Case Report
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
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
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 - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Final approval of the version to be published
Wilber Edison Bernaola-Paredes - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Nicholas Pascuotte Filippetti - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Leonardo Faria Ramos - Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Monica Lucia Rodrigues - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
José Guilherme Vartanian - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Henrique Perez Carvalho - Acquisition of data, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Rodrigo Nascimento Lopes - Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Antonio Cassio Assis Pellizzon - Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
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.
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