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PubMed1992

The development of osteoradionecrosis from sites of periodontal disease activity: report of 3 cases.

Osteoradionecrosis may develop following radiation therapy that involves bone, and most particularly following treatment of cancers within the head and neck. The mandible is at greatest risk of osteoradionecrosis because of the nature of its blood supply and its dense bone configuration. This paper describes 3 cases which demonstrate the development of osteoradionecrosis in the mandible from sites of periodontal disease activity following external beam radiotherapy. The pathogenesis of these events is reviewed, and recommendations for their management are discussed. A proposal for the use of chlorhexidine digluconate and hyperbaric oxygen in the periodontal management of this condition is outlined.

Aged↗

PubMed1996

Surgical treatment of mandibular osteoradionecrosis: versatility of the scapular osteocutaneous flap.

Osteoradionecrosis of the mandible is a serious complication of radiotherapy for head and neck cancer and no single treatment has to date met with consistent success. A free scapular osteocutaneous flap was successfully transferred in nine patients with mandibular osteoradionecrosis who before this had not responded to conservative treatment. All but one of the patients had good bone union and there was no evidence of recurrence during a mean follow up period of four years and one month. This flap not only provides a well-vascularised segment of the bone but also multiple, large skin paddles, each with an abundant and reliable blood supply. In addition, well-vascularised fascia and overlying subcutaneous tissue can be used to fill dead spaces and cover the bony segment and fixation plates. This reduces postoperative infection and promotes primary wound healing. This flap has proved useful for reconstruction of mandibular osteoradionecrosis, particularly when there is a large soft tissue defect.

Adult↗

PubMed2005

Osteoradionecrosis of the cervical spine resulting from radiotherapy for primary head and neck malignancies: operative and nonoperative management. Case report.

Osteoradionecrosis is a process of dysvascular bone necrosis and fibrous replacement following exposure to high doses of radiation. The poorly vascularized necrotic tissue may cause pain and/or instability, and it cannot resist infection well, which may result in secondary osteomyelitis. When these processes affect the cervical spine, the resulting instability and neurological deficits can be devastating, and immediate reestablishment of spinal stability is paramount. Reconstruction of the cervical spine can be particularly challenging in this subgroup of patients in whom the spine is poorly vascularized after radical surgery, high-dose irradiation, and infection. The authors report three cases of cervical spine osteoradionecrosis following radiotherapy for primary head and neck malignancies. Two patients suffered secondary osteomyelitis, severe spinal deformity, and spinal cord compression. These patients underwent surgery in which a vascularized fibular graft and instrumentation were used to reconstruct the cervical spine; subsequently hyperbaric oxygen (HBO) therapy was instituted. Fusion occurred, spinal stability was restored, and neurological dysfunction resolved at the 2- and 4-year follow-up examinations, respectively. The third patient experienced pain and dysphagia but did not have osteomyelitis, spinal instability, or neurological deficits. He underwent HBO therapy alone, with improved symptoms and imaging findings. Hyperbaric oxygen is an essential part of treatment for osteoradionecrosis and may be sufficient by itself for uncomplicated cases, but surgery is required for patients with spinal instability, spinal cord compression, and/or infection. A vascularized fibular bone graft is a very helpful adjunct in these patients because it adds little morbidity and may increase the rate of spinal fusion.

Aged↗

PubMed1999

Hyperbaric oxygen therapy and osteoradionecrosis.

Osteoradionecrosis of the mandible is a potentially devastating complication of head and neck radiation. Radiation causes progressive vascular occlusion with tissue hypoxia, tissue death, and failure of healing. Hyperbaric oxygen therapy is an accepted treatment for osteoradionecrosis. This article reviews the history of hyperbaric oxygen therapy, its physiologic mechanisms, its use in the management of osteoradionecrosis, and its complications and contraindications.

Contraindications↗

PubMed2003

Clinics in diagnostic imaging (85). Mandible osteoradionecrosis complicated by infection.

Mandibular osteoradionecrosis is a rare but well-known complication that may be seen in patients with head and neck tumours following radiation therapy. A 42-year-old man presented with painful soft tissue swelling and a discharging sinus over the right mandible. Radiographs showed osteolytic destruction. Computed tomography confirmed bony destruction and fragmentation, as well as signs of soft tissue infection. The diagnosis of mandible osteoradionecrosis complicated by infection was confirmed by biopsy and surgically. The clinical and imaging features of osteoradionecrosis are highlighted.

Adult↗

PubMed2005

Microvascular free tissue transfer for treatment of osteoradionecrosis of the maxilla.

Head and neck tumors often require radiotherapy as part of the treatment protocol. Although it improves the survival rate in cancer patients, it may cause osteoradionecrosis, especially in the mandible and maxilla. Twelve patients with osteoradionecrosis of the maxilla were treated with microsurgical free tissue transplantations between April of 1996 and August of 2002. There were 10 male and two female patients, with a mean age of 60.2 years. The mean radiotherapy dose was 6674 cGy. The radiation dose could not be traced in three patients because radiotherapy was performed elsewhere. Radical sequestrectomy, soft-tissue debridement, and pathologic proof of no tumor recurrence were performed before microsurgical reconstruction. Free flaps used included the following: anterolateral thigh (n = 7), radial forearm (n = 2), rectus femoris musculocutaneous (n = 2), and supracondylar chimeric (n = 1) flaps. All flaps survived completely and reconstruction succeeded. During a mean 25-month follow-up period, ectropion, plate exposure, and mild infection were encountered in three patients and treated successfully. Radical debridement and obliteration of dead space with well-vascularized tissue are essential for successful treatment of maxillary osteoradionecrosis. The anterolateral thigh flap is most versatile for almost all types of soft-tissue defect reconstruction in the head and neck region.

Adult↗

PubMed1991

[MR imaging of osteoradionecrosis of the mandibula following radiotherapy for head and neck cancers].

Magnetic resonance (MR) images of 13 patients with osteoradionecrosis of the mandibula were analyzed. Abnormalities were noted in all patients and could be classified into three groups. In nine patients, MR signals were homogeneously low in intensity on both T1 weighted images (T1WI) and T2 weighted images (T2WI), suggesting fibrosis of bone marrow. These nine patients had suffered radiologically and/or clinically overt osteoradionecrosis more than ten months previously, and inflammatory symptoms had settled down by the time of MR study. Two patients showed low signal intensity on T1WI and an area of inhomogeneous high intensity in a diffuse area of low signal intensity on T2WI, suggesting acute inflammation in the irradiated fibrous bone marrow. Both patients suffered pathologic fracture due to osteoradionecrosis and showed severe inflammatory symptoms at the time MR study. In one of the two patients, these pathologic changes were confirmed in surgically excised mandibulectomy specimens. The other two patients showed homogeneous low signal intensity on T1WI and high signal intensity on T2WI, a finding that may be due to slight inflammation. However, in one of the two patients, this signal feature possibly indicated loose fibrosis with marked cellularity.

Adult↗

PubMedDate not supplied

[Osteoradionecrosis at the level of coxo-femoral articulation in the adult].

Two cases of either cervical or acetabular osteoradionecrosis were described. One patient had endoprosthetic replacement of the hip, the other did not receive any surgical treatment. Regarding the literature, osteoradionecrosis occurs in 0.3 to 4% of the irradiated bones. Histologically there is a destruction of the bone by direct toxicity of the radiation and by destruction of the vascular supply. The threshold of irreversible bone destruction is 30 Gy. Fractures are epiphenomenons of osseous radionecrosis. The diagnosis can be suspected either by radiographies or by bone scans. Sometimes a bone biopsy is necessary to differentiate between bone necrosis, bone metastasis and eventually a radiation-induced sarcoma of the bone. If the osteoradionecrosis affects the acetabulum, even in the case of a stress fracture without acetabular protrusion of the femoral head, no surgical treatment is recommended. Weight bearing is avoided and spontaneous resolution occurs in most cases. If, on the other hand, there is a fracture through the femoral neck, hemiarthroplasty or total joint replacement is the treatment of choice. Total joint replacement is also recommended in case of an extensive radiation induced coxopathy.

Acetabulum↗

PubMed1986

Osteoradionecrosis of the ossicular chain.

Osteoradionecrosis of the temporal bone is a well-known sequela of radiotherapy for neoplasms at the base of the skull. Presenting symptoms include otalgia, chronic aural drainage, and hearing loss, which can be conductive, sensorineural, or mixed. The conductive component has been hypothesized to be caused by radionecrosis of the ossicular chain. This case report documents the existence of osteoradionecrosis of the ossicular chain in a 10-year-old boy operated on for resection of extensive osteoradionecrosis of the temporal bone.

Child↗

PubMed1997

Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible.

BACKGROUND: Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results. METHODS: Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients. RESULTS: All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result. CONCLUSION: Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Dental Implantation, Endosseous↗

PubMed2001

Management of advanced mandibular osteoradionecrosis with free flap reconstruction.

BACKGROUND: The purpose of this study was to assess the effectiveness of free tissue transfer for treatment of advanced mandibular osteoradionecrosis (ORN) in head and neck cancer patients. METHODS: We reviewed 29 patients who were treated for advanced mandibular ORN by radical resection and reconstruction with free flaps at our institution. All patients had either failed to respond to conservative treatment, including hyperbaric oxygen therapy and debridement or had pathological fracture due to ORN. RESULTS: Twenty-four vascularized bone (17 fibula, five iliac, and two scapula), four rectus abdominis myocutaneous, and one radial forearm fasciocutaneous free flaps were used. The complications occurred in 6 of 29 patients (21%). A total of four flaps (14%) were lost. The mean follow-up was 2 years 9 months. All patients had complete resolution of ORN symptoms. No evidence of ORN recurrence was observed in any patient. CONCLUSION: For advanced osteoradionecrosis of the mandible, radical resection followed by reconstruction using free flap provides a reliable means of obtaining good wound healing with acceptable aesthetic and functional results.

Adult↗

PubMed1983

Management of osteoradionecrosis of the mandible with myocutaneous flaps.

Involvement of large areas of the mandible or the entire mandible with osteoradionecrosis may result in severe functional disability and cosmetic deformity. The use of a well-vascularized pectoralis major myocutaneous flap from outside the original field of irradiation has been successful in obtaining functional and cosmetic goals. Myocutaneous flaps provide bulk for contour and tissue support, and their rich vascular supply promotes healing of the heavily irradiated soft tissue and bone. Successful bone grafting for mandibular reconstruction may follow control of the osteoradionecrosis.

Carcinoma, Squamous Cell↗

PubMed2000

Possibilities of preventing osteoradionecrosis during complex therapy of tumors of the oral cavity.

In recent years, there has been a dramatic increase in the number of tumors of the head and neck. Their successful treatment is one of the greatest challenges for physicians dealing with oncotherapy. An organic part of the complex therapy is preoperative or postoperative irradiation. Application of this is accompanied by a lower risk of recurrences, and by a higher proportion of cured patients. Unfortunately, irradiation also has a disadvantage: the development of osteoradionecrosis, a special form of osteomyelitis, in some patients (mainly in those cases where irradiation occurs after bone resection or after partial removal of the periosteum). Once the clinical picture of this irradiation complication has developed, its treatment is very difficult. A significant result or complete freedom from complaints can be attained only rarely. Attention must therefore be focussed primarily on prevention, and the oral surgeon, the oncoradiologist and the patient too can all do much to help prevent the occurrence of osteoradionecrosis. Through coupling of an up-to-date, functional surgical attitude with knowledge relating to modern radiology and radiation physics, the way may be opened to forestall this complication that is so difficult to cure.

Antineoplastic Agents, Alkylating↗

PubMed1978

Osteoradionecrosis of maxillae.

A case of osteoradionecrosis of the maxilla has been presented. It is hoped that this review and discussion of osteomyelitis and osteoradionecrosis will point out the need for proper management of the dentition of cancer patients who are subjected to radiotherapy.

Carcinoma, Squamous Cell↗

PubMed1978

Clinical observations on osteoradionecrosis of the mandible. Report of a case with sequestration.

A case of osteoradionecrosis of the right mandible is presented. One and one half years after the onset of osteoradionecrosis, sequestration came about in a relatively large region, and the changes were observed on the radiographs over this period of time. A favorable course of the case is described in detail and discussed with reference to the literature.

Alveolar Process↗

PubMed1983

Actinomyces israelii in osteoradionecrosis of the jaws. Histopathologic and immunocytochemical study of five cases.

Five surgically treated patients with osteoradionecrosis of the jaws are presented. The clinical history of the disease varied from 3 to 17 years. In three cases the progression of the disease was enhanced by surgical procedures performed in the irradiated area causing exfoliation of the premaxillary area in one case and spontaneous mandibular fracture in two cases. Actinomyces israelii was demonstrated in tissue sections of all five cases by using FITC-labeled specific antiserum and additionally with peroxidase-antiperoxidase method in one case. Candida was found in histologic sections of three cases. Radiation damage in the oral soft tissues and jawbones makes the atmosphere favorable for anaerobic microorganisms. The present results indicate that the role of A. israelii in the pathogenesis of osteoradionecrosis of the jaws has not been fully appreciated.

Actinomyces↗

PubMed1994

Hyperbaric oxygen treatment of osteoradionecrosis of the mandible with repeated pathologic fracture. Report of a case.

Treatment of patients with osteoradionecrosis of the mandible with a pathologic fracture consists in almost all cases of a continuity resection of the mandible. This leads to functional and esthetic problems that can only be solved by often extensive surgery. In this case report we present a 38-year-old woman who developed osteoradionecrosis of the mandible with a pathologic fracture 1 1/2 years after combined surgical and radiation therapy of an adenocarcinoma of the right parotid gland. The patient had a subcondylar pathologic fracture together with osteolysis in the right mandibular body, normally an indication for partial resection of the mandible. Because of the absence of denuded bone, fistulation, and the poor quality of the surrounding soft tissues, a more conservative approach was chosen. Treatment consisted of hyperbaric oxygen and dental extractions with alveolectomy with the patient under local anesthesia. During follow-up, a second pathologic fracture occurred in the region of the right first and second molar. No additional treatment was given. Six and one-half years after the initial treatment and 5 1/2 years after the last fracture, the patient is free of complaints, the fractures have healed and both esthetic and functional results are good.

Adenocarcinoma↗

PubMed1990

The investigation of osteoradionecrosis of the mandible by 99mTc-methylene diphosphonate radionuclide bone scans.

The need for a reliable non-invasive investigation in osteoradionecrosis (ORN) of the mandible is discussed. The results of 99mTc-methylene diphosphonate bone scans using single photon emission tomography, and measuring dynamic uptake in 13 patients are presented. These suggest that sites of osteoradionecrosis may be defined by a paradoxically increased uptake of 99mTc-methylene diphosphonate.

Gamma Cameras↗