treated by surgery from 2006 to 2012. All patients underwent surgery under general anesthesia.

RESULTS

A total of 33 patients with 46 MRONJ sites were evaluated. Most of the patients were women, with an age range of 39 to 83 years (mean 65.6 ± 10.6). Complete healing of the MRONJ region was observed in 40 of the 46 sites (87%), with partial improvement (symptom control and reduction of the exposed bone area) observed in 3 sites (6.5%), for a 93.5% clinical benefit rate. Of the remaining regions, 2 showed no significant changes, and 1 presented with a worse aspect compared with the patient's preoperative condition. Such cases were located in the posterior mandible region. The number of applications and type of bisphosphonate did not influence the treatment response.

CONCLUSION

The surgical approach to treating MRONJ showed a high rate of clinical control. Therefore, surgery should be considered as a therapy for some cases of this condition.

Pedicled buccal fat pad flap as a reliable surgical strategy for the treatment of medication-related osteonecrosis of the jaw

PURPOSE

The purpose of this study was to evaluate the coverage of the pedicled buccal fat pad flap (PBFP) and the long-term results of this treatment in patients with medication-related osteonecrosis of the jaw (MRONJ).

PATIENTS AND METHODS

Ten patients (2 men and 8 women; average age, 72.9 yr old) diagnosed with MRONJ were selected. Patients were treated with a PBFP. Data from patients regarding MRONJ stage, defect size, bone exposure after surgery, operation time, admission period, duration of antibiotic therapy, recurrence of disease, and postoperative complications were analyzed retrospectively.

RESULTS

Six patients were diagnosed with MRONJ stage 2, and 4 patients were diagnosed with MRONJ stage 3. The maximum defect in the study was 62 × 18 mm. Among the 10 patients, there was only 1 bony exposure, which occurred on postoperative day 2 after receiving the PBFP. This exposure might have been due to an incomplete resection of the affected bone. There were no severe donor site morbidities, and all patients showed satisfactory healing without incident.

CONCLUSIONS

According to this evaluation, the PBFP effectively covered a relatively large surgical defect. Complications were minimal, and there was no recurrence of bony exposure during follow-up. In conclusion, using the PBFP was a reliable treatment option for the management of denuded bone in patients with MRONJ.

Osteonecrosis of the maxilla related to long-standing methamphetamine abuse: a possible new aspect in the etiology of osteonecrosis of the jaw

BACKGROUND

Osteonecrosis of the jaw (ONJ) related to toxic effects of illicit drugs such as cocaine is not very common and might be overshadowed today by the incidence of bisphosphonate-related osteonecrosis of the jaw. However, we present a case which suggests a close relationship between abuse of the illicit drug methamphetamine (MA) and ONJ.

CASE REPORT

A 44-year-old male with extended osteonecrosis of the maxilla admitted chronic abuse and synthesis of MA for at least the previous two decades. Furthermore, he confessed self-extracting teeth since he became addicted to MA. However at presentation, he had been successfully cured of his addiction to MA. A step-by-step surgical treatment was planned using computer-aided design/computer-aided manufacturing techniques. After resection of necrotic bone, a vascularized osteomyocutaneous fibular flap was applied secondarily.

DISCUSSION

Two possible mechanisms, alone or in combination, could possibly lead to MA-related ONJ. Self-extraction of teeth as a psychopathologic behavior of self-destruction among MA abusers results in wounds that allow unhindered invasion of microorganisms causing osteomyelitis and ONJ, while on the other hand, the heating of white phosphor releases toxic phosphorous vapor, which could be inhaled and consequently cause ONJ of the maxilla. However, since the worldwide prevalence of MA abuse is remarkably high, a relationship between MA abuse and ONJ will offer a new aspect in the etiology of ONJ and might present a further therapeutic challenge.

Reconstruction of Defect after Treatment of Bisphosphonate-related Osteonecrois of the Jaw with Staged Iliac Bone Graft

Bisphosphonate is used widely for osteoporosis treatment, but a rising concern is the risk of osteonecrosis after long-term bisphosphonate use. Such cases are increasing, suggesting a need for research to prevent and treat bisphosphonate-related osteonecrosis of jaws. A 63-year-old female took bisphosphonate (Fosamax^®) for four years for treatment of osteoporosis and stopped medication two months ago because of unhealed wound. She was treated with marginal mandibulectomy maintaining the inferior border, and a metal plate was placed to prevent mandible fracture. Four months after the mandibulectomy, mandible reconstruction surgery using iliac bone and allograft was done. Six months after reconstruction, implant placement and treatment with an overdenture was done without complications. This study presents a case with a successful result.

Epidemiology, clinical manifestations, risk reduction and treatment strategies of jaw osteonecrosis in cancer patients exposed to antiresorptive agents

 Osteonecrosis of the jaws (ONJ) is an adverse side event of bisphosphonates and denosumab, antiresorptive agents that effectively reduce the incidence of skeletal-related events in patients with metastatic bone cancer and multiple myeloma. Available data suggest that 0-27.5% of individuals exposed to antiresorptive agents can develop ONJ. There is increasing evidence that avoidance of surgical trauma and infection to the jawbones can minimize the risk of ONJ, but there are still a significant number of individuals who develop ONJ in the absence of these risk factors. Bone necrosis is almost irreversible and there is no definitive cure for ONJ with the exclusion, in certain cases, of surgical resection. However, most ONJ individuals are affected by advanced incurable cancer and are often managed with minimally invasive nonsurgical interventions in order to control jawbone infections and painful symptoms. This article summarizes current knowledge of ONJ epidemiology, manifestations, risk-reduction and therapeutic strategies. Further research is needed in order to determine individual predisposition to ONJ and clarify the effectiveness of available treatments.

Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: systematic review and a new case series

INTRODUCTION

There is currently no gold standard for the treatment of Stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ). The question remains whether osseous reconstruction can offer an additional gain in outcome given the theoretical risk of non-union at the resection margins and recurrence in the osseous free flap. The objective was to conduct a systematic review of articles describing outcomes of osseous microsurgical reconstruction in cases of BRONJ with a minimum follow-up of 12 months, and to present the long-term outcomes of a new case series of three patients.

MATERIAL AND METHODS

A multi-database QUORUM-based single-reviewer systematic review identified eight papers that fulfilled the selection criteria. There are only case series and case reports available (Level 4 of the Oxford Evidence-based medicine scale). A total of 31 patients were analysed including the cases described in this article.

CONCLUSION

The limited overall rate of non-union at the resection margins and the 6.5% recurrence rate of BRONJ in the transplant counters the theoretical objections and advocates for considering osseous free flap reconstruction in the treatment of refractory BRONJ Stage III lesions. However, additional data derived from larger case series or case-control studies are imperative to support this hypothesis.

Pathologic fractures in bisphosphonate-related osteonecrosis of the jaw-review of the literature and review of our own cases

Background Bisphosphonates are powerful drugs used for the management of osteoporosis and metastatic bone disease to avoid skeletal-related complications. Side effects are rare but potentially serious such as the bisphosphonate-related osteonecrosis of the jaws (BRONJ). BRONJ impairs the quality of life and can even lead to pathologic fractures of the mandible. Management of BRONJ is difficult per se. If complicated with pathologic mandibular fractures in advanced stages, the treatment options are controversially discussed. This review delineates the epidemiology and pathogenesis of BRONJ to put the various modalities for the treatment of pathologic mandible fractures into perspective. Methods Various case reports and case series in the literature were reviewed. Cases were reviewed of patients suffering from pathologic fracture due to bisphosphonate-related osteonecrosis of the jaw treated in the Department of Oral and Maxillofacial Surgery (Ludwig-Maximilians-University of Munich) from 2003 to 2010. Of 140 patients suffering from BRONJ, four were identified with pathologic fracture of the mandible. Results Management of pathologic mandibular fractures in patients suffering from BRONJ is an unsolved issue. At present there is a paucity of information to establish reliable therapy guidelines. The published strategies range from conservative treatment to major bone resections with or without internal or external fixation and with or without autogenous reconstruction. There is no evidence for the superiority of a single therapeutic mode, however. Conclusion Further understanding of BRONJ is mandatory to establish a sound rationale for the treatment of associated mandibular fractures.

Importance of patient-specific intraoperative guides in complex maxillofacial reconstruction

BACKGROUND

Conventional maxillofacial reconstruction often leads to suboptimal results due to inaccurate planning or surgical difficulties in adjusting a free flap and osteosynthesis plates into a three-dimensional defect.

OBJECTIVES

To justify the importance of patient-specific intraoperative guides in complex maxillofacial reconstruction. CLINICAL EXAMPLE: A 40-year old patient underwent a left hemimaxillectomy for an adenoid cystic carcinoma of the palate. Six years later, massive recurrence required radical resection of the left orbit and reconstruction with cranial bone grafts and a free latissimus dorsi flap. Postoperative radiotherapy resulted in local osteoradionecrosis. Surgical revision and restoration of the maxillary defect with a prefabricated fibula flap was performed. The authors provide ample information on the application of computer-aided design and manufacturing (CAD-CAM) and rapid prototyping at each reconstructive step.

DISCUSSION

Stereolithographic models enable simulation of the resective and reconstructive phases, prebending of reconstruction plates and fabrication of surgical guides.

CONCLUSIONS

Optimal restitution of complex maxillofacial defects requires meticulous planning of the surgical and prosthetic phases and effective transfer of the plan to the operating room through patient specific guides. CAD-CAM technology and stereolithographic models represent an effective strategy to achieve this. Improved patient outcomes and intraoperative efficiency certainly offset the inherent increase in costs.

A systematic review of microsurgical reconstruction of the jaws using vascularized fibula flap technique in patients with bisphosphonate-related osteonecrosis

Objective

The aim of this systematic review was to assess the role of microsurgical reconstruction of the jaws in patients with bisphosphonate-related osteonecrosis, and biological complications after an observation period of at least 12 months.

Material and methods

An electronic MEDLINE search supplemented by manual searching was conducted to identify studies reporting data of at least 12 months observation on the microsurgical reconstruction of the jaws in patients with bisphosphonate-related osteonecrosis.

Results

Four studies resulted eligible for the analysis yielded. Three out of five studies were free of complications, with a success rate of 100% as no recurrence of osteonecrosis was registered.

Conclusions

Microsurgical reconstruction of the jaws represents a valid treatment modality in patients with bisphosphonate-related osteonecrosis at 3^rd stage of the disease.

Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw

OBJECTIVE

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious side-effect of bisphosphonate therapy. In the majority of cases BRONJ occurs in the mandible. As a consequence a detailed investigation of BRONJ of the maxilla and in particular of involvement of the maxillary sinus has largely so far been neglected. The aim of this study was to analyse the frequency of maxillary sinusitis and oro-antral fistulae in BRONJ of the maxilla.

SUBJECTS AND METHODS

A retrospective multicentre analysis was carried out in three Departments of Oral and Maxillofacial Surgery focussing on patients suffering from BRONJ in the maxilla. The role of involvement of the maxillary sinus, in particular sinusitis and oro-antral fistula, was analysed.

RESULTS

Out of a total of 170 patients suffering from BRONJ 53 cases (31.2%) with involvement of the maxilla were identified. At least one sign of maxillary sinusitis was present in 43.6% (23/53) and an oro-antral fistula in the course of the disease was detected in 35.8% (19/53) of those patients. The mean length of time of bisphosphonate intake was 36.16±16.32 months. Zoledronate was most frequently associated (60.4%) with symptoms, followed by the combination of Zoledronate/Ibandronate (13.2%), and Zoledronate/Pamidronate or Pamidronate alone (both 7.5%).

CONCLUSION

Maxillary sinusitis and oro-antral fistulae are associated with a BRONJ manifestation in the upper jaw in approximately 44%. The involvement of the maxillary sinus should be given special attention and three-dimensional imaging modalities might be necessary, not only to evaluate the extent of necrosis, but also to exclude involvement of the maxillary sinus.

Osteoporosis and bisphosphonates-related osteonecrosis of the jaw: not just a sporadic coincidence--a multi-centre study

INTRODUCTION

Bisphosphonates (BPs) are powerful drugs that inhibit bone metabolism. Adverse side effects are rare but potentially severe such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). To date, research has primarily focused on the development and progression of BRONJ in cancer patients with bone metastasis, who have received high dosages of BPs intravenously. However, a potential dilemma may arise from a far larger cohort, namely the millions of osteoporosis patients on long-term oral BP therapy.

PATIENTS AND METHODS

This current study assessed 470 cases of BRONJ diagnosed between 2004 and 2008 at eleven different European clinical centres and has resulted in the identification of a considerable cohort of osteoporosis patients suffering from BRONJ. Each patient was clinically examined and a detailed medical history was raised.

RESULTS

In total, 37/470 cases (7.8%) were associated with oral BP therapy due to osteoporosis. The majority (57%) of affected individuals did not have any risk factors for BRONJ as defined by the American Association of Oral and Maxillofacial Surgery. The average duration of BP intake of patients without risk factors was longer and the respective patients were older compared to patients with risk factors, but no statistical significant difference was found. In 78% of patients the duration of oral BP therapy exceeded 3 years prior to BRONJ diagnosis.

DISCUSSION

The results from this study suggest that the relative frequency of osteoporosis patients on oral BPs suffering from BRONJ is higher than previously reported. There is an urgent need to substantiate epidemiological characteristics of BRONJ in large cohorts of individuals.

Outcome of treatment and parameters influencing recurrence in patients with bisphosphonate-related osteonecrosis of the jaws

PURPOSE

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is now a well-recognised entity which is difficult to manage and often recurs. The aim of this study was to examine the success of resection of the necrotic bone and identify risk factors for recurrence in these patients.

METHODS

One hundred and eight patients were evaluated prospectively and investigated at least twice. Multiple logistic regression analysis was used to determine factors independently associated with the dependent variable of recurrence of BRONJ.

RESULTS

Factors influencing the development of recurrence of BRONJ were the presence of bacterial bone infection of the necrotic area (P = 0.011), type of treatment (either conservative or surgical, P = 0.001) with a lower recurrence rate for surgically treated patients, extent of surgical treatment with better outcome in larger resections (P < 0.0001), number of debridements performed (P < 0.0001), and the extent of radiographic appearance of osteolysis assessed by dental panoramic tomogram (P = 0.028).

CONCLUSIONS

An increased risk for recurrence can be found in cases with bacterial bone infection of the necrotic area, type of conservative or surgical treatment, extent of surgical treatment with better outcome in larger resections, and the number of debridements performed. Microvascular tissue transfer should be considered in selected cases if other options have been exhausted.

Bisphosphonate related osteonecrosis of the jaw--manifestation in a microvascular iliac bone flap

Bisphosphonate related osteonecrosis of the jaw (BRONJ) is a side effect that may emerge due to a long-term bisphosphonate therapy. Although the timely diagnosis and initiation of treatment are associated with good outcome results, extended cases require whole parts of the jaw to be resected. A possible treatment option is the bony reconstruction of the jaw using microvascular bone flaps. We report, for the first time, the development of a bisphosphonate related osteonecrosis in a microvascular iliac bone graft, a reconstruction that was performed following a partial mandibulectomy due to BRONJ stage III. The observation of BRONJ manifestation in an osseous microvascular transplant is a novel finding that sheds new light on current pathogenesis theories that surround this entity. Furthermore, it is hypothesized that BRONJ is able to progress to adjacent bone. In addition, bone reconstruction in patients suffering from BRONJ may be seen more critically.

Outcomes of vascularized bone graft reconstruction of the mandible in bisphosphonate-related osteonecrosis of the jaws

OBJECTIVES/HYPOTHESIS

To describe the clinical entity and therapeutic challenges of bisphosphonate-related osteonecrosis of the jaws (BRONJ). The use of vascularized bone grafts for reconstruction of the mandible in extensive BRONJ is proposed.

STUDY DESIGN

Multi-institutional retrospective review.

METHODS

Patients undergoing mandible reconstruction with vascularized bone grafts after segmental mandible resection for BRONJ were evaluated. Mandible reconstruction was only performed on patients with intractable pain, fistulae, or pathologic fracture and after failure of comprehensive conservative therapy. No patients had a history of primary or metastatic head and neck malignancy or radiation therapy. Bone union was established with follow-up radiography.

RESULTS

Eleven patients met inclusion criteria. Mean patient age was 61.3 years. Median follow-up was 13.9 months. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. Preoperatively, pathologic mandible fractures were present in 73% of patients, and 36% had orocutaneous fistulae. Fibula osteocutaneous flaps were used in all cases with no failures. In all patients, bony union was demonstrated clinically and radiographically. Postoperative wound complications occurred in 36% of patients but were all treated successfully with conservative therapy. There was no BRONJ recurrence within the study follow-up period.

CONCLUSIONS

Osteonecrosis is a significant complication of bisphosphonate therapy, and current literature does not support vascularized reconstruction. We demonstrate that vascularized bone graft reconstruction with the fibula free flap offers a high success rate of bony union and fistula closure and should be offered to selected patients with advanced cases of BRONJ.