Case Report


Refractory advanced osteoradionecrosis (ORN) in the mandible: Analysis of predictive factors, clinical, imaging, and therapeutic characteristics

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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

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Article ID: 101308Z01VF2022

doi: 10.5348/101308Z01VF2022CR

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How to cite this article

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

SUPPORTING INFORMATION


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 Contributions

Valdener 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 Submission

The corresponding author is the guarantor of submission.

Source of Support

None

Consent Statement

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Conflict of Interest

Authors 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.