Review Paradigm shifts in the management of osteoradionecrosis of the mandible Adam S. Jacobson, Daniel Buchbinder, Kenneth Hu, Mark L. Urken ⇑ Department of Otolaryngology – Head and Neck Surgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA article info Article history: Received 17 August 2010 Accepted 18 August 2010 Available online 16 September 2010 Keywords: Osteoradionecrosis Microvascular surgery Radiation therapy Hyperbaric oxygen Mandible reconstruction Oral oncology summary Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as ‘‘radi- ation osteitis”. In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx’s protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging tech- niques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of dis- ease based on a patient’s response to a standardized treatment protocol. Reconstructions are now rou- tinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question. Ó 2010 Elsevier Ltd. All rights reserved. Introduction Radiation therapy plays a significant role in the contemporary management of head and neck malignancies. It is used in a variety of different treatment protocols, in combination with chemotherapy and surgery. Osteoradionecrosis (ORN) is usually a late complication of radiation exposure, occurring when irradiated bone becomes devitalized. It is classically defined as exposed bone through an opening in the overlying skin or mucosa, persisting as a non-healing wound for three months or more. 1 However, we have recently encountered a patient with a severe case of ORN, with a pathologic fracture but no evidence of bone exposure. When ORN develops, it typically starts as a small area of muco- sal breakdown with exposure of the underlying bone. As ORN pro- gresses, patients often develop trismus, neuropathic pain, and chronic drainage. Additionally, these patients usually experience the full spectrum of collateral damage from radiation therapy (i.e. xerostomia, chronic trismus, dysgeusia, dysphagia, decreased tongue mobility). These extremely difficult problems, in combina- tion with symptoms from ORN, often leave patients physically and emotionally disabled. Furthermore, the treatment of ORN can be frustrating for these already fragile patients because they often must endure repeated interventions without a clear end in sight (i.e. multiple debridements and HBO therapy). Following an extensive review of the literature, there are a vari- ety of issues which are called into question in determining the best staging and treatment for patients with ORN. There are a number of different staging systems which have been published, but few incorporate high resolution CT findings in determining the stage of disease. Marx’s staging system is perhaps the most widely used and is predicated on staging ORN based on response to treatment. 1 Furthermore, there are few publications which address functional outcomes after treatment for ORN (i.e. type of diet, ability to wear dentures, resolution of trismus, and quality of life). Finally, most studies have short durations of follow-up and hence do not address the issue of disease progression over a patient’s lifetime. In this review article, we will discuss the etiology, epidemiol- ogy, and pathophysiology of ORN. Additionally, we will discuss our current management strategies for ORN as well as strategies to prevent the development of ORN. Etiology and pathogenesis The presentation of ORN ranges from superficial, slowly pro- gressive bone erosion, to pathological fracture. Patients often 1368-8375/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2010.08.007 ⇑ Corresponding author. Address: Beth Israel Medical Center, Department of Otolaryngology – Head and Neck Surgery, Albert Einstein College of Medicine, 10 Union Square East, Suite 5B, New York, NY 10003, USA. Tel.: +1 212 844 8775; fax: +1 212 844 6975. E-mail address: murken@chpnet.org (M.L. Urken). Oral Oncology 46 (2010) 795–801 Contents lists available at ScienceDirect Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology 211-268