Mandibulectomy and free flap reconstruction for bisphosphonate-related osteonecrosis of the jaws

IMPORTANCE: Bisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy. Our experience suggests that mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 disease. OBJECTIVE: To analyze indications for segmental mandibulectomy and microvascular free flap reconstruction for bisphosphonate-related osteonecrosis of the jaws and surgical outcomes following this procedure. DESIGN, SETTING, AND PARTICIPANTS: In a multi-institutional case series study conducted in academic tertiary care centers, 13 patients underwent segmental mandibulectomy and microvascular free flap reconstruction, including 8 patients with stage 3 disease and 5 patients with recalcitrant stage 2 disease. All patients had persistent or progressive disease despite conservative oral care and antibiotic treatment. INTERVENTIONS: Segmental mandibulectomy and microvascular free flap reconstruction. MAIN OUTCOMES AND MEASURES: Treatment efficacy and postoperative complications. RESULTS: There was 1 total flap loss due to infection. The patient with a flap loss ultimately underwent a successful fibula osteocutaneous free flap reconstruction after serial irrigation and debridement. The overall complication rate was 46%(n = 6). All complications occurred in patients with stage 3 disease. Ultimately, all patients achieved a successful reconstruction, with no recurrences. All patients tolerated a soft or regular diet postoperatively. CONCLUSIONS AND RELEVANCE: Bisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy that can occasionally progress to involve full-thickness mandibular destruction, pathologic fracture, and fistulization, as well as chronic pain and infection. Mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 bisphosphonate-related osteonecrosis of the jaws. High rates of chronic infection and underlying medical comorbiditiesmay predispose to a substantial perioperative complication rate.