The association between dental therapy timelines and osteoradionecrosis: a nationwide population-based cohort study.

OBJECTIVES: The study aimed to investigate the timeline association with specific dental therapy and osteoradionecrosis (ORN) in oral cancer patients. MATERIALS AND METHODS: A total of 7394 oral cancer patients, including 198 ORN subjects, were retrieved from a Longitudinal Health Insurance Database for Catastrophic Illness Patients of Taiwan and were analyzed with the Cox proportional hazard regression to compare the ORN risk of individual dental treatments under different dental treatments. RESULTS: The initial dental treatment time significantly impacted on the risk of ORN in oral cancer patients (P<0.05). Pre-radiotherapy endodontic treatment and post-radiotherapy scaling or subgingival curettage increased ORN prevalence (hazard ratio [HR], 2.28 and 1.77, respectively). Endodontic treatment within 2 weeks to 1 month prior to radiotherapy increased the ORN risk by 5.83-fold. Dental scaling or subgingival curettage initialized from three to 6 months post-radiotherapy raised the ORN prevalence by 2.2-fold. Exodontia initialized within 2 weeks before radiotherapy (HR=1.49) or 1 to 3 months after radiotherapy (HR=2.63) greatly increased ORN prevalence. To perform oral surgery from 3 months pre-radiotherapy to 6 months after radiotherapy increased the 1.85-fold ORN risk. The chemotherapy combined oral surgery increased the ORN prevalence by 2.55-fold. CONCLUSIONS: Timing of dental treatment, including pre-radiotherapy endodontic treatment, post-radiotherapy scaling or subgingival curettage, and oral surgery or exodontia before and after radiotherapy, could closely relate to ORN development in oral cancer patients. CLINICAL RELEVANCE: Choosing right time to perform appropriate dental treatment could effectively reduce oral infection and ORN risk.

Sialadenitis May Be Associated With an Increased Risk for Osteoradionecrosis: A Nationwide Population-Based Cohort Study.

PURPOSE: The impact of sialadenitis on osteoradionecrosis (ORN) is controversial. The aim of this study was to determine the association between sialadenitis and ORN. MATERIALS AND METHODS: Participants were derived from the Taiwanese Longitudinal Health Insurance Database. From January 1, 2000 to December 31, 2008, cases of sialadenitis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 527.2, 527.3, 527.5 to 527.7, 527.9, and 710.2) and ORN (ICD-9-CM codes 526.89, 526.5, 730.0, and 730.1) were identified. Different treatment modalities, including surgery versus medicine, were used to distinguish the severity of sialadenitis. The primary predictor variable was sialadenitis. The secondary predictor variable was severity of sialadenitis. The primary outcome variable was time to developing ORN. Other study variables were grouped for age, gender, risk factor, and medical treatment. Cox proportional hazard regression was used to investigate the associations between sialadenitis and ORN after adjusting for statistical confounders. RESULTS: The sample was composed of 47,385 patients with a mean age of 46.6 years (standard deviation, 19.9 yr) and 37.2% were men. Twenty percent had a diagnosis of sialadenitis and 1.13% had a diagnosis of ORN. Sialadenitis was associated with an increased risk of ORN (hazard ratio [HR] = 1.93; 95% confidence interval [CI], 1.61-2.31; P < .0001). After adjustment for confounders, sialadenitis was associated with ORN (multivariable HR = 1.83; 95% CI, 1.52-2.19; P < .0001). Severity of sialadenitis was associated with an increased risk of ORN; risks for ORN were 1.79 (95% CI, 1.49-2.16; P < .0001) and 3.52 (95% CI, 1.67-7.44; P < .001) in patients with mild and serious sialadenitis, respectively, compared with the no-sialadenitis cohort. For the joint effect of ORN between sialadenitis and malignancy type, patients with sialadenitis had 11.6-fold risk for ORN (95% CI, 5.58-23.9) compared with patients without malignancy. CONCLUSIONS: Sialadenitis markedly increased the risk to develop ORN. The severity of sialadenitis was positively correlated with the incidence of ORN.

Prospective series of reconstruction of complex composite mandibulectomy defects with double island free fibula flap.

BACKGROUND: A double island free fibula (DIFF) flap can be used for reconstruction of through-and-through or complex mandibulectomy defects, but prospective studies are lacking. METHODS: Prospective analysis of all double skin paddle fibula flaps performed from 2010 to 2016. RESULTS: Overall, 16 patients underwent reconstruction with a DIFF flap (average age: 59.1 years). One patient, who underwent a DIFF flap and developed osteoradionecrosis, requiring a second flap. Thirteen patients were males, and 7 had a history of smoking, 13 had prior radiation, and 14 had prior chemotherapy. The most common primary pathology was squamous cell carcinoma (n = 13). Reconstruction using the DIFF was predominantly for mandible reconstruction with one patient undergoing reconstruction following a orbitomaxillectomy. Complications included infection (n = 2), hematoma (n = 1), and donor site complications were limited. Two patients developed venous congestion requiring re-exploration, and both flaps were successfully salvaged. One patient lost the external skin paddle requiring a pectoralis muscle flap, and there were no total flap losses. CONCLUSIONS: The DIFF flap is a reliable option that can reconstruct complex composite defects often obviating the need for a second free flap, thereby decreasing operating time, added donor site morbidity, and the need for additional recipient vessels.

Is Distraction Osteogenesis of the Irradiated Craniofacial Skeleton Contraindicated?

BACKGROUND: Craniofacial distraction osteogenesis (DO) is a common treatment modality today. Despite its numerous advantages, however, concerns have been expressed regarding the use of DO in the irradiated setting. METHODS: A systematic review was performed to identify all published reports of patients who underwent DO of the irradiated craniofacial skeleton. The following parameters were of particular interest: postoperative complications, specifically, insufficient bone formation, fracture, and hardware exposure (intraoral and cutaneous), as well as the need for additional bone grafting. RESULTS: The initial search retrieved a total of 183 articles of which 20 articles (38 patients) met predetermined inclusion criteria. The most common site of distraction was the mandible (76.3%). The median radiation dose was 50.7 Gy (range, 30-70 Gy). Bone defects ranged from 30 to 80 mm (median, 42.5 mm). Complications were encountered in 19 patients (50%), with insufficient bone formation being most common (9 patients; 23%). The overall incidence of complications was not significantly associated with radiation dosage (P = 0.79). The remaining procedural and demographic variables also failed to meet statistical significance when compared against the overall complication rate (P = 0.27-0.97). CONCLUSION: The complication rate associated with craniofacial DO of the irradiated skeleton does not appear to be substantially higher than what is reported for DO in the nonirradiated setting. As such, patients should be offered this treatment modality, particularly in light of the fact, that it offers the option to decrease patient morbidity as well as treatment complexity.

Reconstruction of severely infected gluteal osteoradionecrosis using negative-pressure wound therapy and latissimus dorsi musculocutaneous flaps.

Radiotherapy is mandatory for aggressive cancer treatment. Unfortunately, the high-energy radiation used can lead to severe osteoradionecrosis. Radical debridement of devitalized bone and soft tissue coupled with reconstruction using well-vascularized tissues is the accepted treatment for this condition. However, osteoradionecrosis cannot be controlled easily or rapidly. The aim of this study was to present the results of the use of serial negative-pressure wound therapy (NPWT) in combination with a latissimus dorsi myocutaneous flap for treatment of gluteal osteoradionecrosis in a consecutive series of patients. Between January 2003 and December 2012, nine patients underwent reconstruction using serial NPWT and latissimus dorsi myocutaneous flaps. We applied negative-pressure dressings for at least 8 weeks. Final reconstruction was performed after the infection was controlled. The superior gluteal artery and vein were used as recipient vessels in all the cases. The mean interval between operation and radiation therapy was 28.3 ± 8.3 years, and the mean number of debridement performed was 6.3 ± 1. NPWT dressings were applied for 8-12 weeks (mean, 9.3 ± 2 weeks). The defects ranged in size from 14 × 8 cm to 18 × 15 cm. The flap size ranged from 15 × 10 cm to 18 × 15 cm. All flaps survived uneventfully except in one patient who experienced chronic seroma and wound dehiscence. There were no recurrences of osteomyelitis during the follow-up periods (mean, 14 ± 6.1 months). Based on the results obtained from this consecutive series of patients, we suggest that this methodology may provide an alternative approach for the treatment of severe osteoradionecrosis of the gluteal region.

The impact of radiation caries on morbidity and mortality outcomes of head and neck squamous cell carcinoma patients.

AIMS: Radiation caries (RC) is a highly prevalent and chronic complication of head and neck radiotherapy (HNRT) and presents a challenge for clinicians and patients. The present study aimed to assess the impact of RC on the morbidity and mortality outcomes of head and neck squamous cell carcinoma (HNSCC) patients. METHODS AND RESULTS: Patients were divided into three groups: (1) RC (n = 20), (2) control (n = 20), and (3) edentulous (n = 20). Information regarding the number of appointments, dental procedures, osteoradionecrosis (ORN), prescriptions, and hospital admissions were collected. Mortality outcomes were assessed through disease-free survival (DFS) and overall survival (OS) rates. RC patients required more dental appointments (p < .001), restorations (p < .001), extractions (p = .001), and antibiotic and analgesic prescriptions (p < .001). Kaplan-Meier subgroup analyses showed a significantly increased risk of ORN in RC compared to edentulous patients (p = .015). RC patients presented lower DFS rates (43.2 months) than the control and edentulous groups (55.4 and 56.1 months, respectively). CONCLUSIONS: RC impacts morbidity outcomes among cancer survivors due to increased demand for medication prescriptions, multiple specialized dental appointments, invasive surgical treatments, increased risk of ORN, and increased need for hospital admissions.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series.

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants.

BACKGROUND: Dental implants offer one way to replace missing teeth. Patients who have undergone radiotherapy and those who have also undergone surgery for cancer in the head and neck region may particularly benefit from reconstruction with implants. Hyperbaric oxygen therapy (HBO) has been advocated to improve the success of implant treatment in patients who have undergone radiotherapy but this remains a controversial issue. OBJECTIVES: To compare the success, morbidity, patient satisfaction and cost effectiveness of dental implant treatment carried out with and without HBO in irradiated patients. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 17 June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 5), MEDLINE via OVID (1946 to 17 June 2013) and EMBASE via OVID (1980 to 17 June 2013). No restrictions were placed on the language or date of publication when searching the electronic databases. We checked the bibliographies of relevant clinical trials and review articles for studies outside the searched journals. We wrote to authors of the identified randomised controlled trials (RCTs) and to more than 55 oral implant manufacturers; we used personal contacts and we made a request on an internet discussion group in an attempt to identify unpublished or ongoing RCTs. SELECTION CRITERIA: Randomised controlled trials (RCTs) of HBO therapy for irradiated patients requiring dental implants. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were analysed using random-effects models to determine mean differences for continuous outcomes and risk ratios for dichotomous outcomes, with 95% confidence intervals. MAIN RESULTS: Only one RCT, providing very low quality evidence, was identified and included. Thirteen patients received HBO therapy while another 13 did not. Two to six implants were placed in people with fully edentulous mandibles to be rehabilitated with bar-retained overdentures. One year after implant loading, four patients had died from each group. One patient, treated with HBO, developed an osteoradionecrosis and lost all implants so the prosthesis could not be provided. Five patients in the HBO group had at least one implant failure versus two in the control group. There were no statistically significant differences for prosthesis and implant failures, postoperative complications and patient satisfaction between the two groups. AUTHORS' CONCLUSIONS: Despite the limited amount of clinical research available, it appears that HBO therapy in irradiated patients requiring dental implants may not offer any appreciable clinical benefits. There is a definite need for more RCTs to ascertain the effectiveness of HBO in irradiated patients requiring dental implants. These trials ought to be of a high quality and reported as recommended by the CONSORT statement (www.consort-statement.org/). Each clinical centre may have limited numbers of patients and it is likely that trials will need to be multicentred.

Using Electronic Dental Records to Assess Osteoradionecrosis Risk in Irradiated Head and Neck Cancer.

OBJECTIVE: Over the last 2 decades, investigations have demonstrated a decreased trend in the likelihood of osteoradionecrosis of the jaw (ORNJ) after extraction. The aim of this study was to explore the potential risk factors for ORNJ in irradiated head and neck cancer by using patients' electronic dental records (EDRs). METHODS: Patients diagnosed with head and neck cancer who had irradiation between January 2010 and December 2020 were included in this retrospective cohort analysis. Patient charts showing evidence of "head and neck cancer," "oral cancer," "radiotherapy," "radiation," and "oral complication" were identified by an informatics analyst querying the EDR. Subsequently, the charts were manually reviewed, and data quality was assessed on 3 dimensions: completeness, accuracy, and consistency. The patient, tumor, systemic condition/drug, oral condition, treatment/trauma, and radiation were all categorized as potential risk factors. RESULTS: A total of 359 patients were included. With the exception of radiation-related factors, we found that the data quality was generally sufficient to support the research. Multivariate logistic regression analysis demonstrated that the following factors were significant in predicting the occurrence of ORNJ development in irradiated head and neck cancer: smoking (odds ratio [OR], 9.0; 95% CI, 1.9 to 43.0; P = 0.006), steroid use (OR, 6.4; 95% CI, 1.3 to 30.8; P = 0.021), oral health status (OR, 23.7; 95% CI, 2.7 to 211.0; P = 0.005), and postirradiation extraction (OR, 3.8; 95% CI, 1.0 to 14.4; P = 0.050). CONCLUSIONS: A 10-y retrospective analysis of data from an EDR revealed that smoking, steroid use, poor oral status, and postirradiation extraction are all factors linked to an increased risk of developing ORNJ. The quality of EDR data may be systematically assessed by determining the completeness, accuracy, and consistency of the underlying data. Radiation-related factors in particular were poorly documented, highlighting the need for collecting or incorporating this information into the EDR. KNOWLEDGE TRANSFER STATEMENT: EDRs can be used to identify risk factors for developing ORNJ in irradiated head and neck cancer and can help clinicians with selecting treatments by incorporating risk and complication considerations.

Tooth extraction prior to radiotherapy for oropharyngeal cancer increases the risk of osteoradionecrosis.

PURPOSE: Osteoradionecrosis of the jaw is a therapy-resistant condition that may occur after treatment for head and neck cancer. The aim of this study was to investigate the incidence of osteoradionecrosis in patients with oropharyngeal cancer in relation to tooth extraction prior to radiation therapy. METHODS: Patients who had undergone radiation therapy for oropharyngeal cancer 5-10 years earlier were included and evaluated for the development of osteoradionecrosis (n = 75). RESULTS: Among the 75 patients, 62 had molar teeth present in the >50 Gy radiation field and 36 of those patients had teeth extracted prior to radiation therapy. Extraction of molars before radiotherapy significantly increased the risk of developing osteoradionecrosis (P < 0.05). There were no identifiable statistically significant correlations between the time from tooth extraction and the start of radiation therapy, the number of teeth in the radiation field, smoking habits, human papillomavirus-status, gender, age or tumor location and the development of osteoradionecrosis. CONCLUSION: Tooth extraction prior to radiation therapy increases the risk of developing osteoradionecrosis. For patients with good oral hygiene and absence of dental disease, avoidance of tooth extraction in the radiation field could therefore reduce the risk of complications.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis.

Importance: Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective: To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants: This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures: Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results: The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance: The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

Superimposed infection in mandibular osteoradionecrosis: diagnosis and outcomes.

BACKGROUND: Radiation therapy can result in osteoradionecrosis (ORN) and mucosal ulceration predisposing to infection. METHODS: Fourteen patients presenting with infectious sequelae related to mandibular ORN were retrospectively reviewed. RESULTS: In most patients, infection followed diagnosis of ORN; but in 4 patients, ORN was not diagnosed until after the time of infection and imaging. An early imaging finding of ORN was lingual cortical defects near the last molar. Pain followed by erythema, purulent drainage, and subperiosteal abscess by imaging were the most common signs of infection. In most patients, conservative management eventually failed and segmental mandibulectomies were required. CONCLUSIONS: Soft tissue infection with characteristic bone findings such as subperiosteal abscess and cortical bone erosions helps to distinguish infected ORN from recurrent tumor or sterile ORN. In patients previously treated with radiation who present with infection, pain or an avid PET scan with bone involvement, the mandible should be scrutinized.

Effectiveness of muscle coverage to manage osteomyelitis of very late onset in the irradiated chest wall.

Radiation therapy for breast cancer has improved survival rates; however, a consequence of this is treatment-induced complications in longer-living patients. Decades after chest wall irradiation, very late onset radiation-induced osteomyelitis can develop, caused by osteoradionecrosis. This may lead to the development of small, but very refractory, skin ulcers. Many reports recommend well-vascularized tissue coverage after appropriate debridement for irradiation ulcers; however, when the ulcers are of very late onset, this sometimes causes recurrence of ulceration in non-muscle-covered areas after flap transfer. Thus, for very late onset cases, we propose treatment with an absolute muscle flap to cover both the obviously infected focus and the surrounding irradiated area. A muscle flap consisting of the entire latissimus dorsi, the shape of which is very large in the horizontal direction, satisfies this requirement. Latissimus dorsi muscle coverage for the treatment of very late onset osteomyelitis should be reappraised.

Long-term hearing results and otological complications of nasopharyngeal carcinoma patients: comparison between treatment with conventional two-dimensional radiotherapy and intensity-modulated radiotherapy.

OBJECTIVE: To assess the long-term audiological outcome and otological complications of nasopharyngeal carcinoma patients who have received intensity-modulated radiotherapy (IMRT) versus conventional two-dimensional radiotherapy (2 DRT). STUDY DESIGN: Prospective study on the audiological outcome and otological complications 5-9 years after radiotherapy. METHODOLOGY: Patients had pure-tone audiogram before radiotherapy and 5 years after radiotherapy. Otological examination was performed 5-9 years after radiotherapy by an otolaryngologist. RESULTS: There is a significant deterioration of the hearing threshold 5 years after radiotherapy but there is no statistically significant difference in the deterioration of hearing between IMRT and 2 DRT. Six patients in the 2 DRT group and 1 patient in the IMRT group had osteoradionecrosis of the external auditory canal (p = 0.042). CONCLUSION: There are fewer incidences of osteoradionecrosis of the external auditory canal in patients treated with IMRT. There is no difference in bone conduction threshold in patients treated with IMRT or 2 DRT.

Effectiveness of hyperbaric oxygen therapy in mandibular osteoradionecrosis shown by thermography monitoring.

BACKGROUND: Osteoradionecrosis (ORN) of the mandible is the most serious and severe side effect of combined treatment of head and neck tumors. Due to frequent failure of its conventional management, new methods are being sought and tested, including hyperbaric oxygen therapy (HBO); however, effective methods of monitoring HBO results are not yet available. The purpose of our study was to assess thermographic records of ORN patients in different stages of hyperbaric oxygen therapy. MATERIAL/METHODS: In the years 2003-2008, hyperbaric oxygen was used as an adjunct in the conventional management of 4 patients with progressive osteoradionecrosis of the mandible. The effects of the treatment were evaluated based on the clinical, radiological, and thermographic examinations. In each patient thermograms were obtained before and after HBO. RESULTS: Clinical examination showed ORN remission following 30 exposures in a hyperbaric chamber at 2.5 atmospheres for 90 minutes. Follow-up thermograms obtained after 35-60 exposures revealed a marked warming of the osteoradionecrotic area of the mandible resulting from an increase in blood supply and tissue metabolism increase. In 1 case of therapy cessation, just 5 sessions of HBO therapy was associated with a decrease in acute inflammation, as manifested by local cooling seen in a follow-up thermogram. CONCLUSIONS: Thermography is an effective method of monitoring HBO results in patients with osteoradionecrosis. However, thermograms should be interpreted in combination with the corresponding clinical picture and radiological findings.

Osteoradionecrosis of the mandible: treatment outcomes and factors influencing the progress of osteoradionecrosis.

PURPOSE: The present study was undertaken to evaluate our recent experience with mandibular osteoradionecrosis (ORN) and to identify factors that contribute to its progress. PATIENTS AND METHODS: The medical records of 114 patients who had been treated for ORN during a 16-year period (1989 to 2004) were reviewed. The patients were then divided into 2 groups according to their response to conservative treatment. Group 1 consisted of patients whose ORN resolved with conservative treatment (n = 47). Group 2 consisted of patients whose ORN was unresolved with conservative treatment or who had required radical resection of the involved tissue (n = 67). The information was obtained from the medical records of the patients and analyzed. RESULTS: The patients whose ORN was associated with an early-stage tumor or preirradiation extraction had a favorable response to conservative treatment. However, those who had an advanced primary tumor, had continued smoking and drinking after radiotherapy, had received palliative radiotherapy or a radiation dose of more than 6,000 rads, and who had an orocutaneous fistula, a pathologic fracture, swelling, or trismus had a poor response to conservative treatment. In these latter cases, radical resection of the involved tissue proved useful. CONCLUSIONS: The results of the present study have indicated that several factors (ie, the stage of the primary tumor, signs of ORN) can influence the progress of ORN. Our results suggest that radical resection is a useful method for treating mandibular ORN that does not respond to conservative treatment.

Management of incidental discovery of microscopic squamous cell carcinoma in zones of osteoradionecrosis of the mandible.

OBJECTIVES: Osteoradionecrosis (ORN) of the mandible is a common complication of head and neck radiotherapy and often requires surgical treatment. Squamous cell carcinoma (SCC) can be exceptionally discovered within zones of ORN on histological examination of the operative specimen. The authors discuss the management of these lesions based on a short patient series. MATERIALS AND METHODS: This single-centre retrospective study was based on patients managed between 2012 and 2014 for ORN with incidental discovery of microscopic SCC. RESULTS: Five patients with incidental discovery of microscopic SCC in a zone of ORN of the mandible were included in this study. The mean time to onset of ORN after the end of radiotherapy for locally advanced SCC of the oral cavity or oropharynx was 42 months. Surgical treatment consisted of marginal or segmental mandibulectomy with free flap reconstruction. No recurrence was observed with a mean follow-up of 35 months [24-46]. CONCLUSION: The incidental discovery of microscopic SCC in a zone of ORN of the mandible is a rare event and has not been reported in the literature. Optimal management cannot be reliably defined due to the lack of data in the literature, but the present study supports careful histological examination of ORN specimens. Treatment must be as conservative as possible to avoid excessively invasive surgery.

Management of radiation-associated fractures.

High-dose radiation is injurious to bone and is a known risk factor for the development of late fracture. Management of radiation-induced fractures is generally thought to be difficult, with prolonged healing times and a high nonunion rate. There is a relative paucity of literature to guide treatment. Fractures of the long bones typically should be managed with intramedullary nailing. A low threshold should exist for supplemental bone grafting, and a vascularized fibula graft should be considered for persistent nonunion. To prevent refracture, fixation should be left in situ indefinitely. Resection of the fracture site and reconstruction with an oncologic endoprosthesis is an effective salvage procedure. Periarticular fractures should be treated with joint arthroplasty, which allows early mobilization and avoids prolonged healing times. Fractures of expendable bones, primarily the clavicle, typically should be managed with débridement or resection.

Treatment rationale for pathological fractures of the mandible: a series of 44 fractures.

This paper reports on the largest series of pathological fractures of the mandible (n=44) in the literature, with the aim of proposing an aetiologic classification and algorithm for treatment. A retrospective review was undertaken of cases treated in the Department of Oral and Maxillofacial Surgery at the University of Maryland Medical Center from 1991 to 2005. Data collected included age, gender, race, aetiology, site, management and outcome. Forty-three patients with 44 pathologic fractures were included. The most common aetiology was osteoradionecrosis (49%), followed by infections (19%) and malignancy (19%). The most frequent primary treatment utilized was mandibular resection of diseased bone and fixation with a locking reconstruction plate alone (55%). Either primary or secondary mandibular reconstruction was performed when co-morbid disease allowed such treatment. Management of pathological fractures is aimed initially at systemic issues, followed by focusing on site-specific issues. This is a complex problem with a 40% complication rate, with radiation therapy associated with 59% of the complications. Free flap reconstruction should be considered when possible, especially in cases secondary to osteoradionecrosis.

Successful conservative treatment of osteoradionecrosis of the mandible associated with pathological fracture.

RESULTS: Treatment of patients with osteoradionecrosis (ORN) of the mandible associated with pathologic fractures usually consists of a continuity resection of the mandible, leading to severe impairment of the patient's health and quality of life. Conservative treatment may be alternatively attempted; however, it is not usually employed. Here, we report a successful conservative treatment of ORN associated with pathologic fracture. A 48-year-old black man who had undergone radiotherapy for a squamous cell carcinoma in the tongue 6 years previously sought care complaining of facial swelling and draining episodes. Since the patient was fiercely resistant to any kind of hospital-based therapy, a conservative approach was proposed. Daily irrigations with 2% potassium iodate, followed by 3% oxygenated water, were performed by the patient at his house. In addition, local cleaning and debridement were weekly performed at our dental clinic. Systemic antibiotics were also administered. Throughout the therapy course, bone fragments were spontaneously exfoliated. Resolution of the ulcer and fracture was observed after 6 weeks of treatment. This report shows that ORN may be conservatively managed in specific situations, with good cosmetic and functional