Managing Mandibular Osteoradionecrosis

Abstract

Objective: Mandibular osteoradionecrosis (MORN) is a morbid complication of head and neck radiation therapy. Recent advances in surgical and medical therapies underscore the need for a shift in traditional treatment paradigms and a disease grading system that can guide appropriate management.

Data sources: Pubmed/MEDLINE.

Review methods: We conducted a detailed review of publications related to MORN, specifically focusing on its staging and management techniques. Articles meeting inclusion criteria were synthesized into a final narrative review.

Conclusion: There has been a paradigm shift away from hyperbaric oxygen therapy in the management of MORN. Growing evidence for the efficacy of pentoxifylline and tocopherol in early-stage disease and novel surgical techniques to manage moderate and late-stage disease warrant an updated staging stratification which is proposed.

Implications for practice: This review summarizes the clinical efficacy of established and novel therapeutic modalities currently available in treating MORN, emphasizing the significant advances achieved over the last decade. It introduces a contemporary staging and treatment algorithm which incorporates traditional, evidence-supported surgical and medical management with effective early intervention strategies.

Keywords: free flap; head and neck; jaw; mandible; microsurgery; osteoradionecrosis; reconstruction; rescue flap; staging.

Figure 1

Illustration of staging system. Illustration credit: Ava Rose Fritz.

Figure 2

Bilateral stage I preoperative panorex demonstrating osteoradionecrosis confined to the dentoalveolar unit surrounding teeth #18 and #31.

Figure 3

Stage II preoperative panorex demonstrating osteoradionecrosis of the left mandibular body with extension past the dentoalveolar unit surrounding tooth #18 but sparing of the inferior alveolar nerve canal.

Figure 4

Stage III preoperative panorex demonstrating osteoradionecrosis of the left mandibular body with involvement of the inferior alveolar nerve canal but sparing greater than 1 cm of mandibular cortex.

Figure 5

Stage IV (“borderline”) preoperative panorex demonstrating osteoradionecrosis of the right mandible with an intact but less than 1‐cm height of the remaining lingual or buccal cortex.

Figure 6

Stage V preoperative panorex demonstrating full‐thickness osteoradionecrosis of the left mandibular body.

Figure 7

Contemporary staging and treatment algorithm. Asterisk (*) denotes that other similar nonosseous free flap may be offered instead of rescue flap. Illustration credit: Mary Reagan. CT, computed tomography; DAU, dentoalveolar unit; IANC, inferior alveolar nerve canal; ICBG, iliac crest bone graft; ORN, osteoradionecrosis; PENTO, pentoxifylline and tocopherol.