La Prevenzione e il trattamento medico-chirurgico delle necrosi ossee dei mascellari

Aim: Osteoradionecrosis (ORN) of the jaws is a serious complication that can occur following radiotherapy in the head and neck. The treatment of ORN of jaws is currently accomplished by surgical bone resection and primary reconstruction with osteo-cutaneous free flap with good aesthetic and functional results. BP-ONJ is an emerging problem seen in patients receiving intravenous aminobisphosphonates (pamidronate disodium or zoledronic acid) therapy, for treatment of multiple myeloma and metastatic cancers affecting bone and also among individuals receiving oral bisphosphonates for osteoporosis. In BP-ONJ, the conventional treatments were associated with high failure rates, progression disease and decline in patient’s QoL and the role of surgical resection and microvascular reconstruction has not been clarified. The goal of this study is to make aware on potential risk of BP-ONJ, develop guidelines for prevention, early diagnosis and multidisciplinary treatment.Methods: A multidisciplinary panel of oral and maxillofacial surgeons, dental specialists, hematologists, oncologists, rheumatologists and radiologists was convened to review the literature and clinical evidence, identify risk factors for ORN and BP-ONJ. A retrospective cohort study was completed by reviewing health plan databases and medical charts of 18 patients with osteonecrosis of the jaws. Three patients with ORN and fifteen with BP-ONJ were evaluated and treated. Extensive surgery with primary microvascular reconstruction was performed in the three case of ORN, seven cases of BP-ONJ were treated conservatively and the others were surgically treated (debridement to mandibulectomy was performed).Results: The patients with ORN recovered successfully. The BP-ONJ was properly controlled in six of seven cases conservatively treated; no relapse was registered in seven of eight patients enrolled in the surgical arms of the study at eighteen months of follow-up. The only patient with relapse was submitted to the conservative protocol and actually is free from pain.Conclusion: Close coordination between treating physician, maxillofacial surgeon and dental specialist is strongly recommended in making therapeutic decisions and strict patient’s selection for primary successful surgery. An increased awareness of potential risk of ONJ in patients receiving biphosphonate therapy is needed.