1228 G. M. Kushner and R. L.

Flint

. Fig. 41.17 Cutting guides fabricated based on CT scan and 3D . Fig. 41.19 Custom milled reconstruction plate requires no addi-
printed model allows extremely accurate surgery tional bending and is stronger than traditional reconstruction plate.
Vessel loop around inferior alveolar nerve that has been preserved in
attempt to maintain sensation

. Fig. 41.18 Bony resection of osteomyelitis for additional pathol-

ogy and microbiology studies

develops paresthesia in mandibular osteomyelitis, resec-

tion and immediate reconstruction are indicated. At this
41 point preservation of the mandible is highly unlikely
and one should attempt to shorten the course of the dis-
ease and treatment (. Figs. 41.23, 41.24, 41.25, 41.26,
41.27, 41.28, and 41.29).

41.2 Osteoradionecrosis

Radiation therapy is a valuable treatment modality in

treating cancer of the maxillofacial region. Radiation
therapy can be used alone or as an adjunctive therapy in
combination with surgery and chemotherapy. Radiation . Fig. 41.20 Autogenous bone graft for immediate reconstruction
therapy, like any treatment modality, has deleterious
side effects, including mucositis and xerostomia. One of to represent a radiation-induced osteomyelitis. However,
the most dreaded complications of radiation therapy is Marx has shown that osteoradionecrosis represents a
osteoradionecrosis (ORN). Historically, ORN was felt chronic nonhealing wound that is hypoxic, hypocellular,
Osteomyelitis, Osteoradionecrosis (ORN), and Medication-Related Osteonecrosis of the Jaws (MRONJ)
1229 41

. Fig. 41.24 Postoperative panoramic image of #17 extraction

site. Patient had postoperative pain and swelling in the #17 surgical
site

. Fig. 41.21 Autogenous bone graft in place with milled recon-

struction plate for immediate reconstruction of mandibular resec-
tion defect for osteomyelitis

. Fig. 41.25 Panoramic image after additional extractions and

debridement to establish diagnosis of osteomyelitis

. Fig. 41.22 Postoperative panoramic view of resection and imme-

diate reconstruction

. Fig. 41.26 Panoramic image of left mandible with “moth eaten”

bony changes consistent with osteomyelitis

. Fig. 41.23 Panoramic view of planned extraction of symptom-

atic #17

and hypovascular [18, 19]. In years past, the radiation

therapist used orthovoltage therapy and there was a
high incidence of ORN. However, the modern radiation
therapists use megavoltage, which is felt to be kinder to
the bone and soft tissues. In addition, collimation and . Fig. 41.27 Postoperative panoramic image after resection of
shielding of tissues in conjunction with careful dental osteomyelitis left mandible and placement of reconstruction plate
 1230 G. M. Kushner and R. L. Flint

. Fig. 41.30 Clinical image of exposed bone in the anterior man-

. Fig. 41.28 Patient required additional surgery for spread of dible after dental extractions in the radiated field
osteomyelitis across mandible. Patient was eventually diagnosed with
hypogammaglobulinemia and was an immunocompromised host

. Fig. 41.31 Panoramic image of patient. Note lytic bony changes

consistent with osteoradionecrosis (ORN)

. Fig. 41.29 Panoramic image after removal of most of patient’s

mandible for recalcitrant osteomyelitis

evaluation preoperatively have greatly decreased the

incidence of ORN. The effects of radiation last a life-
time and do not decrease over time. Ideally, the dental
team is consulted prior to radiation therapy beginning.
41 A thorough dental exam will identify any teeth that
should be extracted prior to radiation therapy. Flouride
carriers can be fabricated if there are teeth remaining
during radiation therapy. The dentist can review the . Fig. 41.32 Panoramic image of heavily radiated patient for oral
squamous cell carcinoma. Note extensive lytic changes in mandible
importance of dental care during and following radia- consistent with ORN
tion therapy. The goal is to perform any invasive dental
procedure prior to radiation therapy in hopes to decrease
the chance of osteoradionecrosis. Unfortunately many spontaneously. The clinical picture of ORN is most
times clinically, the dental clearance is not obtained commonly seen with pain and exposed bone in the max-
before starting radiation therapy. The dental team is illofacial region. ORN is more common in the mandible
then faced with performing invasive dental procedures than in the maxilla for reasons described earlier in this
in the radiated field which can be a set-up for complica- chapter. A dosage of radiation above 5000–6000 rads is
tions (. Figs. 41.30 and 41.31). generally felt to make the mandible susceptible to ORN
ORN is generally caused by trauma to the radiated (. Figs. 41.32, 41.33, 41.34, 41.35, 41.36, 41.37, and
area, usually by dental extraction, but it can also occur 41.38).
Osteomyelitis, Osteoradionecrosis (ORN), and Medication-Related Osteonecrosis of the Jaws (MRONJ)
1231 41

. Fig. 41.36 Specimen of mandibular ORN

. Fig. 41.33 Intra-oral view of exposed bone right mandible

. Fig. 41.34 Intra-oral view of exposed bone left mandible

. Fig. 41.37 Frontal view of “Andy Gump” deformity seen with

no reconstruction of mandibular defect

Radiographically, the appearance on the orthopan-

tomogram or CT scan resembles conventional osteomy-
elitis with areas of osteolysis and bony sequestrum.
Often there is an appearance of moth-eaten bone pres-
ent on these films. Cone beam CT(CBCT) has become
common in dental offices and can provide three-
dimensional imaging which can help diagnose osteora-
dionecrosis.
The treatment of ORN is aimed at removing the
nonviable (necrotic) tissue and allowing the body to heal
. Fig. 41.35 Intra-operative view of mandibular debridement of itself. The clinician must always be aware that tissue
mandibular ORN removed in a prior cancer patient should be sent to
 1232 G. M. Kushner and R. L. Flint

negative effect on bacteria and a positive effect on angio-

genesis and increased blood #ow to the area. HBO has
been used effectively to treat ORN and as an adjunctive
treatment with maxillofacial reconstructive procedures
such as dental extractions, dental implants, and jaw
reconstruction in the radiated patient.
HBO treatment consists of dives or treatment ses-
sions for 90 min based at 2.4 atm of pressure. Twenty
to 30 dives are given preoperatively before any surgical
intervention is performed. The area of ORN is then
debrided and followed with 10 additional HBO treat-
ments. Reconstruction of the maxillofacial region is
based on the patient’s response to the treatment proto-
col. HBO treatments are expensive and facilities are
often scarce, available only in larger cities with medi-
cal centers or academic health science centers. Despite
its documented clinical benefits, there still remains
some controversy about the effectiveness of HBO
therapy [26].
With the addition of microvascular surgery to the
surgical armamentarium, there now exists an excellent
surgical option in treatment of the patient with
ORN. Microvascular surgery (free #aps) allows the sur-
. Fig. 41.38 Lateral view of “Andy Gump” deformity geon to bring in hard and soft tissues that have their own
independent blood supply. The fibula, iliac crest, scap-
ula, and radius are all considered applicable donor sites
pathology to rule out occult or recurrent malignant dis- [27, 28]. The fibula is very popular in maxillofacial
ease that is masquerading as a bony infection. Minor reconstruction as the surgeon can bring an excellent
debridements of exposed bone may work in most minor length of bone which can be osteotomized and fabri-
cases of ORN. Surgery in the radiated field always has cated into a new mandible [29, 30]. There is an excellent
the potential of delayed healing. skin paddle to provide soft tissue coverage. The micro-
There have been additional methods to combat vascular #ap is plugged into facial vessels or the carotid
osteoradionecrosis. Treatment with oral artery and jugular vein system for blood supply and
pentoxifylline(Trental) and tocopherol (Vitamin E) has drainage. The clinical advantage of microvascular sur-
proven effective in medically managing early- and even gery is that the surgeon does not have to rely on a com-
late-stage osteoradionecrosis. The pentoxifylline and promised host bed from radiation therapy or a lack of
Vitamin E clinically combat fibrosis, increase blood soft tissue, which very often occurs in ablative cancer
#ow, and scavenge free radical that are detrimental to surgery. In addition, HBO treatments are not necessary
healing [20–22]. Addition of Clodronate has also shown with microvascular surgery. Lastly dental implant recon-
41 promising results in clinical trials [23–25]. Platelet-rich struction has been used with free tissue transfer tech-
plasma, which is rich in growth factors, has also shown niques and has proven successful in the dental
promise when used to debride the necrotic bone of reconstruction of these patients [31]. We now have the
ORN. Hyperbaric oxygen (HBO) can also be used for capability to restore patients as close as possible to their
delayed healing or ORN in the radiated field. Current premorbid status with modern reconstructive tech-
therapy calls for augmentation of tissue healing response niques. Microvascular free tissue transfer has withstood
by the use of HBO. HBO therapy consists of 100% oxy- the test of time and is now commonplace in managing
gen delivered in a pressurized manner. Tissues treated oncologic and other hard and soft tissue defects
with HBO have increased levels of oxygen, which has a (. Figs. 41.39, 41.40, 41.41, 41.42, 41.43, and 41.44).
Osteomyelitis, Osteoradionecrosis (ORN), and Medication-Related Osteonecrosis of the Jaws (MRONJ)
1233 41

. Fig. 41.39 Panoramic view of extraction site of left mandibular

molar (#18) in radiated field. Patient had SCCA of tongue treated
with surgery and radiation therapy

. Fig. 41.42 Free fibula removed from donor site. The fibula can
be used with or without the skin paddle. Note the vascular pedicle
for attachment to patient’s native neck vessels

. Fig. 41.40 Panoramic image showing pathologic fracture of left

mandibular angle in the radiated field

. Fig. 41.43 Anastomosis of vascular pedicle and fixation of bony

fibula left mandible

. Fig. 41.41 Planned free fibula surgery to reconstruct left mandi-

ble after resection of ORN and pathologic fracture

41.3 Medication-Related Osteonecrosis

of the Jaws
A new pathologic entity was discovered in 2001–2002 . Fig. 41.44 Postoperative panoramic image of free fibula to the
when clinicians noticed an increased incidence of exposed left mandible
alveolar bone and “refractory osteomyelitis” in patients
taking medications in a new class of drugs named Spontaneous exposure of alveolar jawbone was also
bisphosphonates. Dental patients had common proce- reported. Bisphosphonates were used to treat bony
dures such as extraction of teeth with postoperative com- sequelae of malignant disease such as multiple myeloma
plications of nonhealing, exposed jawbone [32]. and metastatic disease, very typically, breast cancer.