Pedicled flaps in the reconstruction of medication-related osteonecrosis and osteoradionecrosis of the jaws: a systematic review and meta-analysis

Abstract

Medication-related osteonecrosis (MRONJ) and osteoradionecrosis (ORN) present a significant reconstructive challenge. Assessing the suitability of pedicled flap (PF) reconstruction in the context of a compromised tissue bed is essential for effective surgical management. This systematic review evaluates the outcomes of PF reconstruction in MRONJ and ORN. PubMed, Ovid (MEDLINE ALL, Embase), and Cochrane CENTRAL were searched for outcomes of PF reconstruction from inception through to November 2024. A total of 48 studies met inclusion criteria (32 MRONJ, 16 ORN). Analysis included 575 patients (MRONJ: n = 478; ORN: n = 97) receiving 607 flaps (MRONJ: n = 509; ORN: n = 98). The pooled success rate was 90% (95% CI: 87% to 92%) for MRONJ and 98% (95% CI: 94 to 100%) for ORN. Both conditions showed an 18% pooled complication rate (MRONJ: 95% CI, 14% to 23%; ORN: 95% CI: 11% to 28%). In MRONJ, buccal fat pad flap was most common (n = 189, 37.13%), while submental island flap with mylohyoid muscle showed the highest success rate (94%, 95% CI: 67% to 99%). There were significant differences in complication rates across flap types (p < 0.0001), with the mylohyoid flap showing the lowest rate (9%, 95% CI: 2% to 36%). For ORN, pectoralis major musculofascial flap was most common (n = 36, 36.73%). Pedicled flaps demonstrate high success rates (>90%) in MRONJ and ORN reconstruction, supporting their use as a reliable option in compromised tissue beds. Flap selection should be individualised based on defect characteristics and patient factors. Further research is needed to better define indications and optimise patient selection.

Keywords: medication-related osteonecrosis of the jaw; osteoradionecrosis; pedicled flap; reconstruction; surgical outcomes.