OSTEORADIONECROSIS

S. Naga Praneeth
180301170
CONTENTS

1. Introduction / Definition
2. Etiology
3. Risk Factors
4. Pathophysiology
5. Clinical Features
6. Investigations
7. Radiologic Features
8. Treatment & Management
9. Prevention
INTRODUCTION

ALSO CALLED AS RADIATION OSTEOMYELITIS.

Osteoradionecrosis is an exposure of nonviable, non-healing, non-septic lesion
in the irradiated bone, which fails to heal without intervention.
It is a sequelae of irradiation induced tissue injury, in which hypocellularity,
hypo-vascularity and hypoxia are the underlying causes.
• ‘Osteo’ – Bone
• ‘Radio’ – Radiation related
• ‘Necros’ – Dead
• Most serious and late complication of Therapeutic Radiotherapy for Head and Neck.
• INCIDENCE: Mandible > Temporal bone > Maxilla (Dense Bone)
• LETHAL DOSE: A total dosage of approx. 6500-7500 uGy or greater, particularly to
the floor of mouth and mandible show significant incidence of ORN of mandible.
• The time period between the Radiotherapy and the development of ORN has been
reported as a mean of 7.5 and up to 20 yrs.
ETIOLOGY

1. Spontaneous Osteoradionecrosis – 39%

2. Trauma Induced – 61%
3. Sources of Bone Injury:
Tooth extraction
Cancer surgery
Denture Irritation
Soft Tissue Necrosis, exposing the bone
 RISK FACTORS
Dosage (>60 Gy) 1.Advanced tumor Severe periodontitis Post-radiation trauma
Modality – Brachytherapy 2.Recurrent tumor 1.Poor oral hygiene Tooth extraction
has highest incidence 3.Tumor invading bone Smoking, Alcohol history
1.Fractionation 4.Tumor of tongue, 1.Poor patient compliance
retromolar trigone, FOM

RADIATION TUMOR DENTAL

OTHERS
FACTORS FACTORS FACTORS
 PATHOPHYSIOLOGY

MARX’s
3H CONCEPT

Marx described its causes as 3

‘H’ (1983)
1. Hypocellularity
2. Hypovascularity of the
Irradiated Tissue
3. Hypoxia
FIBRO-ATROPHIC
THEORY
PATHOLOGICAL CHANGES
• Mucositis • Aseptic necrosis
• Atrophic Mucosa • Destruction of
• Xerostomia Osteoblast &
Osteoclast
• Radiation Caries
CLINICAL FEATURES

1. Severe Deep Boring Pain which may

continue for weeks and months.
2. Swelling of face.
3. Soft Tissue Abscess and persistent drainage.
4. Exposed bone
5. Oro-Cutaneous Fistula.
6. Trismus.
7. Fetid odour / Halitosis.
8. Pyrexia.
9. Pathological fracture.
INVESTIGATIONS

1. Radiographs
2. CT
3. MRI – Best modality for Marrow Assessment.
4. PET Scan – Differentiate between ORN and Recurrent Tumor.
5. Nuclear Imaging – Degree of Bone Turnover.
6. Doppler Ultrasound – Determine Vascularity.
RADIOGRAPHIC FEATURES

Appears as Radiolucent, modelling with

indefinite non-sclerotic border and
occasional areas of radiopacity associated
with Bony Sequestrum.
 Mottled Bone Appearance
 Mixed Radiopaque – Radiolucent Areas
 Areas of Decalcification or Sclerosis
 Formation of Sequestra or Involucre
 Pathologic Fracture
 TREATMENT
1. Debridement
2. Control of Infection
3. Hospitalisation
4. Fluid therapy, High protein, and Vitamin Diet
5. Analgesics: Narcotic & Non-narcotic Analgesics, Bupivacaine (Marcaine), Alcohol nerve
blocks;
6. Oral rinse to prevent radiation induced caries
7. Sequestrectomy – Intraorally
8. Bone Resection – In advanced stage
9. Hyper Baric Oxygen Therapy
 SURGICAL MANAGEMENT WOUND < 1 cm
Wound < 1cm – Gently debride the Sequestra, but no attempt should be made to achieve
soft tissue closure. Wound might eventually heal with conservative methods in weeks to
months.

SURGICAL MANAGEMENT
SURGICAL MANAGEMENT – NON-HEALING WOUND
NON-HEALING WOUND
For non healing wounds following surgical technique can be followed:
1. Resection of the Exposed Bone.
2. With a margin of Unexposed Bone.
3. Attempt to achieve a soft tissue closure.
4. Growth factors like (Platelet-Rich Fibrin) PRF / (Platelet-Rich Plasma) PRP to
enhance wound healing.
1

3
2
RECONSTRUCTIVE
SURGERY
1. A large continuity defect is a good candidate
for reconstruction with a free vascularized
flap.
2. The ideal free vascularized flap for
reconstruction is –free fibula
3. Other options include –free radial forearm
flap, vascularized iliac crest graft.
HYPERBARIC OXYGEN THERAPY (HBOT)

• The goal of treating ORN is to overcome HYPOXIA.

• HBO is an adjuvant to surgery.
• In order to increase tissue oxygenation, the patient is subjected to
increased concentration and pressure of oxygen.
• HBO therapy consists of delivering 100% oxygen at more than 1 atm
pressure.
• This in turn increases oxygen concentration in plasma and tissues,
resulting in angiogenesis.
 HBO THERAPY MECHANISM
Increase in Plasma Oxygen Concentration
leads to Increased Recruitment and function
of Leukocytes. 1. HBO Therapy is administered in an HBO chamber.
2. Consists of a Session called as DIVE of 90 mins duration
during which 100% Oxygen is delivered at 2-2.4 atm pressure.
Increased Angiogenesis, Increased 3. Depending upon the need, different regimes are decided.
Fibrogenesis (Leading to Increased Collagen
Formation)

Inhibits Aerobic and Anaerobic Bacteria &

Inhibition of Bacterial Toxin by Free Oxygen
Radicals.

Also, there is Increased Oxygen

Concentration in Deeper tissues. Reversal of
Tissue Hypoxia.
 1. Untreated pneumothorax —
(Absolute contraindication)
2. Pregnancy
3. Emphysema
CONTRAINDICATION
FOR HBO THERAPY 4. Upper respiratory tract infection
5. Uncontrollable fever
6. Optic neuritis
7. Ear problems
STAGING AND TREATMENT
ALGORITHM
A MODIFIED “MARX” PROTOCOL

CLINICAL STAGING
I. Stage I: Exposed Bone, Non-Healing Wound.
II. Stage II: Stage I Non-responders, after 30 Hyperbaric Oxygen dives.
III. Stage III: ORN Cutaneous Fistula, Pathological Fractures, Inferior Border Resorption.
THE MARX – UNIVERSITY OF MIAMI PROTOCOL
FOR OSTEORADIONECROSIS
30 HBO treatments – 2.4 ATA for 90 minutes each.
No improvement – Stage II.
STAGE I Improvement – 10 more sessions to achieve full mucosal
coverage.

Transoral Alveolar Sequestrectomy with minimal periosteal reflection

followed by primary closure.
STAGE II  Satisfactory healing – 10 more HBO sessions
 Wound breakdown – Stage III

Transoral Partial Jaw resection + Soft tissue reconstruction followed by

10 more HBO sessions.
STAGE III 1. Transcutaneous Reconstruction 10 – 12 weeks later.
2. 10 HBO treatments immediately following reconstruction.
3. Prosthetic rehabilitation 3 months later.
 • Cutaneous Fistula
• Pathological Fracture
• Resorption of Interior
Border of Mandible

STAGE I No Response STAGE II STAGE III

30 x (100% O2 Surgery (Maintain Excision of Non-Viable
for 90 minutes at • NO SURGERY Inferior Border of Bone
Mandible) No Response Fixation of the Mandibular
2.4 ATA) • NO
ANTIBIOTICS Segments
Examine • SALINE 10 x (100% O2 for 90 10 x (100% O2 for 90
Exposed Bone SOLUTION minutes at 2.4 ATA) minutes at 2.4 ATA)
RINSE ONLY

10 x (100% O2 for 90 Healing Without

minutes at 2.4 ATA Exposed Bone
Response Response
(STAGE I (STAGE II
RESPONDER) RESPONDER)
FIBRO-ATROPHIC
Theory states
The Role of
ANTIOXIDANTS in the
Management of
Osteoradionecrosis
 TOOTH EXTRACTION AFTER RADIATION
THERAPY
Recommendations in absence of HBO therapy:
1. 0.2% chlorhexidine mouthwash prior to extractions
2. Amoxicillin 3 g orally 1 h pre extraction (or if allergic 600 mg clindamycin)
3. Postoperative amoxicillin 250 mg tdsor metronidazole 200 mg tdsfor 3–5 days
4. Minimal trauma, simple extraction of mobile teeth
5. Primary closure for firm teeth, by a minimal periosteal flap and alveolectomy
6. Possibly preoperative hyperbaric oxygen for mandibular molars in areas of
high radiation
7. Review after 5 days, weekly review until healing is complete
 PREVENTION

PRE-IRRADIATION DENTAL CARE POST IRRADIATION DENTAL CARE

1. Extraction of those teeth which are in direct 1. Avoidance of Denture.

beam of radiation. 2. Maintenance of Oral Hygiene.
2. Application of Topical Fluoride, Maintenance 3. Saliva substitutes to rule out Xerostomia
of Oral Hygiene Care. induced soft tissue disorder.
3. Dose Fractionation. 4. Restoration of Teeth with post irradiation
4. Meticulous Collimation. pulpitis.
5. Replacement of Orthovoltage with Mega 5. Extraction as a Last resort.
voltage.
 REFERENCES
1. Oral Maxillofacial Infections –Topazian.
2. PowerPoint Presentation on the topic “OSTEORADIONECROSIS”
by Dr. Anupam Singh, MDS OMFS.
THANK YOU