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Original Investigation |

Mandibulectomy and Free Flap Reconstruction for Bisphosphonate-Related Osteonecrosis of the Jaws

Matthew M. Hanasono, MD1; Oleg N. Militsakh, MD2; Jeremy D. Richmon, MD3; Eben L. Rosenthal, MD4; Mark K. Wax, MD5
[+] Author Affiliations
1Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
2Department of Otolaryngology/Head and Neck Surgery, University of Nebraska Medical Center and Nebraska Methodist Hospital, Omaha
3Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
4Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Alabama, Birmingham
5Department of Otolaryngology/Head and Neck Surgery, Oregon Health & Science University, Portland
JAMA Otolaryngol Head Neck Surg. 2013;139(11):1135-1142. doi:10.1001/jamaoto.2013.4474.
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Importance  Bisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy. Our experience suggests that mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 disease.

Objective  To analyze indications for segmental mandibulectomy and microvascular free flap reconstruction for bisphosphonate-related osteonecrosis of the jaws and surgical outcomes following this procedure.

Design, Setting, and Participants  In a multi-institutional case series study conducted in academic tertiary care centers, 13 patients underwent segmental mandibulectomy and microvascular free flap reconstruction, including 8 patients with stage 3 disease and 5 patients with recalcitrant stage 2 disease. All patients had persistent or progressive disease despite conservative oral care and antibiotic treatment.

Interventions  Segmental mandibulectomy and microvascular free flap reconstruction.

Main Outcomes and Measures  Treatment efficacy and postoperative complications.

Results  There was 1 total flap loss due to infection. The patient with a flap loss ultimately underwent a successful fibula osteocutaneous free flap reconstruction after serial irrigation and debridement. The overall complication rate was 46% (n = 6). All complications occurred in patients with stage 3 disease. Ultimately, all patients achieved a successful reconstruction, with no recurrences. All patients tolerated a soft or regular diet postoperatively.

Conclusions and Relevance  Bisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy that can occasionally progress to involve full-thickness mandibular destruction, pathologic fracture, and fistulization, as well as chronic pain and infection. Mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 bisphosphonate-related osteonecrosis of the jaws. High rates of chronic infection and underlying medical comorbidities may predispose to a substantial perioperative complication rate.

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Figures

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Figure 1.
Patient 1: Preoperative Computed Tomographic Scan

A 63-year-old woman with bisphosphonate-related osteonecrosis of the mandible demonstrated pathologic fractures and bony erosion.

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Figure 2.
Patient 1: Surgical Specimen and Defect

Specimen from segmental mandibulectomy (A) and the surgical defect (B).

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Figure 3.
Patient 1: Planning for Reconstruction

A rapid prototype model was created (A) to help guide fibula free flap reconstruction such that the patient’s mandibular shape and occlusion were restored (B).

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Figure 4.
Patient 1: Postoperative Intraoral Photograph

Complete healing of the fibula osteocutaneous free flap was achieved.

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Figure 5.
Patient 2: Preoperative Computed Tomographic Scan

A 57-year-old man with a history of bisphosphonate-related osteonecrosis of the mandible who had undergone segmental mandibulectomy and titanium plate reconstruction at an outside facility and then presented with a fractured plate.

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Figure 6.
Patient 2: Surgical Defect and Titanium Plate

Left mandibular surgical defect (A) following removal of the fractured titanium plate (B).

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Figure 7.
Patient 2: Planning for Reconstruction

Computer-assisted design software (A) and rapid prototype modeling (B) were used to help guide fibula free flap reconstruction of the mandible, which had malaligned left and right segments following fracture of the titanium reconstruction plate placed after initial mandibulectomy.

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Figure 8.
Patient 2: Postoperative Photographs

Anterior (A), left lateral (B), and intraoral (C) postoperative results of surgery.

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