Osteoradionecrosis of the Mandible after Oromandibular Cancer Surgery

Abstract

Although postoperative radiotherapy has proved effective in improving local control and survival in patients with head and neck cancers, its complications, especially mandibular osteoradionecrosis, reduce the quality of life. Mandibular surgery before the radiotherapy adds an additional risk factor for osteoradionecrosis. This study reviews patients in Chang Gung Memorial Hospital, Taipei, Taiwan, over a 10-year period, who underwent intraoral cancer resection followed by postoperative radiotherapy and thereafter developed osteoradionecrosis of the mandible. A total of 24 men and three women with a mean age of 49.9 years were identified and included in the study. In 10 cases, tumor resection was performed with a marginal mandibulectomy; in eight cases, tumor resection was performed after mandibular osteotomy; and in three cases, a segmental mandibulectomy was performed, and the defect was reconstructed with a fibula osteoseptocutaneous flap. In six cases, tumor excisions were performed without interfering with the mandibular continuity. Patients received postoperative external beam radiotherapy into the primary site and the neck, with a mean dose (+/-SD) of 5900 +/- 1300 cGy in an average of 35 fractions during an average of 6.5 weeks. The average elapsed time between the end of radiation therapy and clinical diagnosis of osteoradionecrosis of the mandible was 11.2 months (range, 2 to 36 months). The time elapse between the end of the radiation therapy and the diagnosis of osteoradionecrosis was influenced by initial treatment (Kruskal-Wallis test: n = 27, chi-square = 12.884, p < 0.005), and this period was shorter if the mandibular osteotomy or marginal mandibulectomy was performed (the two lowest mean ranks in the test). However, if the initial surgery resulted in a segmental mandibulectomy reconstructed with a fibula osteoseptocutaneous flap, onset of the osteoradionecrosis was relatively late (Kruskal-Wallis test: n = 21, chi-square = 7.731, p = 0.052). After resection of osteoradionecrotic bone and surrounding soft tissue, 22 patients underwent reconstructive procedures with a fibula osteoseptocutaneous flap, and five patients underwent reconstructive procedures with an inferior genicular artery osteoperiosteal cutaneous flap. One fibula osteoseptocutaneous flap showed total failure and another showed a 25 percent skin loss; both were revised with pedicled flaps. The skin paddle of an inferior genicular artery flap was replaced with an anterolateral thigh flap because of anatomic variation of the skin vessel. Once the diagnosis of osteoradionecrosis is established, replacement of the dead bone and surrounding tissue with a vascularized free bone flap is inevitable, and a composite osteocutaneous free flap is a good option.

Free flap reconstruction of osteoradionecrosis of the mandible: A 10‐year review and defect classification

“…The incidences of postoperative wound infection (13%) and fistula formation (10%) in our series were also similar to what has been reported in the literature, which range from 12% to 33%. 12,15,16 The goals of surgical intervention for ORN are to relieve intractable pain, control infection with thorough debridement of infected necrotic bone and soft tissue, provide bone continuity if possible, repair soft tissue defects, and improve overall function and quality of life. All patients with intractable preoperative pain typically experience complete pain relief after surgery.…”

Effect of concurrent mental nerve reconstruction at the same time as mandibular reconstruction using a fibula osteoseptocutaneous flap

“…6,7 The fibula osteoseptocutaneous flap provides an additional advantage for mandibular reconstruction. The fibula is the most versatile bone stock for reconstructing the mandible with a high degree of precision.…”

“…The peroneal vessels are large enough to perform reliable vascular anastomoses with the neck vessels. 6,7 The donor site's distant location from the head allows the harvest of the flap while performing the Effect of concurrent mental nerve reconstruction 5 mandible resection. Furthermore, the sural nerve can be harvested for nerve grafting from its donor site.…”

Doble injerto microvascularizado de peroné para reconstrucción bilateral mandibular por osteorradionecrosis

“…Aunque estos límites intentan determinarse de forma preoperatoria tomando como base los cambios radiológicos, la extensión de la resección debe ser lo suficientemente amplia, pues en ocasiones es difícil diferenciar entre hueso radionecrótico y una recidiva tumoral 10 . En la serie publicada por Hao et al 11 , el 21% de los pacientes con sospecha clínica de ORN padecía recidiva de carcinoma epidermoide tras el análisis anatomopatológico de la muestra obtenida tras la secuestrectomía.…”