Microsurgical Reconstruction of the Jaws Using Vascularised Free Flap Technique in Patients with Medication-Related Osteonecrosis: A Systematic Review

Abstract

Background Osteonecrosis of the jaw (ONJ) has been reported to be associated with patients receiving primarily bisphosphonate (BP) therapies. However, lately it has been documented that other medications, such as RANK ligand inhibitor (denosumab) and antiangiogenic drug, can cause ONJ. Micro-osseous-vascular reconstruction of the jaws in patients affected by medication-related osteonecrosis of the jaw represents a viable option of treatment for patients affected by stage III of the disease. However, there are still considerable doubts about the success of this procedure in the short, medium, and long term. Material and Methods A multidatabase (PubMed/MEDLINE, EMBASE, and CENTRAL) systematic search was performed. Any type of studies considering human patients treated with antiresorptive and antiangiogenic drugs was considered. The aim of the research is to primarily understand the success rate of micro-osseous-vascular reconstruction in the short, medium, and long period of time. This review has also the goal of better understanding any perioperative and postoperative complications resulting from the use of the reconstruction techniques. Results Eighteen studies resulted eligible for the study. Fibula free flap is the most commonly utilised vascularised free flap reconstruction technique (80.76%). Ten out of eighteen studies reported no complications. Recurrence of osteonecrosis was registered in five cases (6.41%) after free flap reconstruction. The overall free flap success rate was 96.16%. Conclusions Based on the limited data available in literature (Level 4 of the Oxford Evidence-based medicine scale), micro-osseous-vascular reconstruction of the jaws represents a valid treatment in patients with bisphosphonate-related osteonecrosis at stage III of the disease. However, additional data based on a larger cohort of patients are necessary to justify this type of intervention in patient affected by MRONJ.

Medication-Related Osteonecrosis of the Jaws: Two Center Retrospective Cohort Studies

“…This simultaneous therapy is associated with less favourable outcome [10, 17]. The patients who present such a serious stage of MRONJ after concomitant BPs and chemotherapy could be eligible candidates for radical resection of the lesion and reconstruction with microvascular free flaps [18]. It should be highlighted that patients with MRONJ require meticulous preoperative assessment to avoid failure in treatment.…”

Clinicostatistical analyses of medication‐related osteonecrosis of the jaws (MRONJ): Evaluation of the treatment method and prognosis

“…In this regard, some recent studies have suggested that surgical treatment is more effective and yielded higher patient QOL than nonsurgical treatment 27‐33 . Although surgical treatment is typically recommended for the later stages, the extent of operative treatment remains controversial 28,34,35 . The range of treatment modalities includes the simplest conservative treatment, and when necessary/possible, combined with a sequestrectomy, 36,37 to bony resection of all affected bone, with or without reconstruction with a microvascular free flap 35,36,38,39 …”

A Review Into the Effects of Pamidronic Acid and Zoledronic Acid on the Oral Mucosa in Medication-Related Osteonecrosis of the Jaw

“…A key focus is the effects of BPs on the oral mucosa, and research in the area includes both 2D and 3D cell culture, and a wide variety of BP effects, including viability, migration, proliferation and adhesion have been studied. This section only reviews articles which have used either pamidronic acid (PA) or zoledronic acid (ZA), as these BPs have been commonly associated with MRONJ development and have the largest body of literature [ 49 , 50 ]. PA has an intermediate anti-resorptive potency, while ZA is one of the highest potency BPs.…”