Outcomes of vascularized bone graft reconstruction of the mandible in bisphosphonate-related osteonecrosis of the jaws.
OBJECTIVE
To describe the clinical entity and therapeutic challenges of bisphosphonate-related osteonecrosis of the jaws (BRONJ). The use of vascularized bone grafts for reconstruction of the mandible in extensive BRONJ is proposed.


METHODS
Multi-institutional retrospective review.


METHODS
Patients undergoing mandible reconstruction with vascularized bone grafts after segmental mandible resection for BRONJ were evaluated. Mandible reconstruction was only performed on patients with intractable pain, fistulae, or pathologic fracture and after failure of comprehensive conservative therapy. No patients had a history of primary or metastatic head and neck malignancy or radiation therapy. Bone union was established with follow-up radiography.


RESULTS
Eleven patients met inclusion criteria. Mean patient age was 61.3 years. Median follow-up was 13.9 months. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. Preoperatively, pathologic mandible fractures were present in 73% of patients, and 36% had orocutaneous fistulae. Fibula osteocutaneous flaps were used in all cases with no failures. In all patients, bony union was demonstrated clinically and radiographically. Postoperative wound complications occurred in 36% of patients but were all treated successfully with conservative therapy. There was no BRONJ recurrence within the study follow-up period.


CONCLUSIONS
Osteonecrosis is a significant complication of bisphosphonate therapy, and current literature does not support vascularized reconstruction. We demonstrate that vascularized bone graft reconstruction with the fibula free flap offers a high success rate of bony union and fistula closure and should be offered to selected patients with advanced cases of BRONJ.
Seth
Rahul
R
Head and Neck Institute, the Cleveland Clinic, Cleveland, Ohio, USA.
Futran
Neal D
ND
Alam
Daniel S
DS
Knott
P Daniel
PD
D000368:Aged; D016025:Bone Transplantation / Q000009:adverse effects / Q000379:methods*; D001842:Bone and Bones / Q000098:blood supply* / Q000601:surgery; D015331:Cohort Studies; D004164:Diphosphonates / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008297:Male; D008334:Mandible / Q000601:surgery*; D008336:Mandibular Diseases / Q000139:chemically induced / Q000601:surgery; D008875:Middle Aged; D010020:Osteonecrosis / Q000139:chemically induced* / Q000175:diagnosis / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013524:Surgical Flaps / Q000098:blood supply; D016896:Treatment Outcome
D004164:Diphosphonates