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Case Report
Refractory advanced osteoradionecrosis (ORN) in the mandible: Analysis of predictive factors, clinical, imaging, and therapeutic characteristics
1 Master student, Department of Radiation Oncology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
2 PhD Student, Department of Radiation Oncology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
3 Master candidate, Department of Radiation Oncology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
4 Head and Neck & Plastic Surgeon, Department of Head and Neck Surgery & Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
5 Head and Neck Surgeon, Department of Head and Neck Surgery & Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
6 Medical resident from Department of Head and Neck Surgery & Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
7 Department of Stomatology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
8 Head of Department of Radiation Oncology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
Address correspondence to:
Wilber Edison Bernaola-Paredes
DDS, OMS, MSc., PhD Student, Department of Radiation Oncology, A.C. Camargo Cancer Center, Sao Paulo,
Brazil
Message to Corresponding Author
Article ID: 101308Z01VF2022
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Bella-Filho V, Bernaola-Paredes WE, Filippetti NP, Ramos LF, Rodrigues ML, Vartanian JG, Carvalho HP, Lopes RN, Pellizzon ACA. Refractory advanced osteoradionecrosis (ORN) in the mandible: Analysis of predictive factors, clinical, imaging, and therapeutic characteristics. Int J Case Rep Images 2022;13:101308Z01VF2022.ABSTRACT
Introduction: Osteoradionecrosis (ORN) of the jaws is a late, severe and difficult to manage side effect in patients who underwent radiotherapy (RT) in the head and neck region. Treatment remains controversial, especially in refractory cases that do not respond to multiple attempts with different therapies, due to their complex pathophysiology. It is based on conservative non-surgical approaches, even in large resections using free flaps. The present study aims to present and describe a clinical case of refractory ORN treated through microsurgical reconstruction and adjuvant therapies.
Case Report: A 51-year-old female patient with oncological background of oral squamous cell carcinoma (OSCC) of the floor of the mouth, previously treated with marginal mandibulectomy, and who subsequently relapsed. In a second surgical time, left hemimandibulectomy was performed, followed by microsurgical reconstruction with the fibular osteomusculocutaneous free flap, besides, dental implants were placed in the perioperative time. Radiotherapy was performed using a 3D conformal technique with a total dose of 66 Gy and after six months the patient developed infection in the treated region and it was observed partial exposure of the fibular flap and intra and extraoral purulent drainage, and after imaging analysis the diagnosis of ORN was established. Some non-surgical therapeutic attempts were performed without clinical response and a new surgical approach was performed based on sequestrectomy, the removal of the titanium plaque and dental implants with a second microsurgical reconstruction with forearm fasciocutaneous free flap to cover the soft tissue defect was done.
Conclusion: The pathophysiology of ORN remains controversial and the predictive factors for its appearance, development, and progression are still unclear. Marginal mandibulectomy could be associated with a rapid onset of ORN in patients submitted to adjuvant RT and it could be considered as a potential predictive factor. Combined therapies are reliable alternatives for local control in refractory cases and in advanced stages, and surgical removal with microsurgical reconstruction procedures are still a feasible alternative that has shown satisfactory clinical results.
Keywords: Dental implants, Free tissue flaps, Microsurgery, Oral cavity squamous cell carcinoma, Osteoradionecrosis, Radiotherapy, Segmental mandibulectomy
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Acknowledgments
The authors thank D.M.C. Company, NUPEN Research Institute and Professor Luciana Almeida from Sao Carlos, Sao Paulo, Brazil and their teams who supported this work with full resources for applying photobiomodulation and antimicrobial Photodynamic Therapy (aPDT). Wilber E. Bernaola-Paredes is a student fellow and supported with a scholarship provided by the National Council for Scientific and Technological Development of Brazil (CNPq), Sao Paulo, Brazil (140071/2019-9).
Author ContributionsValdener Bella-Filho - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Wilber Edison Bernaola-Paredes - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Nicholas Pascuotte Filippetti - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Leonardo Faria Ramos - Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Monica Lucia Rodrigues - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
José Guilherme Vartanian - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Henrique Perez Carvalho - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Rodrigo Nascimento Lopes - Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Antonio Cassio Assis Pellizzon - Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2022 Valdener Bella-Filho et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
