Bisphosphonate-associated osteonecrosis of the mandible: reliable soft tissue reconstruction using a local myofascial flap

Abstract

For the treatment of bisphosphonate-associated osteonecrosis of the jaw (BP-associated ONJ), poor cure rates are reported. In many cases, repeated osseous exposition and infection may occur. The currently recommended management of affected patients is antibiotic treatment and bony decortication, which is often complicated by soft tissue deficits due to chronic infection. In severe cases osteonecrosis can be managed often only by continuity resections of the mandible. For this purpose, we developed a new surgical procedure, which allows an effective closure of difficult jaw wounds in the lateral mandible. In the last 3 years, 20 patients with BP-associated osteonecrosis of the lower jaw were treated successfully with a modified defect-covering method using a myofascial flap. A mylohyoid muscle flap was detached from mylohyoid line and used to cover the bony defect. During 19 months mean follow-up, 90% of patients were asymptomatic, the oral mucosa was intact, and no exposed bone was observed. In consequence, we are able to demonstrate that a mylohyoid muscle flap provides a reliable wound closure in the lower jaw in patients treated with BPs. Although there are still no consensual therapy guidelines for patients affected by BP-associated ONJ, the results of the presented study provide evidence for an effective surgical therapy with long-term success. Covering compromised bone with well-vascularized tissue, a muscle flap, increased healing chances by enabling and supporting the necessary nutrition and defense against opportunistic infections. This therapy concept showed a good clinical outcome.

Treatment perspectives for medication-related osteonecrosis of the jaw (MRONJ)

“…In most cases buccal mucoperiosteal flaps are best suited to achieve a tension-free mucosal coverage. Some surgeons suggest a two-layer coverage of the exposed bone to achieve saver wound closure (Lemound et al, 2012;Mast et al, 2012) and although the mucosa in MRONJ patients can be of inferior quality and stability (Lorenzo et al, 2013), soft tissue free flap reconstruction is only necessary in rare cases. (vi) Since the exposed bone in MRONJ is colonized with bacteria of the oral cavity (e.g.…”

Surgical treatment of bisphosphonate-associated osteonecrosis of the jaw: Technical report and follow up of 21 patients

“…Of these papers only a small number clearly describe the soft tissue management. While Wilde uses a bilayered suturing technique with a submucosal connective tissue flap, Lemound attaches the released mylohyoid muscle to the vestibular periosteum (Wilde et al, 2011;Lemound et al, 2011). Markose et al reduced the exposed bone until there was adequate mucosa to allow primary wound closure (Markose et al, 2009).…”

Surgical treatment of bisphosphonate-associated osteonecrosis: Prognostic score and long-term results

“…As there is mostly a lack of sufficient mucosa and fragility of margins, local flaps are crucial (Wilde et al, 2011;Lemound et al, 2012;Otto et al, 2012;Voss et al, 2012;Toshihiro et al, 2013, Fig . 6).…”