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Osteoradionecrosis of the Mandible

  • Author: Remy H Blanchaert, Jr, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Sep 16, 2015
 

Background

Osteoradionecrosis (ORN) is a condition of nonvital bone in a site of radiation injury. ORN can be spontaneous, but it most commonly results from tissue injury. The absence of reserve reparative capacity is a result of the prior radiation injury. Even apparently innocuous forms of trauma such as denture-related injury, ulcers, or tooth extraction can overwhelm the reparative capacity of the radiation-injured bone. Traditionally, 3 grades of disease (I, II, III) are recognized. Grade I ORN is the most common presentation. Exposed alveolar bone is observed. Grade II designates ORN that does not respond to hyperbaric oxygen (HBO) therapy and requires sequestrectomy/saucerization. Grade III is demonstrated by full-thickness involvement and/or pathologic fracture. Therefore, patients can demonstrate grade I or grade III ORN at initial presentation.

Osteoradionecrosis of the mandible is depicted in the images below.

This patient developed osteoradionecrosis (ORN) foThis patient developed osteoradionecrosis (ORN) following radical radiotherapy. His primary tumor was located in the floor of mouth. An orocutaneous fistula is demonstrated here. A pathologic fracture was evident on examination. Biopsies were negative for carcinoma.
This is the panoramic radiograph of the patient seThis is the panoramic radiograph of the patient seen in the image above. Bone necrosis and pathologic fracture are evident.
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Epidemiology

Frequency

ORN is rare in patients who receive less than 60 gray (Gy) radiation therapy. Patients with ORN who receive less than 60 Gy and more than 50 Gy have been reported, but these cases are extremely rare. The overall incidence of ORN has decreased over the last 3 decades. In general, studies from prior to the 1970s showed an ORN incidence from 5.4-11.8%. More recent studies, however, have placed the incidence closer to 3.0%.[1] The true frequency of ORN is impossible to determine because no mechanism exists for reporting the disease. Incidence is increased in patients who receive combined chemotherapy-radiation. The Radiation Therapy Oncology Group (RTOG) requires their members to report radiation toxicity including ORN; however, the disease is probably under-reported.

More valuable than an understanding of frequency is an appreciation for the decrease in reparative capacity in tissue exposed to more than 60 Gy of radiation.

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Etiology

ORN can be either spontaneous or the result of an insult. Spontaneous ORN occurs when, in the process of otherwise normal turnover of bone, the degradative function exceeds new bone production. ORN develops following injury when the reparative capacity of bone within an irradiated field is insufficient to overcome an insult. Bone injury can occur through direct trauma (eg, tooth extraction [84%], related cancer surgery or biopsy [12%], denture irritation [1%]) or by exposure of the irradiated bone to the hostile environment of the oral cavity secondary to overlying soft tissue necrosis. The cumulative progressive endarteritis caused by radiotherapy results in insufficient blood supply (tissue oxygen delivery) to effect normal wound healing.

A study by Chronopoulos et al indicated that risk factors for grade III osteoradionecrosis include active smoking, excessive alcohol use, diabetes mellitus, and dental treatment and/or local pathologic conditions. The study involved 115 patients (153 lesions).[2]

The images below depict a patient who developed ORN following tooth extractions.

This patient developed ORN following tooth extractThis patient developed ORN following tooth extractions. Sequential debridement was attempted prior to patient referral.
The patient seen in the image above developed a paThe patient seen in the image above developed a pathologic fracture at the mandibular angle. He underwent resection of the area of the fracture. At the time of surgery, surgeons thought the patient had bleeding bone, but further ORN is evident.
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Pathophysiology

ORN was first described by Marx in 1983 as hypovascularity, hypocellularity, and local tissue hypoxia.[3, 4] Prior to this, many other theories existed regarding the etiology of ORN. The report by Marx, clinical experience, and subsequent research support this now widely accepted theory.

The irradiated mandible, periosteum, and overlying soft tissue undergo hyperemia, inflammation, and endarteritis. These conditions ultimately lead to thrombosis, cellular death, progressive hypovascularity, and fibrosis. The radiated bed is hypocellular and devoid of fibroblasts, osteoblasts, and undifferentiated osteocompetent cells.

Mandibular ORN develops most commonly after local trauma, such as dental extractions, biopsies, related cancer surgery, and periodontal procedures, but it may also occur spontaneously.

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Presentation

Clinical symptoms include the following:

On physical examination, missing hair follicles, surface texture changes, and color changes are common findings that assist clinicians in assessment of the area of radiation injury.

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Relevant Anatomy

In a histologic study of irradiated osteoradionecrotic mandibles, several characteristic changes were noted. The inferior alveolar artery (the predominant arterial blood supply to the body of the mandible) and periosteal arteries had significant intimal fibrosis and thrombosis. Normal marrow was replaced by dense fibrous tissue with loss of osteocytes. Finally, the study noted buccal cortical necrosis with sequestrum formation and periosteal fibrosis with a tendency to detach from the cortex.[5] In the elderly, the inferior alveolar artery’s flow to the mandible diminishes and the periosteum and muscle attachments predominate as the primary blood supply. The thrombosis of the inferior alveolar artery and surgical disruption of this soft tissue blood supply may contribute to the development of osteoradionecrosis (ORN).

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Contributor Information and Disclosures
Author

Remy H Blanchaert, Jr, DDS, MD Private Practice

Remy H Blanchaert, Jr, DDS, MD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher M Harris, MD, DMD Residency Program Director, Department of Oral and Maxillofacial Surgery, Maxillofacial Tumor and Reconstruction, Naval Medical Center Portsmouth

Christopher M Harris, MD, DMD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Thyroid Association, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

William M Lydiatt, MD Professor and Division Director, Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center

William M Lydiatt, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, Nebraska Medical Association

Disclosure: Nothing to disclose.

References
  1. Wahl MJ. Osteoradionecrosis prevention myths. Int J Radiat Oncol Biol Phys. 2006 Mar 1. 64(3):661-9. [Medline].

  2. Chronopoulos A, Zarra T, Troltzsch M, Mahaini S, Ehrenfeld M, Otto S. Osteoradionecrosis of the mandible: A ten year single-center retrospective study. J Craniomaxillofac Surg. 2015 Jul. 43 (6):837-46. [Medline].

  3. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983 May. 41(5):283-8. [Medline].

  4. Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg. 1983 Jun. 41(6):351-7. [Medline].

  5. Bras J, de Jonge HK, van Merkesteyn JP. Osteoradionecrosis of the mandible: pathogenesis. Am J Otolaryngol. 1990 Jul-Aug. 11(4):244-50. [Medline].

  6. Rogers SN, D'Souza JJ, Lowe D, Kanatas A. Longitudinal evaluation of health-related quality of life after osteoradionecrosis of the mandible. Br J Oral Maxillofac Surg. 2015 Aug 24. [Medline].

  7. D'Souza J, Goru J, Goru S, Brown J, Vaughan ED, Rogers SN. The influence of hyperbaric oxygen on the outcome of patients treated for osteoradionecrosis: 8 year study. Int J Oral Maxillofac Surg. 2007 Sep. 36(9):783-7. [Medline].

  8. Donoff RB. Treatment of the irradiated patient with dental implants: the case against hyperbaric oxygen treatment. J Oral Maxillofac Surg. 2006 May. 64(5):819-22. [Medline].

  9. Granström G. Placement of dental implants in irradiated bone: the case for using hyperbaric oxygen. J Oral Maxillofac Surg. 2006 May. 64(5):812-8. [Medline].

  10. Bui QC, Lieber M, Withers HR, Corson K, van Rijnsoever M, Elsaleh H. The efficacy of hyperbaric oxygen therapy in the treatment of radiation-induced late side effects. Int J Radiat Oncol Biol Phys. 2004 Nov 1. 60(3):871-8. [Medline].

  11. Gbara A, Darwich K, Li L, Schmelzle R, Blake F. Long-term results of jaw reconstruction with microsurgical fibula grafts and dental implants. J Oral Maxillofac Surg. 2007 May. 65(5):1005-9. [Medline].

  12. Chana JS, Chang YM, Wei FC, Shen YF, Chan CP, Lin HN. Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg. 2004 Jan. 113(1):80-7. [Medline].

  13. Rohner D, Jaquiéry C, Kunz C, Bucher P, Maas H, Hammer B. Maxillofacial reconstruction with prefabricated osseous free flaps: a 3-year experience with 24 patients. Plast Reconstr Surg. 2003 Sep. 112(3):748-57. [Medline].

  14. Urken ML, Buchbinder D, Costantino PD, Sinha U, Okay D, Lawson W. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg. 1998 Jan. 124(1):46-55. [Medline].

  15. Martin IC, Cawood JI, Vaughan ED, Barnard N. Endosseous implants in the irradiated composite radial forearm free flap. Int J Oral Maxillofac Surg. 1992 Oct. 21(5):266-70. [Medline].

  16. Tahir AR, Westhuyzen J, Dass J, et al. Hyperbaric oxygen therapy for chronic radiation-induced tissue injuries: Australasia's largest study. Asia Pac J Clin Oncol. 2015 Mar. 11 (1):68-77. [Medline].

  17. Granström G. Osseointegration in irradiated cancer patients: an analysis with respect to implant failures. J Oral Maxillofac Surg. 2005 May. 63(5):579-85. [Medline].

  18. Ang E, Black C, Irish J, Brown DH, Gullane P, O'Sullivan B, et al. Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J Plast Surg. 2003 Mar. 56(2):92-9. [Medline].

  19. Bachmann G, Rossler R, Klett R, Rau WS, Bauer R. The role of magnetic resonance imaging and scintigraphy in the diagnosis of pathologic changes of the mandible after radiation therapy. Int J Oral Maxillofac Surg. 1996 Jun. 25(3):189-95. [Medline].

  20. Coulthard P, Esposito M, Worthington HV, Jokstad A. Therapeutic use of hyperbaric oxygen for irradiated dental implant patients: a systematic review. J Dent Educ. 2003 Jan. 67(1):64-8. [Medline].

  21. Curi MM, Oliveira dos Santos M, Feher O, Faria JC, Rodrigues ML, Kowalski LP. Management of extensive osteoradionecrosis of the mandible with radical resection and immediate microvascular reconstruction. J Oral Maxillofac Surg. 2007 Mar. 65(3):434-8. [Medline].

  22. Futran ND, Trotti A, Gwede C. Pentoxifylline in the treatment of radiation-related soft tissue injury: preliminary observations. Laryngoscope. 1997 Mar. 107(3):391-5. [Medline].

  23. Ioannides C, Fossion E, Boeckx W, Hermans B, Jacobs D. Surgical management of the osteoradionecrotic mandible with free vascularised composite flaps. J Craniomaxillofac Surg. 1994 Dec. 22(6):330-4. [Medline].

  24. Lydiatt DD, Lydiatt WM, Hollins RR, Friedman A. Use of free fibula flap in patients with prior failed mandibular reconstruction. J Oral Maxillofac Surg. 1998 Apr. 56(4):444-6. [Medline].

  25. Marx RE, Ames JR. The use of hyperbaric oxygen therapy in bony reconstruction of the irradiated and tissue-deficient patient. J Oral Maxillofac Surg. 1982 Jul. 40(7):412-20. [Medline].

  26. Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol. 1987 Oct. 64(4):379-90. [Medline].

  27. Meraw SJ, Reeve CM. Dental considerations and treatment of the oncology patient receiving radiation therapy. J Am Dent Assoc. 1998 Feb. 129(2):201-5. [Medline].

  28. Sandel HD 4th, Davison SP. Microsurgical reconstruction for radiation necrosis: an evolving disease. J Reconstr Microsurg. 2007 May. 23(4):225-30. [Medline].

  29. Schoen PJ, Raghoebar GM, Bouma J, Reintsema H, Vissink A, Sterk W, et al. Rehabilitation of oral function in head and neck cancer patients after radiotherapy with implant-retained dentures: effects of hyperbaric oxygen therapy. Oral Oncol. 2007 Apr. 43(4):379-88. [Medline].

  30. Shaha AR, Cordeiro PG, Hidalgo DA, Spiro RH, Strong EW, Zlotolow I, et al. Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible. Head Neck. 1997 Aug. 19(5):406-11. [Medline].

  31. Sulaiman F, Huryn JM, Zlotolow IM. Dental extractions in the irradiated head and neck patient: a retrospective analysis of Memorial Sloan-Kettering Cancer Center protocols, criteria, and end results. J Oral Maxillofac Surg. 2003 Oct. 61(10):1123-31. [Medline].

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This patient developed osteoradionecrosis (ORN) following radical radiotherapy. His primary tumor was located in the floor of mouth. An orocutaneous fistula is demonstrated here. A pathologic fracture was evident on examination. Biopsies were negative for carcinoma.
This is the panoramic radiograph of the patient seen in the image above. Bone necrosis and pathologic fracture are evident.
This patient developed ORN following tooth extractions. Sequential debridement was attempted prior to patient referral.
The patient seen in the image above developed a pathologic fracture at the mandibular angle. He underwent resection of the area of the fracture. At the time of surgery, surgeons thought the patient had bleeding bone, but further ORN is evident.
An absence of healing is evident in this radiograph following extraction of a tooth within a field of radiation therapy.
Osteoradionecrosis developed in the patient seen in the image above. Osteolysis is clearly evident.
Pathologic fracture has developed in this case of osteoradionecrosis (ORN). This constitutes, by definition, stage III disease. This is the same patient seen in the 2 images above.
 
 
 
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