Osteoradionecrosis of the Midface and Mandible: Pathogenesis and Management

Abstract

Radiation therapy is an important and commonly used treatment modality for head and neck cancers. Osteoradionecrosis (ORN) is a potential debilitating complication of treatment, which most commonly affects the mandible. Management strategies are tailored to the severity of disease. Medical management including oral rinses, irrigations, antibiotics, and pharmacological treatments is viable for mild-to-moderate ORN. More severe disease is best addressed with a combination of medical management and surgical intervention aimed at aggressively removing devitalized tissue until bleeding bone is encountered and reconstructing the soft tissue and bone defect. Reconstruction with either regional vascularized flaps or vascularized osteocutaneous free flaps in case of larger full-thickness bone defects (greater than 6 cm) or anterior mandible (medial to mental foramen) is most appropriate. Maxillary ORN complications can present with a wide range of functional problems and facial disfigurement. Life-threatening and time-sensitive problems should be treated first, such as skull base bone coverage or correction of severe ectropion, to avoid blindness from exposure keratopathy. Then, less time-sensitive issues can be addressed next, such as nasal obstruction, velopharyngeal insufficiency, and chronic tearing. It may require a combination of specialists from different disciplines to address various issues that can arise from maxillary ORN.

Efeitos da radioterapia sobre as condições bucais de pacientes oncológicos

“…A osteorradionecrose (ORN) representa um efeito tardio particularmente mórbido da radioterapia para CCP que pode afetar significativamente os resultados estéticos e funcionais dos pacientes. O manejo conservador da ORN custa US$ 4.000 a US$ 35.000, com algumas estimativas de até US$ 74.000 por paciente (Rivero et al, 2017;Vahidi et al, 2020) A osteorradionecrose (ORN) é definida como exposição do tecido ósseo necrótico persistente por mais de três meses em uma área anteriormente exposta a radiação ionizante, acima de 50 Gy (Ribeiro et al, 2018). Acomete, majoritariamente, regiões em que há menor vascularização e maior densidade óssea, sendo, portanto, a mandíbula mais afetada (Haroun & Coblens, 2019;Leonetti et al, 2020) A ORN é a complicação mais grave da radioterapia de cabeça e pescoço, e, embora sua incidência tenha diminuído com os avanços nas medidas terapêuticas preventivas, ela continua sendo uma complicação mórbida do tratamento oncológico.…”

Factors Associated with Treatment Outcomes and Pathological Features in Patients with Osteoradionecrosis: A Retrospective Study

“…Surgical intervention is considered for advanced cases (intractable pain, osteomyelitis, orocutaneous fistula, and pathological fracture) [ 5 , 17 , 18 , 19 ]. In advanced cases, segmental or hemi-mandibulectomy with a vascularized free flap reconstruction is performed as a surgical intervention [ 20 ]. Matsuo et al described that the cure rates of ORN treatment were 44% by only conservative therapy and 63% by combination therapy including surgery [ 21 ].…”

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

“…These palatal defects can be associated with tissue atrophy, trismus, osteoradionecrosis (ORN), recurrent infections, plate exposure, and occult recurrence. 8,10 Aggressive surgical management is typically required for these palatal defects. 11 In this article, we describe the management of palatal defects that develop following free-flap reconstruction and adjuvant radiotherapy.…”

“…This communication leads to nasal regurgitation, taste disturbances, hypernasality, and reduced quality of life. 8 Palatal defects occurring following free-flap reconstruction and adjuvant radiotherapy present with unique challenges. Radiation results in damaged cellular mechanisms in nonmalignant cells, leading to progressive loss of cellularity, vascularity, and tissue integrity in the irradiated field.…”

“…These palatal defects can be associated with tissue atrophy, trismus, osteoradionecrosis (ORN), recurrent infections, plate exposure, and occult recurrence. 8 10 Aggressive surgical management is typically required for these palatal defects. 11…”