Introduction:
Osteoradionecrosis (ORN) of the jaws is a severe late side effect in patients treated for oral squamous cell carcinoma with radiation. ORN can be refractory to conservative non-surgical or extensive surgical resections and requires microvascular reconstruction.
The fibular osteomusculocutaneous free flap (FFF) is the preferred flap among surgeons to reconstruct mandibular ORN. It is easy to harvest and allows for dental implant placement.
Reconstruction of mandibular defects due to osteoradionecrosis (ORN)
Osteoradionecrosis (ORN) of the jaws is a serious and potentially life-threatening complication in patients with head and neck cancer who are treated with radiation therapy. While the radiation used in head and neck cancer treatments kills cancer cells, it also damages healthy cells and can interfere with blood flow to these areas. The lack of blood supply to the area causes the bone to die. The ORN can be localized to a specific area of the bone or it can affect all the bones in the jaw.
ORN is a multifactorial disease that can develop due to multiple factors including radiotherapy, vascular problems, infection and trauma. Various staging systems have been developed to help doctors assess and treat ORN. The stages of ORN range from early to advanced, with the latter characterized by pathologic fractures and orocutaneous fistulas.
The early stages of ORN may respond to conservative treatment with oral hygiene, transoral debridement and hyperbaric oxygen (HBO) therapy. However, there is a subset of patients who develop more extensive bone necrosis and fail to respond to these conservative measures. Those patients may require aggressive surgical debridement with microvascular reconstruction to avoid complications such as orocutaneous fistula, pathologic fracture and bone resorption.
A variety of techniques have been proposed for mORN reconstruction, including the use of pedicled or free flaps. The latter are preferred because they allow for the placement of dental implants after reconstruction. However, there is limited literature on the clinical outcomes of mORN reconstruction using free flaps.
In this retrospective cohort study, we reviewed all patients who underwent a free flap reconstruction for mORN at the Amsterdam UMC – VUmc between 1995 and 2021. Twenty-eight patients were included; 17 males and 11 females, with a mean age of 63 years. All had received radiation for various head and neck malignant tumors including squamous cell carcinoma of the head and neck in 27 patients, squamous cell carcinoma of the larynx in five patients and pleomorphic sarcoma in one patient.
Patients with mORN are at high risk for complications such as oro-cutaneous fistulas, pathologic fractures and infections. These complications can lead to a decline in functionality and quality of life. The majority of mORN cases can be successfully reconstructed with microvascular free flap surgery. The most common free flap for mORN is the fibula free flap (FFF). However, the choice of which type of free flap to use is dependent on several variables including defect size, donor site availability, and patient characteristics. It is important that surgeons be familiar with the management of these complex defects and understand how the initial type of reconstruction can impact final rehabilitation outcomes. This is particularly important in mORN, which can occur in patients who have had previous mandibular ORN. Second-time reconstructions have been shown to have worse speech outcomes compared to first-time reconstructions. This is because the scars from previous reconstructions can limit tongue movement and thereby impair speech production.