Mandibulectomy and Free Flap Reconstruction for Bisphosphonate-Related Osteonecrosis of the Jaws | Clinical Pharmacy and Pharmacology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
November 2013

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

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
Abstract

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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