Osteoradionecrosis

1. OSTEORADIONECROSIS

2. Introduction
 Most serious complication of radiation therapy for cancer
 Probably the first evidence of ORN related to radiotherapy
was reported by Regaud in 1922
 Its pathology was further described by Ewing in 1926,
under the name ‘radiation osteitis’
 Meyer classified ORN as one special type of osteomyelitis.
 Titterington also related ORN to osteomyelitis, providing
one of its first definitions, and used the term ‘osteomyelitis
of irradiated bone’
 Marx defined it as ‘an area greater than 1 cm of exposed
bone in a field of irradiation that had failed to show any
evidence of healing for at least 6 months’. He also clarified
that in ORN there is no intersticial infection, but only
superficial contamination

3.  1. The affected site should have been previously
irradiated;
 2. There should be absence of recurrent tumour on
the affected site;
 3. Mucosal breakdown or failure to heal should occur,
resulting in bone exposure (except in cases of bones
that lie within thick soft tissue integument’s, such as
the pelvis or femur, or rarely in cases of a
pathological fracture of the mandible after
irradiation);
 4. The overlying bone should be ‘dead’, usually due to
a hypoxic necrosis;
 5. Cellulitis, fistulation, or pathologic fracture need
not be present to be considered ORN

4. Classification of bone exposures
 Bone exposure resulting from tumor necrosis where
tumor death results in a loss of soft tissue coverage.
 bone exposure at the site of tumor during or within a
week of radiotherapy
 Bone exposure as a consequence of tumor recurrence.
 In all cases surgical resection was undertaken –tumor
recurrence
 Bone exposure resultant from oral surgical or dental
interventions.
 Extractions sites. Persistent bone necrosis due to
denture irritation
 Bone exposure de novo.
 no obvious source of trauma

5. DEFINITION
 An exposure of irradiated bone which fails to
heal with out intervention (Marx 1983)
 It is a chronic nonhealing wound caused by
hypoxia, hypocellularity, and hypovascularity
of irradiated tissue. Marx and Johnson (1987)
Clinical definition by Van Merkesteyn (1995)
 Bone and soft tissue necrosis of 6 months
duration excluding radiation induced
periodontal breakdown

6. INCIDENCE
 Before 1960 orthovoltage -ORN ranging
from 17%-37%
 megavoltage therapy is bone sparing.
 Incidence ranges from upto 10%.
 By Reuther et al the incidence was found to
be 8.2% in population of 830 individuals
investigated for over a period of 30 years
 Mandible is affected more commonly;
because most oral tumors are peri
mandibular. More extensive blood supply
in maxilla

7. Int J Oral Maxillofac Surg. 2003
Jun;32(3):289-95
 Osteoradionecrosis of the jaws as a
side effect of radiotherapy of head
and neck tumor patients--a report of
a thirty year retrospective review
 Reuther T, Schuster T, Mende U,
Kubler A.

8. Retrospective 830 pts
Incidence 8.2%
3 fold higher in Men
Body of mandible
Extraction -50%
Presurgical earlier ORN
Combined radio and chemo

9.  Bedwinek et.al T3 AND T4 lesions -
more prone
 higher tissue destruction, larger
treatment volume. No necrosis if 50-
60Gy used
 Low dosing brachytherapy higher
ORN, secondary to decay profile of a
combination of mix of alpha, beta and
gamma particle spin off.

10. Etiology
 Radiation in excess of 50Gy- kills bone cells
– osteoblasts & fibroblasts leading to
hypocellularity
 Vessels -tunica intima endarteritis,
periarteritis hyalinization and fibrosis
 Progressive obliterative arteritis.—
hypovascularity Periosteal vessels
and inferior alveolar artery involved
 Hypoxia

11.  angiogenesis and stem cell
mitogenisis -platelet derived growth
factors
 third day -under macrophage
 Migrate - excess of 20 mm of Hg.
 Radiation
shallow oxygen gradient
macrophage chemotaxis
angiogenic and fibroblast growth
factors 3-H TISSUE
wound healing

12. Radiation beam
 field effect
 greater -central beam
 tapers off -outward
 resemble a target
 center -most affected
 Healing -reduced or absent

13. Precipitating factors
 Triad
 Concept challenged by Gowgiel.
Approximately one third of ORN occur
spontaneously.
RADIATION
TRAUMA INFECTION

14. Modern concept - Marx
biochemical and cellular
pathology
ORN is radiation induced,
nonhealing hypoxic wound
rather than true osteomyelitis
or irradiated bone

15. Microbiology
 Cultures streptococci, Candida spp., and
gram negative organisms.
 When skin is affected S. aureus and
S.epidermidis.
 No organisms are found deep in bone.
 Radiation predisposes to actinomycotic
infection; because is favorable environment
for microorganism to flourish due to bone
tissue alteration

16. CLINICAL FEATURES
 Within two years
 Asymptomatic dehiscence of mucosa
 Glabrous skin
 As necrosis progresses site more
erythematous and severe, deep
burning pain
 Evidence of exposed bone

19.  Tissue surrounding may be ulcerated from
infection or recurrent tumor.
 Trismus
 Fetid breath
 Elevated temperature
 Exposed bone with a grey to yellow color
 Intraoral and extra oral fistula
 Pathological fracture

20. Radiographic changes
 Little-evident
 sequestra or involucra occur late
 radiolucent modeling -nonsclerotic
 Nuclear isotope technetium 99
methylene diphosphonate
 Bony algorithm high resolution CT

22. Histologically
 look like MICROANATOMIC DESERT
 Reduced vascularity, fibrosis

23.  Diagnosis of osteoradionecrosis
should focus primarily on ruling out
recurrent or metastatic disease.
Therefore is diagnosis of exclusion

24. MANAGEMENT

25. Protocol for preirradiation oral
evaluation
Osteoradionecrosis of jaws
 Marciani RD, Ownby H E
 J Oral Maxillofac Surg 44; 218-223;
1986

26. Post irradiation care
 Dentures should not be used for one year
 Good oral hygiene maintenance
 Fluoride therapy
 Saliva substitute to prevent dry mouth
 Pulpitis- endodontic therapy
 Atraumatic extractions –no flap or linear
closure
 Local anesthetic without adrenaline should
be used
 Antibiotic should be administered

27. Management of osteoradionecrosis
 Aim - To control frank infection
 Antibiotics
 Penicllin plus metronidazole or clindamycin
 Supportive therapy with fluids
 Pulsating irrigation device can be used.
High pressure should not be used debris
might be forced deeply into tissues
 Exposed bone can be mechanically
debrided and smoothed with round burs
and covered with a pack saturated with zinc
peroxide and neomycin

28. Conservative management of
osteoradionecrosis
J K Wong, R E Wood, Mc Lean
Triple O 1997; 84:16-21

29.  local irrigation (saline solution,
NaHCO3, or chlorhexidine), systemic
antibiotics in acute infectious
episodes, avoidance or irritants and
oral hygiene instruction.
 Simple management refers to the
gentle removal of sequestra in
sequestrating lesions
 Had 48% success rates

30.  Treatment of small areas with drilling
multiple holes into vital bone is
recommended by Hahn and Cargill
(1967) to encourage sequestration.
 Daland (1949) advised electro
coagulation of exposed bone to
expedite sequestration and drainage
of subcutaneous abscesses to prevent
sloughing of skin.

31. Treatment of osteonecrotic
wounds
 Rule out neoplastic disease
 Stabilize the patient medically
especially nutritional status
 Preoperative hyperbaric oxygen
 Debridement of necrotic mass
 Postoperative hyperbaric oxygen
 Soft tissue vascular flap support
 Bony reconstruction

32. Ultra sound therapy
 Is non invasive and reportedly
promotes neovascularity and
neocellularity of ischemic tissues

33.  Major healing of refractory mandible
osteoradionecrosis after treatment
combining pentoxifylline and
tocopherol: a phase II trial.
 Head Neck. 2005 Feb;27(2):114-23.
 Delanian S, Depondt J, Lefaix JL

34. Effective in reversing fibronecrotic
process
 Eighteen patients
 a daily oral combination of 800 mg of
PTX and 1000 IU of vitamin E for 6 to
24 months
 In addition, the last eight patients
who were the worst cases were given
1600 mg/day clodronate 5 days
 at 6 months, with 84% healing

35. HYPER BARIC
OXYGEN
THREAPY

36. DEFINITION
 Short term -100% oxygen
inhalation therapy at a pressure
greater than that of sea level. The
pressure is usually about 2.4 absolute
atmospheres or ATA.

37.  Greenwood and Gilchrist (1973) were
the first to report beneficial effects of
HBO on wound healing in post RT.
 1975 – Mainous and Hart – 14 cases of
refractory ORN of mandible treated with
HBO and hemimandibulectomy
 1981 Mansfield reported complete
healing with HBO
 1993 McKenzie reported resolution of
ORN following HBO in 69% patients

38. USES
Decompression sickness
Elective surgery to prevent
clinical radiation necrosis
Treatment of
osteoradionecrosis
Non healing diabetic ulcers

39. Mechanism
 Partial reversal of 3-H tissue
 physical mechanism
 dissolution of oxygen into blood
 80-100 mm Hg range to 1000-1200 mm Hg
 HBO elevates the PAO2
 irrespective of hemoglobin
 O2 gradients -radiated tissue from 50 to 250
mm Hg-macrophage activity

40.  Angiogenic and fibroblastic
effects- collagen synthesis crucially
depends on the availability of
molecular O2 that incorporates into a
peptide chain to form hydroxyl propyl
and hydroxyl lysyl residues.

41.  HBO inhibits inflammation through
direct bactericidal effects on
anaerobes due to increased
production of free radical and toxic
products
 HBO enhances phagocytic killing by
WBC (Parl 1994)

42. Stage I
30 x (100% O2 for 90 mins at 2.4 ATA)
Examine exposed bone
No surgery cutaneous fistula
No antibiotics
Rinsing only pathologic fracture
resorption of Inferior border
of mandible
Response
no response
10x (100% O2 for
90 mins at 2.4 ATA)
Stage I responder
Stage II
Stage III

43. Stage II
Surgery maintain inferior border
10x (100% O2 for 90 mins at 2.4 ATA)
Response no response
Stage II responder
Healing with out
exposed bone
stage III
Excision of nonviable bone
Fixation of mandibular
segments 10x (100% O2 for
90 mins at 2.4 ATA)
Reconstruction
after three
monthsNo HBO Required

44. Protocol of hyperbaric oxygen
for elective surgery.
 20 sessions of hyperbaric oxygen
prior to elective surgery, followed
by 10 sessions after surgery
 100% oxygen at 2.4 atmospheric
pressure or ATA for 90 treatment
minutes
 single person chambers 120
treatment minutes

45.  The elective surgery protocol is used
in all elective surgery in radiated
tissue, which may range from tooth
extraction, to bone graft
reconstruction to vascularized
pedicled and free anatomic transfers
 effects of hyperbaric oxygen are
permanent,

46. Absolute contraindication
 Optic neuritis – exacerbation of
retinal inflammation and hyperemia
 Immunosuppressive disorders-
reports of viral encephalitis

47. Relative contraindication
 Chronic obstructive pulmonary
disease
 Bullous lung change and significant
CO2 retention
 Claustrophobia.
 Acute respiratory infections
 Surgery induced Eustachian tube
dysfunction

48. Hyper baric oxygen in therapeutic
management of osteoradionecrosis
of facial bones
S Vudiniabola, P J Williamson, A N
Goss
Int J Oral Maxillofac Surg 2000;
29:435-438

49.  Have reviewed 17 cases of facial bone
osteoradionecrosis treated according
to Marx protocol plus or minus
surgery
 Dental extraction was the cause in 9
cases.
 Three cases of temporal bone ORN
were of spontaneous onset.
 All were stage I responded well to
HBO

50. FREE OMENTAL TRANSFER FOR
ORN OF MANDIBLE
 Int J Oral Maxillofac Surg
2000 :29:201-206
 K.Wataru, K Makoto et.al

51.  Omentum is an intra abdominal organ
rich in vascular and lymphatic plexus.
 McLEAN &BUNCKE first to use greater
omentum
 Moran and Panje use it for ORN of
mandible.
 4 cases treated with same no
recurrence

52. Advantages
 The natural mandibular contour and
continuity can be preserved
 Can be used regardless of size of
defect
 No need for bone grafting
 Short procedure compared to
osteocutaneous flaps

53. CONCLUSION
 ORN is best defined as a slow healing
radiation induced ischemic necrosis of
bone with associated soft tissue
necrosis of variable extent occurring
in absence of local primary, tumor
necrosis, recurrence or metastatic
disease that may or may not

54.  Be super infected
 And companied by fistulation
 End in pathologic fracture
 Resolve with out surgery HBO or both

55. THANK YOU