Downgrading advanced stage Medication Related Osteonecrosis of Jaw using pedicled flap

What is it about?

Introduction: Medication related osteonecrosis of the jaw (MRONJ) is a locally destructive, and potentially devastating disease process that occurs in patients with a history of antiresorptive or antiangiogenic therapy. A widely accepted practice of surgical intervention in the management of advanced stage MRONJ involves segmental resection of the affected bone. Aim: We propose to downgrade the stage with pedicled flaps for eradication of biofilm and vascular coverage with load sharing or load bearing constructs of the skeleton. As patients that receive antiresorptive or antiangiogenic therapy often have multiple medical comorbidities, this limits their surgical options and precludes them from being able to undergo expansive segmental resections or microvascular free tissue transfers and are left with palliative measures, thus compromising their care. Summary: Either concept of MRONJ progression- bone metabolism or vascular breakdown is treated with immediate advancement of a pedicled local tissue flap and is performed for soft tissue coverage, thus providing a new vascular envelope and decreasing soft tissue toxicity to halt furtherance of the disease. Submental island flaps, nasolabial flaps, pedicled buccal fat pad flaps, and facial artery musculomucosal flaps have demonstrated success for longer than two years. This technique addresses downgrading MRONJ stage II and III in the mandible as a possible long-term treatment. This unreported innovative approach consists of marginal resection of the involved alveolar bone, while preserving the affected basal bone and subsequently provides reinforcement with a titanium bone plate, decreasing the chance of pathologic fracture. Keywords: MRONJ; Flap; Pedicled flap; Medication related osteonecrosis of the jaw; Bisphosphonate related osteonecrosis of the jaw.

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