Management of advanced mandibular osteoradionecrosis with free flap reconstruction

Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysis

Our study aimed to estimate the prevalence of total free flap failure following free flap reconstruction for mandibular osteoradionecrosis (mORN) and assess the impact of potential moderators on this outcome. A comprehensive systematic literature search was independently conducted by two reviewers using the Medline, Scopus, Web of Science and Cochrane Library databases. Quality assessment of the selected studies was performed, and prevalence estimates with 95% confidence intervals (CI) were calculated. Outlier and influential analyses were conducted, and meta-regression analyses was employed to investigate the effects of continuous variables on the estimated prevalence. Ultimately, forty-six eligible studies (involving 1292 participants and 1344 free flaps) were included in our meta-analysis. The findings of our study revealed a prevalence of 3.1% (95% CI 1.3-5.4%) for total free flap failure after reconstruction for mORN. No study was identified as critically influential, and meta-regression analysis did not pinpoint any potential sources of heterogeneity. These findings provide valuable insights for researchers and serve as a foundation for future investigations into the management of mandibular osteoradionecrosis and the prevention of free flap failure in this context.

Development and Standardization of a Classification System for Osteoradionecrosis: Implementation of a Risk-Based Model

Purpose

Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN.

Methods

Consecutive head-and-neck cancer (HNC) patients treated with curative-intent IMRT (≥ 45Gy) in 2011-2018 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared to fifteen existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection).

Results

ORN was identified in 219 out of 2732 (8%) consecutive HNC patients. Factors associated with high-risk of ORN were: oral-cavity or oropharyngeal primaries, received IMRT dose ≥60Gy, current/ex-smokers, and/or stage III-IV periodontal disease. The ORN rate for high-risk vs low-risk patients was 12.7% vs 3.1% (p<0.001) with an area-under-the-receiver-operating-curve (AUC) of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, RadORN, was proposed based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems.

Conclusion

We identified risk factors for ORN, and proposed a novel ORN classification system based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN, and may facilitate clinical care and clinical trials.

Anterior Skull Base Osteoradionecrosis in the Age of Intensity-Modulated Radiation Therapy: A Case Series

Background  Despites advances in radiation technology, skull base osteoradionecrosis (ORN) continues to be a rare, devastating, and hard to treat complication of radiotherapy. We present three cases of anterior skull base ORN in a cohort treated with intensity-modulated radiation therapy (IMRT). Case Series  Three patients developed anterior skull base ORN after receiving at least one round of IMRT. ORN was diagnosed through either nasal endoscopy or imaging findings. The first was a 59-year-old woman with a sinonasal squamous cell carcinoma. Her chemoradiation history was notable for reirradiation and a high dose of radiation (143.3 Gy). The second was a 55-year-old man with recurrent nasopharyngeal carcinoma, whose history was notable for a high dose of radiation (∼140 Gy) and for being reirradiated. The final patient was a 37-year-old woman with an unremarkable history who received radiotherapy (65.0 Gy) for an esthesioneuroblastoma. One patient was asymptomatic and did not receive ORN-specific therapy. The other two were treated with a combination of medical and surgical intervention with successful short-term outcomes (no evidence of infection). Conclusion  Anterior skull base ORN can be treated through conservative and surgical means to achieve successful short-term outcomes. Further investigation of long-term outcomes is warranted.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Importance

Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed.

Objective

To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN.

Design, Settings, and Participants

This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023.

Main Outcomes and Measures

Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals.

Results

The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months.

Conclusions and Relevance

The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

Reconstruction of mandibular defects in osteoradionecrosis and medication-related osteonecrosis of the jaw using fibula free flap and management of postoperative wound infections

BACKGROUND

Complications from osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ) include oro-cutaneous fistulas, necrotic bone exposure, soft-tissue defects, and pathologic fractures. The fibula free flap (FFF) is a common free flap method used to reconstruct the mandible in severe cases. Recently, we have used the FFF successfully for the reconstruction of ORN and MRONJ mandibular defects. We report this method as a recommended technique for the treatment of ORN and MRONJ and the management method of postoperative infections.

METHODS

Four patients who were diagnosed with ORN of the mandible and 3 patients who were diagnosed with MRONJ of the mandible were included in the study. Among the 7 patients, 3 patients also had pathologic fractures. Partial mandibulectomy and FFF reconstruction were performed at the Department of Oral and Maxillofacial Surgery, Samsung Medical Center from April 2019 to March 2021.

RESULTS

All 7 patients recovered following the reconstruction of the defect by FFF. Four patients experienced infections after surgery and pus cultures were performed. All were well healed without flap damage after changing the antibiotics by consultation with infectious medicine experts.

CONCLUSION

FFF is a widely used method and can provide an extensive flap to reconstruct the mandible, especially those affected by ORN or MRONJ. If an infection occurs after surgery, appropriate antibiotic changes should be made through cooperation with the infectious medicine department. Therefore, FFF is a well-established and recommended method even in cases of challenging reconstruction.

Quality of life after segmental mandibulectomy and free flap for mandibular osteonecrosis: Systematic review

OBJECTIVE

Review QOL outcomes among patients undergoing segmental mandibulectomy and bony free flap reconstruction for ONJ.

DATA SOURCES

PubMed was searched for MeSH terms "Quality of life," "Osteonecrosis," "Osteoradionecrosis," "Bisphosphonate-associated osteonecrosis of the jaw," "Free tissue flaps," and "Mandibular reconstruction."

REVIEW METHODS

English language studies with QOL outcomes data for patients undergoing free flap reconstruction for advanced ONJ were included. 197 records were initially screened; 18 full texts assessed; 10 full texts included. PRISMA guidelines were followed.

RESULTS

Ten studies were included in this systematic review: six retrospective, three retrospective with comparison groups, and one prospective. In studies with comparison groups, ONJ patients have worse self-reported QOL than the general population as well as head and neck cancer patients without ONJ. Nearly all patients with QOL measurements (220/235 patients) had ONJ from prior radiation. Segmental mandibulectomy and bony free flap improved overall QOL in over half of patients, as well as pain associated with ONJ in 70-75 % of patients. Surgery did not improve long-term effects of radiation such as chewing, swallowing, and salivary production. Donor site morbidity rarely affects QOL.

CONCLUSIONS

Osteonecrosis of the jaw (ONJ) worsens quality-of-life, and advanced disease often requires segmental mandibulectomy and bony free flap reconstruction. Patients and surgeons may expect improvement in some, but not all, domains of patient-reported QOL by the use of segmental mandibulectomy and reconstruction for advanced ONJ.

Free vascularized flap reconstruction for osteoradionecrosis of the mandible: a 25-year retrospective cohort study

Background

Osteoradionecrosis of the jaw is a severe complication of radiotherapy in head and neck cancer patients. If conservative treatment and surgical debridement have been unsuccessful, the preferred treatment for symptomatic mandibular osteoradionecrosis (mORN) is radical surgery and subsequent reconstruction with a free vascularized flap. This study aims to assess the outcomes of free vascularized flap reconstruction in mORN.

Methods

A retrospective study was conducted on all patients who underwent a free vascularized flap reconstruction for mORN between 1995 and 2021 in Amsterdam UMC – VUmc, The Netherlands.

Results

In our cohort study, three of the twenty-eight flap reconstructions failed (10.7%). No recurrences of mORN were observed during a mean follow-up of 8 years.

Conclusions

The success rate of free vascularized flap reconstruction for mORN is high. The fibula is the preferred free flap for mandibular reconstruction in mORN cases. However, this type of surgery is at risk for complications and patients need to be informed that these complications may require surgical re-intervention.

Level of evidence: Level IV, Therapeutic; Risk/Prognostic.

Bacterial Colonization of the Condyle in Patients with Advanced Mandibular Osteoradionecrosis: Analysis of Hemimandibulectomy Specimens

Advanced mandibular osteoradionecrosis (ORN) sometimes requires extended resection (e.g., hemimandibulectomy). Bacterial infection contributes to ORN pathogenesis. To control infection and determine the extent of debridement required, an understanding of bacterial spread within sites of mandibular ORN is important. The current study used a histopathological approach to assess bacterial colonization in the mandibular condyle and elucidate possible paths of bacterial spread towards the mandibular condyle. Four hemimandibulectomy specimens were selected. Areas of bone destruction were macroscopically assessed and confirmed using hematoxylin and eosin staining. Bacterial presence within mandibular condyle was confirmed with Gram staining. Bone exposure was observed in the molar area in all specimens. Macroscopic bone destruction was apparent especially near the medial side of the cortical wall. Gram staining revealed bacterial colonization of the mandibular condyle in three of the four specimens. In conclusion, bacteria tended to spread posteriorly and through the medial side of the mandibular cortical wall. In patients with advanced ORN, the potential for bacterial colonization of the mandibular condyle should be considered during treatment.

Survival of vascularized osseous flaps in mandibular reconstruction: A network meta-analysis

Objective

An evidence regarding which bony flap for reconstruction of mandibular defects following tumour resection is associated with the highest survival rate is still lacking. This network meta-analysis (NMA) aimed to guide surgeons selecting which vascularized osseous flap is associated with the highest survival rate for mandibular reconstruction.

Methods

From inception to March 2021, PubMed, Embase, Scopus, and Cochrane library were searched to identify the eligible studies. The outcome variable was the flap survival rate. The Bayesian NMA accompanied by a random effect model and 95% credible intervals (CrI) was calculated.

Results

Twenty-two studies with a total of 1513 patients, comparing four osseous flaps namely fibula free flap (FFF), deep circumferential iliac artery flap (DCIA), scapula flap, and osteocutaneous radial forearm flap (ORFF) were included. The respective survival rates of FFF, DCIA, Scapula, and ORFF were 94.50%, 93.12%, 97%, and 95.95%. The NMA failed to show a statistically significant difference between all comparators (FFF versus DCIA (Odd ratio, 1.8; CrI, 0.58,5.0); FFF versus ORFF (Odd ratio, 0.57; CrI, 0.077; 2.9); FFF versus scapula flap (Odd ratio, 0.25; CrI, 0.026; 1.5); DCIA versus ORFF (Odd ratio, 0.32; CrI, 0.037; 2.1); DCIA versus scapula flap (Odd ratio, 0.14; CrI, 0.015; 1.1) and ORFF versus scapula flap (Odd ratio, 2.3; CrI, 0.16; 34)).

Conclusion

Within the limitations of the current NMA, FFF, DCIA, Scapula, and ORFF showed a comparable survival rate for mandibular reconstruction. Although the scapula flap reported the highest survival rate compared to other osseous flaps for mandibular reconstruction; however, the decision making when choosing an osseous flap should be based on many factors rather than simply flap survival rate.

Surgical Management of Bilateral Osteoradionecrosis of the Mandible

PURPOSE

The purpose of this study was to evaluate our 10 years clinical experience in surgical management of patients with bilateral osteoradionecrosis (BORN) of the mandible in head and neck malignancies patients.

MATERIALS AND METHODS

The authors reviewed 22 patients with bilateral mandibular bone mineral density changed in image who had failed to respond to conservative treatments. They were treated by radical resection and reconstruction with free flaps immediately or second-stage at our institution between January 2008 and January 2018.

RESULTS

Nine patients received immediate bilateral mandibular radical resection. Six bone flaps (4 fibula osteocutaneous [fibular OC], 1 fibular OC + pectoralis major myocutaneous flap [PMMF] and 1 fibular OC + anterolateral thigh flap [ALTF]) and 3 soft flaps (1 PMMF, 1 PMMF + titanium plate and 1 ALTF) were used. Three (33.3%) of these patients complications occurred in the immediate postoperative period, but all patients have an acceptable follow-up outcomes. In remaining 13 patients who only experienced immediate unilateral mandible resection for the first time. Complications occurred in 1 patient (7.7%), and all patients have a good outcome in the immediate postoperative period. In follow-up, 1 patient titanium plate exposed, and 6 patients (46.2%) contralateral mandible ORN developed that underwent radical resection in second time. Three fibular OC, 2 PMMF, and 1 latissimus dorsi myocutaneous flap were used. The overall outcome of our experience with the use of bone or soft tissue transfers in managing BORN of mandible is encouraging.

CONCLUSIONS

An individualized management plan should be given for each patient depending on their own local and general condition. Radical resection followed by vascularized flaps reconstruction is an acceptable and reliable procedure for patients with BORN of the mandible.

Occurrence and Treatment Outcome of Late Complications After Free Fibula Flap Reconstruction for Mandibular Osteoradionecrosis

PURPOSE

This study aimed to evaluate the occurrence and treatment outcome of late complications after free fibula osteocutaneous flap reconstruction for mandibular osteoradionecrosis (ORN).

METHODS

We enrolled 15 consecutive patients (14 men, one woman; median age 65 years, range 57-80 years) who underwent free fibula reconstruction for advanced mandibular ORN during 2013-2017 with two or more years of follow-up. Late complications included infection, plate exposure, and recurrence at the resection margin. The effect of perioperative antibiotic administration on late complications was also assessed.

RESULTS

Late complications occurred in 33.3% (5/15) of patients, including two infections (local and distant), two plate exposures, and two recurrences (plate exposure and recurrence occurred in one patient). Perioperative antibiotic administration duration did not significantly affect the occurrence of postoperative late complications. All late complications were treated without problems.

CONCLUSIONS

Late complications after ORN reconstructive surgery are not uncommon, but can be treated properly.

Therapeutic alternatives in the management of osteoradionecrosis of the jaws. Systematic review

Background

to systematically review the literature, comparing the healing of osteoradionecrosis (ORN) among the therapeutic alternatives: surgical, pharmacological and combined.

Material and Methods

The review was organized according to the PRISMA protocol with regards to the following PICO question: patients with ORN of the jaws (P=Patient); all interventions reported (I = intervention); between all therapies (C=Comparison); healing of lesions (O=outcome).

Results

Surgical treatment was the most common choice (46.3%) followed by pharmacological treatment, exclusively (25.9%) or combined (26.9%). Treatment exclusively by surgical intervention seems to be most effective option, with 51.2% of the lesions healed, OR for healing of 5.7 (CI95% 1.9-16.9, p=0.002). Only 1 case (0.9%) corresponded to low level laser therapy.

Conclusions

It seems clear that early intervention with conservative surgical combined with pharmacological methods improves the prognosis of ORN.

Key words:Osteoradionecrosis, radiotherapy bone necrosis, hyperbaric oxygen, pentoxifylline, teriparatide, low level laser therapy.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction

BACKGROUND

 Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN.

METHODS

 This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared.

RESULTS

 Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test).

CONCLUSION

 Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Osteoradionecrosis: Exposing the Evidence Not the Bone

Osteoradionecrosis is a relatively rare but potentially morbid and costly complication of radiation therapy for head and neck cancer. Multidisciplinary diagnosis and treatment are essential. Despite evidence guiding individual aspects of care for osteoradionecrosis, there is a lack of broad consensus on the overall diagnosis and management of this condition. This study comprehensively reviews the literature, with a focus on the past 10 years, to guide evaluation and treatment.

Advanced osteoradionecrosis of the maxilla: a 15-year, single-institution experience of surgical management

BACKGROUND

Osteoradionecrosis (ORN) of the maxilla is a rare disease. In contrast with a mandibular predominance, maxillary ORN has not been widely reported.

OBJECTIVE

To review clinical features, surgical treatments, and results of maxillary ORN and offer recommendations for surgical decision-making.

MATERIAL AND METHODS

We retrospectively reviewed medical records of maxillary ORN at our hospital between 2002 and 2017. Clinical data were collected, including age, sex, primary tumor characteristics, radiotherapy dose, clinical findings of maxillary ORN, and treatment outcomes. Descriptive statistics and multiple factors were analyzed.

RESULTS

Twenty-four patients were included for analysis. The primary symptoms of maxillary ORN were pain, trismus, pus, bone exposure, and skin fistula. Twenty (83.3%) patients were completely cured after single-operation. Thirteen patients underwent sequestrectomy, and the cure rate was 76.9% (10/13). Eleven patients received segmental osteotomy and flap reconstruction, with the cure rate of 90.9% (10/11). There was no significant statistical difference in the cure rate between these two groups (p = .596).

CONCLUSIONS AND SIGNIFICANCE

Compared with mandibular ORN, the surgical effect of maxillary lesions is better and the choice of operation methods can be relatively conservative. Both sequestrectomy and segmental osteotomy with flap reconstruction can achieve good results in appropriate conditions.

Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series

Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Submental Island Flap Combined With Reconstruction Titanium Plate: A New Way to Treat Mandibular Osteoradionecrosis

Objective. The purpose of this study was to investigate the effect of reconstruction for bone defects in patients with mandibular osteoradionecrosis using submental flap combined with reconstructive titanium plate. Methods. A total of 23 patients with mandibular osteoradionecrosis were included. All patients underwent surgical resection and immediate reconstruction with submental flap combined with reconstructive titanium plate. The postoperative effects and flap success rate were evaluated with a 6- to 18-month follow-up. Results. Twenty-two flaps were successful; 1 flap suffered from partial necrosis in the distal end, but the patient was treated with hyperbaric oxygen therapy and iodoform gauze dressing, and no plate exposure was found after operation in the follow-up period. Conclusion. The use of submental flap combined with reconstructive titanium plate for treating the patients with osteoradionecrosis is a feasible, cost-effective, simple, and safe procedure.

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.

Primary vs Secondary Endosseous Implantation After Fibular Free Tissue Reconstruction of the Mandible for Osteoradionecrosis

Importance

The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established.

Objective

To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible.

Design, Setting, and Participants

A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015.

Interventions

All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11).

Main Outcomes and Measures

Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis.

Results

Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation (P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation.

Conclusions and Relevance

Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON.

Level of Evidence

3.

Vastus Lateralis Muscle Free Flap for Skull Base Osteoradionecrosis in Nasopharyngeal Carcinoma

Objectives  To describe the first experience with a free vastus lateralis muscle-only flap to be used to cover and protect the exposed skull base and carotid artery from radiotherapy-induced skull base osteoradionecrosis (ORN). Design  Retrospective review of a case series. Setting  Tertiary academic medical center. Participants  Post treatment nasopharyngeal carcinoma patients with skull base ORN. Main Outcome Measures  Coverage of the internal carotid artery (ICA). Results  Four patients underwent the procedure. Following the procedure, all patients were documented to have adequate viable soft tissue covering their ICA. Topical nasal steroids were prescribed to all patients as florid granulation tissue was noted to occur overlying the muscle flap in the early postoperative period. There were no flap failures. All patients noted an improvement in speech, cacosmia, and nasal crusting. No significant epistaxis occurred following surgery. Choanal stenosis was noted in three patients. Conclusion  For skull base ORN resulting from the treatment of nasopharyngeal carcinoma (NPC) with radiotherapy that fails conservative management, an open approach to the nasopharynx, that allows debridement then placement of a vastus lateralis muscle-only free flap for coverage, offers a unique and viable approach to the management of this challenging condition.

Nomogram model to predict postoperative infection after mandibular osteoradionecrosis surgery

Osteoradionecrosis of the mandible (ORNM) is one of the most dreaded complications of radiotherapy. The poor healing capacity of soft tissue after radiation may lead to surgical failure. The current study was designed to identify prognostic factors for postoperative infection (PPI) and propose corresponding prophylaxis and intervention protocols. A retrospective study was conducted concerning ORNM patients from 2000 to 2015. A risk-stratification score and nomogram model were established to predict the risk of PPI. A total of 257 patients were analyzed, and the total incidence of PPI was 23.3% (60/257). In multiple logistic regression analysis, radiation dose [Formula: see text]80 Gy (versus <80 Gy, OR = 2.044, P = 0.035, 95% CI: 1.05-3.979), bilateral ORNM (versus unilateral, OR = 4.120, P = 0.006, 95% CI: 1.501-11.307), skin fistula (versus none, OR = 3.078, P = 0.040, 95% CI: 1.05-9.023), and implant utilization (versus none, OR = 2.115, P = 0.020, 95% CI: 1.125-3.976) were significantly associated with PPI. The susceptibility to PPI in patients with risk-stratification scores of 14-22 was 2.833 times that of patients with scores of 7-13, and 7.585 times that of cases defined as scores of 0-6. The discrimination capability of the nomogram model was estimated using a ROC curve with an AUC of 0.708, revealing potentially useful predictive abilities. In conclusion, current risk-stratification scores and nomogram models effectively predicted the risk of PPI in ORNM patients.

The use of the buccal fat pad flap for oral reconstruction

Many congenital and acquired defects occur in the maxillofacial area. The buccal fat pad flap (BFP) is a simple and reliable flap for the treatment of many of these defects because of its rich blood supply and location, which is close to the location of various intraoral defects. In this article, we have reviewed BFP and the associated anatomical background, surgical techniques, and clinical applications. The surgical procedure is simple and has shown a high success rate in various clinical applications (approximately 90%), including the closure of oroantral fistula, correction of congenital defect, treatment of jaw bone necrosis, and reconstruction of tumor defects. The control of etiologic factors, size of defect, anatomical location of defect, and general condition of patient could influence the prognosis after grafting. In conclusion, BFP is a reliable flap that can be applied to various clinical situations.

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.

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.

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.

Outcomes of microvascular free flap reconstruction for mandibular osteoradionecrosis: A systematic review

INTRODUCTION

Osteoradionecrosis of the mandible is a devastating complication of radiotherapy in patients with head and neck cancer. Many cases present at a late stage, from months to years following completion of radiation therapy. When medical treatment fails, surgery may be required with a variety of free flaps available for microvascular reconstructive techniques.

OBJECTIVE

To conduct a systematic review of the literature investigating the outcomes of free flap reconstruction of the jaw in mandibular osteoradionecrosis and determine the failure rates of different flap tissue.

METHODS

A systematic literature search was performed using Medline (Ovid) Pubmed and Embase databases and Google Scholar. Primary outcome measures were flap failures and complications, with donor site complications representing the secondary outcome measure. Analysis of pooled outcomes was undertaken for different flaps.

RESULTS

333 articles were identified and 15 articles met the final inclusion criteria, detailing 368 primary free tissue flap transfers. There was a flap failure rate of 9.8%. There were 146 post-operative complications (39.7%), the most common being fistula formation (8.4%), hardware plate exposure (7.1%) and flap wound infections (6.5%).

CONCLUSION

The fibula is the workhorse free flap for reconstruction in mandibular osteoradionecrosis. Evidence to date is largely limited with the need for larger powered multi-institutional prospective studies to determine the ideal flap donor tissue and evaluate patient and treatment predictors of free flap outcomes in order to tailor the best patient-based surgical approach for mandibular osteoradionecrosis.

Synchronous reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular osteocutaneous flap in patients with nasopharyngeal carcinoma

BACKGROUND

The reconstruction of bilateral osteoradionecrosis (ORN) of mandibular defects using a single free bone flap is rarely performed because extensively radiated neck tissue with severe fibrosis is usually unsuitable for vascularized reconstruction.

METHODS

Thirty-one patients with nasopharyngeal carcinoma (NPC) underwent bilateral reconstruction of advanced ORN in the mandible using a single fibular osteocutaneous flap. Clinical factors associated with the operation were assessed, including classification of mandible defects, types of recipient vessels, perioperative complications, and postoperative outcomes.

RESULTS

All of the fibular osteocutaneous flaps survived completely, with the exception of 1 inner skin paddle that presented partial necrosis in a reconstruction of through-and-through defects. All patients experienced an improvement in cosmetic results 6 months after the reconstruction, whereas 23 patients experienced improved mouth opening compared to the preoperative condition.

CONCLUSION

Advanced bilateral ORN in patients with NPC could be synchronously reconstructed with a single fibular osteocutaneous flap. © 2015 Wiley Periodicals, Inc. Head Neck 38: E-E, 2016.

Reconstruction of composite oral cavity defects with temporalis flaps after prior treatment

BACKGROUND

Reconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects.

OBJECTIVE

To report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment.

METHODS

Three patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature.

RESULTS

All patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications.

CONCLUSION

In previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.

Clinical outcomes in cranioplasty: risk factors and choice of reconstructive material

BACKGROUND

Continuing advances in cranioplasty have enabled repair of increasingly complicated cranial defects. However, the optimal materials and approaches for particular clinical scenarios remain unclear. This study examines outcomes following cranioplasty for a variety of indications in patients treated with alloplastic material, autogenous tissue, or a combination of both.

METHODS THE AUTHORS CONDUCTED

a retrospective analysis on 180 patients who had 195 cranioplasties performed between 1993 and 2010.

RESULTS

Materials used for cranioplasty included alloplastic for 42.6 percent (83 of 195), autologous for 19.0 percent (37 of 195), and both combined for 38.5 percent (75 of 195). Mean defect size was 70.5 cm. A subset of patients had undergone previous irradiation (12.2 percent; 22 of 180) or had preoperative infections (30.6 percent; 55 of 180). The most common complication was postoperative infection (15.9 percent; 31 of 195). Factors that significantly predisposed to complications included preoperative radiation, previous infection, and frontal location. Preoperative radiation was the strongest predictor of having any postoperative complications, with an adjusted odds ratio of 6.91 (p < 0.005). Irradiated patients (OR, 7.96; p < 0.05) and patients undergoing frontal cranioplasties (OR, 2.83; p < 0.05) were more likely to require repeated operation. Preoperative infection predisposed patients to exposure of hardware in alloplastic reconstructions (OR, 3.13; p < 0.05).

CONCLUSIONS

Despite the evolution of cranioplasty techniques and materials, complications are not uncommon. The choice of reconstructive material may modify the risk of developing postoperative complications but appears less important than the clinical history in affecting outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Can we predict which patients are likely to develop severe complications following reconstruction for osteoradionecrosis?

High morbidity has been reported for free vascularised reconstruction for osteoradionecrosis (ORN) and there are no apparent risk factors. A single nucleotide polymorphism in the transforming growth factor beta 1 gene (TGF-β1) has been implicated in the cause of ORN and may also predict these complications. We studied a series of 30 consecutive patients who had had reconstruction for severe ORN with free tissue transfer in relation to their outcomes and complications for a number of risk factors including TFG-β1 genotype, age, sex, comorbidities, site and stage of tumour, type of initial operation, and dose of radiotherapy or chemoradiotherapy. Two patients died and 2 flaps failed. Using the Clavien-Dindo classification, 16 patients developed grade III complications and 6 grade II. Median (IQR) duration of inpatient stay was 19.5 (12-25) days and the median (IQR) duration of outpatient treatment was 6 (4-11) weeks. No specific risk factors for postoperative complications were identified. In view of the severity and unpredictability of the complications, careful preoperative counselling of patients is essential.

Pathological mandibular fractures: a review of the literature of the last two decades

Pathological mandibular fractures are rare, accounting for fewer than 2% of all fractures of the mandible. They could be defined as fractures that occur in regions where bone has been weakened by an underlying pathological process. Pathological fractures usually may follow surgical interventions such as third molar removal or implant placement, result from regions of osteomyelitis, osteoradionecrosis, and bisphosphonate-related osteonecrosis of the jaw, occur because of idiopathic reasons or be facilitated by cystic lesions, benign, malignant, or metastatic tumors. Pathological mandibular fractures may be challenging to treat because of their different etiology and peculiar local and general conditions, often requiring a more rigid fixation. In patients with poor medical conditions, simpler and more limited options may be preferred.

Analysis of surgical margins in cases of mandibular osteoradionecrosis that progress despite extensive mandible resection and free tissue transfer

INTRODUCTION

Approximately 1 of 4 patients with osteoradionecrosis (ORN) of the mandible develop ongoing disease despite extensive mandible resection to margins determined by the presence of bleeding bone at the time of surgery.

OBJECTIVE

To determine whether pathologic examination of bony margins in assessing for the presence of necrotic edges is correlated with ongoing ORN.

METHODS

Resected mandible specimens from 34 patients with severe mandibular ORN were examined histologically for the presence of necrotic margins and compared with clinical outcome of ORN persistence at follow-up.

RESULTS

Median follow-up was 17.4 months. Eight specimens had histologic evidence of necrotic, nonviable bone at the margins of resections; however, there was no progression of disease among patients in this group. Twenty-six specimens were clear of necrotic margins; however, 8 patients from this group developed persistent disease.

CONCLUSIONS

Irradiated mandible is susceptible to ORN progression even if clinical and final histopathologic assessments confirm complete resection of necrotic bone margins. Progression of disease in ORN is not related to inadequate resection of necrotic bone.

Osteoradionecrosis of the mandible and mastoiditis after radiotherapy for parotid mucoepidermoid carcinoma

Osteoradionecrosis of the mandible in conjunction with mastoiditis is an extremely rare occurrence following irradiation of salivary gland malignancy in the orofacial region. We report one such case of a patient who presented to us with trismus, jaw pain, and ear discharge. Imaging of the jaws revealed classical features of osteoradionecrosis and mastoiditis. This case is important because presenting features like trismus and dental infection led us to investigative procedures that revealed extensive bone involvement including mastoiditis. Trismus progressively increased over a period of 8 years. In this case, we would like to emphasize the importance of good oral hygiene in the postradiotherapy stage for head and neck cancer.

Use of recombinant bone morphogenetic protein 2 in free flap reconstruction for osteonecrosis of the mandible

PURPOSE

Osteoradionecrosis of the mandible is a debilitating consequence of radiation therapy for head-and-neck malignancy. It can result in pain, bone exposure, fistula formation, and pathologic fracture. Recombinant human bone morphogenetic protein 2 (rhBMP-2) has shown promise in reconstruction of bone defects. The purpose of this study is to determine whether the addition of rhBMP-2 at the union of vascularized bone and native bone improves surgical outcomes in patients with osteonecrosis of the mandible.

MATERIALS AND METHODS

This study was a retrospective analysis of patients who were treated between 2006 and 2010 for osteonecrosis of the mandible. Patients requiring definitive reconstruction after failure of a course of conservative management were included. Patients were divided into 2 cohorts depending on whether rhBMP-2 was used during the reconstruction. The primary outcome measure was defined as stable mandibular union.

RESULTS

Seventeen patients were included. The development of malunion was similar in both groups (13% for rhBMP-2 group vs 11% for non-rhBMP-2 group). Infectious complications were similar between the groups (25% in rhBMP-2 group vs 56% in non-rhBMP-2 group, P = .33). The rates of hardware removal were similar for the 2 groups (33% in non-rhBMP-2 group vs 25% in rhBMP-2 group, P = .10). No cancer recurrences were observed in patients receiving rhBMP-2.

CONCLUSIONS

The use of rhBMP-2 is safe in free flap reconstruction of the mandible, but its ability to significantly improve patient outcomes, as measured by rates of malunion, reoperation, or infection, is still unknown.

Reconstruction of osteomyelitis defects

Reconstruction of large skeletal defects secondary to osteomyelitis remains a challenging problem. Osteomyelitis can result from a variety of etiologies; most often, it is a consequence of trauma to a long bone. Despite advances in antibiotic therapy, treatment of chronic osteomyelitis requires adequate surgical debridement, which can often lead to large soft tissue and bone loss. Free vascularized bone can be used to reconstruct large skeletal defects greater than 6 cm or bone defects of smaller size that failed to heal with nonvascularized bone grafting. The length, cortical strength, and anatomic configuration of the free vascular fibular graft make it an ideal bone graft to bridge extremity defects, and it can be transferred with skin, fascia, and muscle to fill soft tissue defects in the recipient site.