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Semin Plast Surg 2020; 34(02): 106-113
DOI: 10.1055/s-0040-1709144
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Osteoradionecrosis of the Maxilla: Conservative Management and Reconstructive Considerations

Tom Shokri
1   Department of Otolaryngology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
,
Weitao Wang
2   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Aurora Vincent
2   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Jason E. Cohn
3   Department of Otolaryngology–Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
,
Sameep Kadakia
4   Department of Plastic and Reconstructive Surgery, Wright State University, Dayton, Ohio
,
Yadranko Ducic
2   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
› Author Affiliations
Further Information

Publication History

Publication Date:
06 May 2020 (online)

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Abstract

The implementation of radiotherapy in the multimodal treatment of advanced head and neck cancer has greatly improved survival rates. In some patients, however, this benefit comes at the potential expense of the tissue surrounding the primary site of malignancy. Osteoradionecrosis (ORN) of the facial bones, in particular the maxilla, is a debilitating complication of radiation therapy. Exposure to ionizing radiation results in devitalization of underlying bone with necrosis of adjacent soft tissue. Controversy surrounding appropriate early intervention in ORN persists and no consensus for clinical treatment has been established. In the present article, we review the pathophysiology of maxillary ORN and discuss the role of both conservative medical therapy and reconstruction.

Keywords

maxillary osteoradionecrosis - maxillary osteonecrosis - management of osteoradionecrosis - free flap reconstruction
 

  • References

  • 1 Reuther T, Schuster T, Mende U, Kübler A. Osteoradionecrosis of the jaws as a side effect of radiotherapy of head and neck tumour patients--a report of a thirty year retrospective review. Int J Oral Maxillofac Surg 2003; 32 (03) 289-295
    CrossrefPubMedGoogle Scholar
  • 2 Thorn JJ, Hansen HS, Specht L, Bastholt L. Osteoradionecrosis of the jaws: clinical characteristics and relation to the field of irradiation. J Oral Maxillofac Surg 2000; 58 (10) 1088-1093 , discussion 1093–1095
    CrossrefPubMedGoogle Scholar
  • 3 Vissink A, Burlage FR, Spijkervet FK, Jansma J, Coppes RP. Prevention and treatment of the consequences of head and neck radiotherapy. Crit Rev Oral Biol Med 2003; 14 (03) 213-225
    CrossrefPubMedGoogle Scholar
  • 4 Jereczek-Fossa BA, Orecchia R. Radiotherapy-induced mandibular bone complications. Cancer Treat Rev 2002; 28 (01) 65-74
    CrossrefPubMedGoogle Scholar
  • 5 Delanian S, Lefaix JL. Mature bone radionecrosis: from recent physiopathological knowledge to an innovative therapeutic action [in French]. Cancer Radiother 2002; 6 (01) 1-9
    CrossrefPubMedGoogle Scholar
  • 6 Beadle BM, Liao KP, Chambers MS. , et al. Evaluating the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated for oral cancers: a SEER-Medicare analysis. Head Neck 2013; 35 (11) 1599-1605
    CrossrefPubMedGoogle Scholar
  • 7 Rice N, Polyzois I, Ekanayake K, Omer O, Stassen LF. The management of osteoradionecrosis of the jaws--a review. Surgeon 2015; 13 (02) 101-109
    CrossrefPubMedGoogle Scholar
  • 8 Raggio BS, Winters R. Modern management of osteoradionecrosis. Curr Opin Otolaryngol Head Neck Surg 2018; 26 (04) 254-259
    CrossrefPubMedGoogle Scholar
  • 9 Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg 1983; 41 (05) 283-288
    CrossrefPubMedGoogle Scholar
  • 10 Buglione M, Cavagnini R, Di Rosario F. , et al. Oral toxicity management in head and neck cancer patients treated with chemotherapy and radiation: dental pathologies and osteoradionecrosis (Part 1) literature review and consensus statement. Crit Rev Oncol Hematol 2016; 97: 131-142
    CrossrefPubMedGoogle Scholar
  • 11 Dhanda J, Pasquier D, Newman L, Shaw R. Current concepts in osteoradionecrosis after head and neck radiotherapy. Clin Oncol (R Coll Radiol) 2016; 28 (07) 459-466
    CrossrefPubMedGoogle Scholar
  • 12 Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol 1987; 64 (04) 379-390
    CrossrefPubMedGoogle Scholar
  • 13 Hao SP, Chen HC, Wei FC, Chen CY, Yeh AR, Su JL. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope 1999; 109 (08) 1324-1327 , discussion 1327–1328
    CrossrefPubMedGoogle Scholar
  • 14 Shaha AR, Cordeiro PG, Hidalgo DA. , et al. Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible. Head Neck 1997; 19 (05) 406-411
    CrossrefPubMedGoogle Scholar
  • 15 Chang YM, Santamaria E, Wei FC. , et al. Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg 1998; 102 (03) 680-688
    CrossrefPubMedGoogle Scholar
  • 16 Celik N, Wei FC, Chen HC. , et al. Osteoradionecrosis of the mandible after oromandibular cancer surgery. Plast Reconstr Surg 2002; 109 (06) 1875-1881
    CrossrefPubMedGoogle Scholar
  • 17 Coskunfirat OK, Wei FC, Huang WC, Cheng MH, Yang WG, Chang YM. Microvascular free tissue transfer for treatment of osteoradionecrosis of the maxilla. Plast Reconstr Surg 2005; 115 (01) 54-60
    PubMedGoogle Scholar
  • 18 Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008; 46 (08) 653-660
    CrossrefPubMedGoogle Scholar
  • 19 Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004; 73 (02) 119-131
    CrossrefPubMedGoogle Scholar
  • 20 Lyons AJ, Brennan PA. Pentoxifylline - a review of its use in osteoradionecrosis. Br J Oral Maxillofac Surg 2017; 55 (03) 230-234
    CrossrefPubMedGoogle Scholar
  • 21 Costa DA, Costa TP, Netto EC. , et al. New perspectives on the conservative management of osteoradionecrosis of the mandible: a literature review. Head Neck 2016; 38 (11) 1708-1716
    CrossrefPubMedGoogle Scholar
  • 22 Levi LE, Lalla RV. Dental treatment planning for the patient with oral cancer. Dent Clin North Am 2018; 62 (01) 121-130
    CrossrefPubMedGoogle Scholar
  • 23 Wang TH, Liu CJ, Chao TF, Chen TJ, Hu YW. Risk factors for and the role of dental extractions in osteoradionecrosis of the jaws: a national-based cohort study. Head Neck 2017; 39 (07) 1313-1321
    CrossrefPubMedGoogle Scholar
  • 24 Nabil S, Samman N. Risk factors for osteoradionecrosis after head and neck radiation: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113 (01) 54-69
    CrossrefPubMedGoogle Scholar
  • 25 Rivero JA, Shamji O, Kolokythas A. Osteoradionecrosis: a review of pathophysiology, prevention and pharmacologic management using pentoxifylline, α-tocopherol, and clodronate. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124 (05) 464-471
    CrossrefPubMedGoogle Scholar
  • 26 Powell C, Chang C, Naguwa SM, Cheema G, Gershwin ME. Steroid induced osteonecrosis: an analysis of steroid dosing risk. Autoimmun Rev 2010; 9 (11) 721-743
    CrossrefPubMedGoogle Scholar
  • 27 Goldwaser BR, Chuang SK, Kaban LB, August M. Risk factor assessment for the development of osteoradionecrosis. J Oral Maxillofac Surg 2007; 65 (11) 2311-2316
    CrossrefPubMedGoogle Scholar
  • 28 Brennan PA, Bradley KL, Brands M. Intensity-modulated radiotherapy in head and neck cancer - an update for oral and maxillofacial surgeons. Br J Oral Maxillofac Surg 2017; 55 (08) 770-774
    CrossrefPubMedGoogle Scholar
  • 29 Caparrotti F, Huang SH, Lu L. , et al. Osteoradionecrosis of the mandible in patients with oropharyngeal carcinoma treated with intensity-modulated radiotherapy. Cancer 2017; 123 (19) 3691-3700
    CrossrefPubMedGoogle Scholar
  • 30 De Felice F, Musio D, Tombolini V. Osteoradionecrosis and intensity modulated radiation therapy: an overview. Crit Rev Oncol Hematol 2016; 107: 39-43
    CrossrefPubMedGoogle Scholar
  • 31 Butler Jr FK, Hagan C, Murphy-Lavoie H. Hyperbaric oxygen therapy and the eye. Undersea Hyperb Med 2008; 35 (05) 333-387
    PubMedGoogle Scholar
  • 32 Dhanda J, Hall TJ, Wilkins A, Mason V, Catling J. Patterns of treatment of osteoradionecrosis with hyperbaric oxygen therapy in the United Kingdom. Br J Oral Maxillofac Surg 2009; 47 (03) 210-213
    CrossrefPubMedGoogle Scholar
  • 33 Kanatas AN, Lowe D, Harrison J, Rogers SN. Survey of the use of hyperbaric oxygen by maxillofacial oncologists in the UK. Br J Oral Maxillofac Surg 2005; 43 (03) 219-225
    CrossrefPubMedGoogle Scholar
  • 34 Bennett MH, Feldmeier J, Hampson NB, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev 2016; 4 (04) CD005005
    PubMedGoogle Scholar
  • 35 Sultan A, Hanna GJ, Margalit DN. , et al. The use of hyperbaric oxygen for the prevention and management of osteoradionecrosis of the jaw: a Dana-Farber/Brigham and Women's Cancer Center Multidisciplinary guideline. Oncologist 2017; 22 (03) 343-350
    CrossrefPubMedGoogle Scholar
  • 36 Cheng SJ, Lee JJ, Ting LL. , et al. A clinical staging system and treatment guidelines for maxillary osteoradionecrosis in irradiated nasopharyngeal carcinoma patients. Int J Radiat Oncol Biol Phys 2006; 64 (01) 90-97
    CrossrefPubMedGoogle Scholar
  • 37 Gavriel H, Eviatar E, Abu Eta R. Hyperbaric oxygen therapy for maxillary bone radiation-induced injury: a 15-year single-center experience. Head Neck 2017; 39 (02) 275-278
    CrossrefPubMedGoogle Scholar
  • 38 Shaw R, Forner L, Butterworth C. , et al. Randomised controlled trials in HBO: “A call to arms” for HOPON & DAHANCA-21. Br J Oral Maxillofac Surg 2011; 49 (01) 76-77
    CrossrefPubMedGoogle Scholar
  • 39 Fan H, Kim SM, Cho YJ, Eo MY, Lee SK, Woo KM. New approach for the treatment of osteoradionecrosis with pentoxifylline and tocopherol. Biomater Res 2014; 18 (01) 13
    CrossrefPubMedGoogle Scholar
  • 40 Delanian S, Chatel C, Porcher R, Depondt J, Lefaix JL. Complete restoration of refractory mandibular osteoradionecrosis by prolonged treatment with a pentoxifylline-tocopherol-clodronate combination (PENTOCLO): a phase II trial. Int J Radiat Oncol Biol Phys 2011; 80 (03) 832-839
    CrossrefPubMedGoogle Scholar
  • 41 Delanian S, Porcher R, Balla-Mekias S, Lefaix JL. Randomized, placebo-controlled trial of combined pentoxifylline and tocopherol for regression of superficial radiation-induced fibrosis. J Clin Oncol 2003; 21 (13) 2545-2550
    CrossrefPubMedGoogle Scholar
  • 42 Delanian S, Depondt J, Lefaix JL. Major healing of refractory mandible osteoradionecrosis after treatment combining pentoxifylline and tocopherol: a phase II trial. Head Neck 2005; 27 (02) 114-123
    CrossrefPubMedGoogle Scholar
  • 43 Suh JD, Blackwell KE, Sercarz JA. , et al. Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 2010; 142 (04) 586-591
    CrossrefPubMedGoogle Scholar
  • 44 Zaghi S, Miller M, Blackwell K, Palla B, Lai C, Nabili V. Analysis of surgical margins in cases of mandibular osteoradionecrosis that progress despite extensive mandible resection and free tissue transfer. Am J Otolaryngol 2012; 33 (05) 576-580
    CrossrefPubMedGoogle Scholar
  • 45 Futran ND. Primary reconstruction of the maxilla following maxillectomy with or without sacrifice of the orbit. J Oral Maxillofac Surg 2005; 63 (12) 1765-1769
    CrossrefPubMedGoogle Scholar
  • 46 Goiato MC, Pesqueira AA, Ramos da Silva C, Gennari Filho H, Micheline Dos Santos D. Patient satisfaction with maxillofacial prosthesis. Literature review. J Plast Reconstr Aesthet Surg 2009; 62 (02) 175-180
    CrossrefPubMedGoogle Scholar
  • 47 Futran ND. Improvement in the art of midface reconstruction. Curr Opin Otolaryngol Head Neck Surg 2001; 9: 214-219
    CrossrefPubMedGoogle Scholar
  • 48 Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Maxillary reconstruction using anterolateral thigh flap and bone grafts. Microsurgery 2009; 29 (06) 430-436
    CrossrefPubMedGoogle Scholar
  • 49 Coleman III JJ. Osseous reconstruction of the midface and orbits. Clin Plast Surg 1994; 21 (01) 113-124
    CrossrefPubMedGoogle Scholar
  • 50 Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000; 105 (07) 2331-2346 , discussion 2347–2348
    CrossrefPubMedGoogle Scholar
  • 51 Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 1998; 40 (04) 397-402
    CrossrefPubMedGoogle Scholar
  • 52 Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77 (04) 530-545
    CrossrefPubMedGoogle Scholar
  • 53 Shrime MG, Gilbert RW. Reconstruction of the midface and maxilla. Facial Plast Surg Clin North Am 2009; 17 (02) 211-223
    CrossrefPubMedGoogle Scholar
  • 54 Coleman III JJ, Sultan MR. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 1991; 87 (04) 682-692
    CrossrefPubMedGoogle Scholar
  • 55 Maranzano M, Atzei A. The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction. Microsurgery 2007; 27 (01) 37-42
    CrossrefPubMedGoogle Scholar
  • 56 Shokri T, Stahl LE, Kanekar SG, Goyal N. Osseous changes over time in free fibular flap reconstruction. Laryngoscope 2019; 129 (05) 1113-1116
    CrossrefPubMedGoogle Scholar
  • 57 Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002; 128 (02) 161-166
    CrossrefPubMedGoogle Scholar
  • 58 Yim KK, Wei FC. Fibula osteoseptocutaneous free flap in maxillary reconstruction. Microsurgery 1994; 15 (05) 353-357
    CrossrefPubMedGoogle Scholar
  • 59 Ducic Y, Defatta R, Wolfswinkel EM, Weathers WM, Hollier Jr LH. Tunneling technique for expedited fibula free tissue harvest. Craniomaxillofac Trauma Reconstr 2013; 6 (04) 233-236
    Article in Thieme ConnectPubMedGoogle Scholar
  • 60 Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996; 18 (05) 412-421
    CrossrefPubMedGoogle Scholar