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DOI: 10.1055/s-0045-1813709
Management of Osteoradionecrosis in Jaws
Authors
Abstract
Osteoradionecrosis of the mandible refers to necrosis of bone and often with surrounding tissues after radiotherapy. This is often compounded by chronic infection, leading to debilitating outcomes on the patient's quality of life. In this article, we discuss the incidence, risk factors, diagnosis, staging, pathophysiology, and management of this condition. We discuss our experience in managing this condition, which can vary depending on severity and patient factors, when taking into account approaches ranging from conservative to surgical resection and free flap reconstruction.
Keywords
osteonecrosis - mandible - osteoradionecrosis - fibrosis - free flap - mandible reconstructionPublication History
Article published online:
18 December 2025
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References
- 1 Borras JM, Barton M, Grau C. et al. The impact of cancer incidence and stage on optimal utilization of radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project. Radiother Oncol 2015; 116 (01) 45-50
- 2 Regaud C. Sur la necrose des os attentē par un processus cancereux et traites par les radiaions. [On the necrosis of the bones affected by a cancerous process and treated by radiation [in French]. C R Soc Biol 1922; 87: 629-632
- 3 Marx RE. Osteoradionecrosis: A new concept of its pathophysiology. J Oral Maxillofac Surg 1983; 41 (05) 283-288
- 4 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
- 5 He Y, Liu Z, Tian Z, Dai T, Qiu W, Zhang Z. Retrospective analysis of osteoradionecrosis of the mandible: Proposing a novel clinical classification and staging system. Int J Oral Maxillofac Implants 2015; 44 (12) 1547-1557
- 6 Chronopoulos A, Zarra T, Ehrenfeld M, Otto S. Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review. Int Dent J 2018; 68 (01) 22-30
- 7 Miyamoto I, Tanaka R, Kogi S. et al. Clinical diagnostic imaging study of osteoradionecrosis of the jaw: A retrospective study. J Clin Med 2021; 10 (20) 4704
- 8 Moon DH, Moon SH, Wang K. et al. Incidence of, and risk factors for, mandibular osteoradionecrosis in patients with oral cavity and oropharynx cancers. Oral Oncol 2017; 72: 98-103
- 9 Iqbal Z, Kyzas P. Analysis of the critical dose of radiation therapy in the incidence of osteoradionecrosis in head and neck cancer patients: A case series. BDJ Open 2020; 6: 18
- 10 Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on late complications in patients with free fibular flaps for mandibular reconstruction. Ann Plast Surg 1999; 42 (06) 662-664
- 11 Nabil S, Samman N. Incidence and prevention of osteoradionecrosis after dental extraction in irradiated patients: A systematic review. Int J Oral Maxillofac Implants 2011; 40 (03) 229-243
- 12 Jereczek-Fossa BA, Orecchia R. Radiotherapy-induced mandibular bone complications. Cancer Treat Rev 2002; 28 (01) 65-74
- 13 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
- 14 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
- 15 Peterson DE, Doerr W, Hovan A. et al. Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 2010; 18 (08) 1089-1098
- 16 Studer G, Bredell M, Studer S, Huber G, Glanzmann C. Risk profile for osteoradionecrosis of the mandible in the IMRT era. Strahlenther Onkol 2016; 192 (01) 32-39
- 17 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
- 18 Robard L, Louis MY, Blanchard D, Babin E, Delanian S. Medical treatment of osteoradionecrosis of the mandible by PENTOCLO: Preliminary results. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131 (06) 333-338
- 19 Clayman L. Clinical controversies in oral and maxillofacial surgery: Part two. Management of dental extractions in irradiated jaws: A protocol without hyperbaric oxygen therapy. J Oral Maxillofac Surg 1997; 55 (03) 275-281
- 20 Möring MM, Mast H, Wolvius EB. et al. Osteoradionecrosis after postoperative radiotherapy for oral cavity cancer: A retrospective cohort study. Oral Oncol 2022; 133: 106056
- 21 Kubota H, Miyawaki D, Mukumoto N. et al. Risk factors for osteoradionecrosis of the jaw in patients with head and neck squamous cell carcinoma. Radiat Oncol 2021; 16 (01) 1
- 22 Girardi FM, Wagner VP, Martins MD. et al. Risk factors for jaw osteoradionecrosis: A case control study. Braz Oral Res 2022; 36: e132
- 23 Mendenhall WM, Suárez C, Genden EM. et al. Parameters associated with mandibular osteoradionecrosis. Am J Clin Oncol 2018; 41 (12) 1276-1280
- 24 Mendenhall WM. Mandibular osteoradionecrosis. J Clin Oncol 2004; 22 (24) 4867-4868
- 25 Fitzgerald KT, Lyons C, England A. et al. Risk factors associated with the development of osteoradionecrosis (ORN) in head and neck cancer patients in Ireland: A 10-year retrospective review. Radiother Oncol 2024; 196: 110286
- 26 Ewing J. Radiation osteitis. Acta Radiol 1926; 6: 399-412
- 27 Watson WL, Scarborough JE. Osteoradionecrosis in intraoral cancer. Am J Roentgenol 1938; 40: 524-534
- 28 Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: Therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004; 73 (02) 119-131
- 29 Kolokythas A, Rasmussen JT, Reardon J, Feng C. Management of osteoradionecrosis of the jaws with pentoxifylline-tocopherol: A systematic review of the literature and meta-analysis. Int J Oral Maxillofac Implants 2019; 48 (02) 173-180
- 30 Nadella KR, Kodali RM, Guttikonda LK, Jonnalagadda A. Osteoradionecrosis of the jaws: Clinico-therapeutic management: A literature review and update. J Maxillofac Oral Surg 2015; 14 (04) 891-901
- 31 McLeod NMH, Pratt CA, Mellor TK, Brennan PA. Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience. Br J Oral Maxillofac Surg 2012; 50 (01) 41-44
- 32 Michikawa C, Uzawa N, Kayamori K. et al. Clinical significance of lymphatic and blood vessel invasion in oral tongue squamous cell carcinomas. Oral Oncol 2012; 48 (04) 320-324
- 33 Rasmusson L, Abtahi J. Bisphosphonate associated osteonecrosis of the jaw: an update on pathophysiology, risk factors, and treatment. Int J Dent 2014; 2014: 471035
- 34 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
- 35 D'Souza J, Lowe D, Rogers SN. Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: Experience from a regional head and neck unit. Br J Oral Maxillofac Surg 2014; 52 (04) 356-362
- 36 Hayashi M, Pellecer M, Chung E, Sung E. The efficacy of pentoxifylline/tocopherol combination in the treatment of osteoradionecrosis. Spec Care Dentist 2015; 35 (06) 268-271
- 37 Patel V, Gadiwalla Y, Sassoon I, Sproat C, Kwok J, McGurk M. Use of pentoxifylline and tocopherol in the management of osteoradionecrosis. Br J Oral Maxillofac Surg 2016; 54 (03) 342-345
- 38 Dos Anjos RS, de Pádua Walfrido GN, de Hollanda Valente RO. et al. Pentoxifylline, tocopherol, and sequestrectomy are effective for the management of advanced osteoradionecrosis of the jaws-a case series. Support Care Cancer 2021; 29 (06) 3311-3317
- 39 Patel S, Patel N, Sassoon I, Patel V. The use of pentoxifylline, tocopherol and clodronate in the management of osteoradionecrosis of the jaws. Radiother Oncol 2021; 156: 209-216
- 40 Dissard A, P Dang N, Barthelemy I. et al. Efficacy of pentoxifylline-tocopherol-clodronate in mandibular osteoradionecrosis. Laryngoscope 2020; 130 (11) E559-E566
- 41 Lyons A, Osher J, Warner E, Kumar R, Brennan PA. Osteoradionecrosis. –a review of current concepts in defining the extent of the disease and a new classification proposal. Br J Oral Maxillofac Surg 2014; 52 (05) 392-395
- 42 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
- 43 Gal TJ, Yueh B, Futran ND. Influence of prior hyperbaric oxygen therapy in complications following microvascular reconstruction for advanced osteoradionecrosis. Arch Otolaryngol Head Neck Surg 2003; 129 (01) 72-76
- 44 Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: a randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Am Dent Assoc 1985; 111 (01) 49-54
- 45 Forner LE, Dieleman FJ, Shaw RJ. et al. Hyperbaric oxygen treatment of mandibular osteoradionecrosis: Combined data from the two randomized clinical trials DAHANCA-21 and NWHHT2009-1. Radiother Oncol 2022; 166: 137-144
- 46 Annane D, Depondt J, Aubert P. et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group. J Clin Oncol 2004; 22 (24) 4893-4900
- 47 Batstone MD, Cosson J, Marquart L, Acton C. Platelet rich plasma for the prevention of osteoradionecrosis. A double blinded randomized cross over controlled trial. Int J Oral Maxillofac Implants 2012; 41 (01) 2-4
- 48 Gallesio G, Del Fabbro M, Pol R, Mortellaro C, Mozzati M. Conservative treatment with plasma rich in growth factors-Endoret for osteoradionecrosis. J Craniofac Surg 2015; 26 (03) 731-736
- 49 Cha YH, Hong N, Rhee Y, Cha IH. Teriparatide therapy for severe, refractory osteoradionecrosis of the jaw. Osteoporos Int 2018; 29 (04) 987-992
- 50 Andrews EB, Gilsenan A, Midkiff K, Harris D. Challenges in studying very rare cancer outcomes and infrequent exposures: Example of teriparatide and osteosarcoma. Ann Epidemiol 2016; 26 (11) 751-753
- 51 Woodruff LD, Bounkeo JM, Brannon WM. et al. The efficacy of laser therapy in wound repair: A meta-analysis of the literature. Photomed Laser Surg 2004; 22 (03) 241-247
- 52 Ribeiro GH, Minamisako MC, Rath IBDS. et al. Osteoradionecrosis of the jaws: case series treated with adjuvant low-level laser therapy and antimicrobial photodynamic therapy. J Appl Oral Sci 2018; 26: e20170172
- 53 Al Deek NF, Wei FC. The osteosarcoradionecrosis as an unfavorable result following head and neck tumor ablation and microsurgical reconstruction. Clin Plast Surg 2016; 43 (04) 753-759
- 54 Peterson DE, Koyfman SA, Yarom N. et al. Prevention and management of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy: ISOO-MASCC-ASCO Guideline. J Clin Oncol 2024; 42 (16) 1975-1996
- 55 Bettoni J, Olivetto M, Duisit J. et al. Treatment of mandibular osteoradionecrosis by periosteal free flaps. Br J Oral Maxillofac Surg 2019; 57 (06) 550-556
- 56 Chaiyasate K, Gupta R, John J. et al. Utilization of a chimeric medial femoral condyle free flap for mandibular osteoradionecrosis. Plast Reconstr Surg Glob Open 2022; 10 (08) e4489
- 57 Hurrell MJL, Leinkram D, Stokan MJ, Clark JR. Medial femoral condyle periosteal free flap for bone coverage following debridement of intermediate-stage osteoradionecrosis of the jaw. J Craniofac Surg 2024; 35 (04) 1174-1176
- 58 Arianpour K, Meleca JB, Liu SW. et al. Evaluation of anterolateral thigh fascia lata rescue flap for mandibular osteoradionecrosis. JAMA Otolaryngol Head Neck Surg 2023; 149 (07) 621-627
- 59 Fritz MA, Arianpour K, Liu SW. et al. Managing mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 2025; 172 (02) 406-418
- 60 Mayland E, Curry JM, Wax MK. et al. Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction. Head Neck 2022; 44 (03) 698-709
- 61 O'Connell JE, Brown JS, Rogers SN, Bekiroglu F, Schache A, Shaw RJ. Outcomes of microvascular composite reconstruction for mandibular osteoradionecrosis. Br J Oral Maxillofac Surg 2021; 59 (09) 1031-1035
- 62 Contrera KJ, Chinn SB, Weber RS. et al. Outcomes after definitive surgery for mandibular osteoradionecrosis. Head Neck 2022; 44 (06) 1313-1323
- 63 Lee ZH, Shuck JW, Largo RD. et al. Free fibula mandible reconstruction for osteoradionecrosis is more challenging than for primary cancer. Head Neck 2024; 46 (11) 2834-2842
- 64 Klibngern H, Hung SY, Tsao CK, Kao HK, Lin CH, Wei FC. Plast Reconstr Surg 2025; ( E-pub ahead of print)
- 65 Farsi S, Benafield A, Dorman J. et al. Outcomes of free flap reconstruction for mandibular ORN: Systematic review and meta-analysis. Am J Otolaryngol 2025; 46 (01) 104508
- 66 Al Deek NF, Kao HK, Wei FC. The fibula osteoseptocutaneous flap: Concise review, goal-oriented surgical technique, and tips and tricks. Plast Reconstr Surg 2018; 142 (06) 913e-923e
- 67 Hamahata A, Konoeda H, Shirakura S, Yagihara K, Sakurai H. Utility of free fibula flap with an extended banana-shaped skin paddle for oro-mandibular reconstructions. Plast Reconstr Surg Glob Open 2025; 13 (01) e6385
- 68 Jacobson AS, Zevallos J, Smith M. et al. Quality of life after management of advanced osteoradionecrosis of the mandible. Int J Oral Maxillofac Implants 2013; 42 (09) 1121-1128
- 69 Wu RT, Lin JA, Su CL, Wei FC. Quality of life for osteoradionecrosis reconstruction in the head and neck: A longitudinal framework and risk factors. Plast Reconstr Surg 2025; 155 (04) 695-705
- 70 Sweeny L, Mayland E, Swendseid BP. et al. Microvascular reconstruction of osteonecrosis: Assessment of long-term quality of life. Otolaryngol Head Neck Surg 2021; 165 (05) 636-646
