Search Results (75)

Background/Objectives: This retrospective study evaluated whether the association between post-CCRT dental extraction timing and osteoradionecrosis of the jaw (ORNJ) risk is modified by mandibular radiation exposure in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) treated with definitive concurrent chemoradiotherapy (CCRT). Methods: A total of 247 patients who did not undergo pre-CCRT dental extraction but underwent post-CCRT extraction were analyzed. Mandibular radiation exposure was quantified using EQD2. Associations between clinical, tumoral, dental, and dosimetric variables and ORNJ were assessed using multivariable logistic regression, including assessment of EQD2–timing interaction. ROC analyses were performed to evaluate discriminative performance and estimate exploratory thresholds. ORNJ developed in 23 patients (9.3%). Mandibular EQD2 was independently associated with ORNJ risk (OR 2.10 per 5 Gy; 95% CI 1.40–3.15; p < 0.001). A significant interaction between EQD2 and extraction timing was observed (OR 1.07; 95% CI 1.03–1.11; p = 0.023). EQD2 demonstrated excellent discrimination (AUC 0.885; cutoff 46.5 Gy), whereas extraction timing showed modest discrimination (AUC 0.691; cutoff 10 months). At <46.5 Gy, ORNJ rates remained low regardless of timing (1.0% vs. 3.9%). At ≥46.5 Gy, delayed extraction was associated with substantially higher ORNJ incidence (31.1% vs. 11.3%). Number of extracted teeth (OR 1.16; p = 0.012) and hemoglobin level (OR 0.62; p = 0.007) were also independent predictors. Conclusions: The effect of post-CCRT dental extraction timing on ORNJ risk is modified by mandibular radiation dose, supporting interpretation in conjunction with mandibular radiation exposure rather than as an isolated factor. Full article

Background and Objectives: Osteonecrosis of the jaw (ONJ) occurring after infection with SARS-CoV-2 has emerged as an increasingly reported complication in the post-COVID-19 era. Post-COVID-19 osteonecrosis of the jaw (PC-ONJ) has been described in association with both COVID-19-associated mucormycosis (CAM) and non-fungal phenotypes. This narrative review aims to synthesize and critically analyze the available evidence regarding terminology and classification, epidemiology and risk factors, pathophysiological mechanisms, clinical and imaging characteristics, diagnostic challenges, and management strategies relevant to oral and maxillofacial surgery practice. Materials and Methods: An extensive literature search was conducted in the PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect, and Google Scholar databases. The search targeted peer-reviewed publications published between 2020 and 2025, reflecting the post-pandemic emergence of this clinical spectrum. Original studies, systematic and narrative reviews, multicenter case series, consensus guidelines, and well-documented case reports were considered. Results: Available data, largely derived from case reports and small series, demonstrate a predominance of maxillary involvement and frequent association with diabetes mellitus and systemic corticosteroid therapy. Proposed mechanisms include COVID-19-associated endothelial dysfunction, microvascular thrombosis, immune dysregulation, metabolic imbalance, and treatment-related effects. Clinically, patients may present with persistent orofacial pain, tooth mobility, exposed or probeable bone, and frequent sinonasal extension, with symptoms sometimes preceding bone exposure. Diagnostic challenges arise from the overlap with medication-related osteonecrosis of the jaw (MRONJ), osteoradionecrosis (ORN), and chronic osteomyelitis. Imaging is essential for assessing disease extent but remains insufficient for etiologic differentiation, making histopathological examination and targeted microbiological investigations necessary, particularly to exclude invasive fungal infection. Conclusions: Management must be etiology-driven. CAM requires urgent antifungal therapy combined with surgical debridement, whereas non-fungal forms are generally managed with conservative surgery and appropriate antimicrobial stewardship. Standardized diagnostic criteria and prospective multicenter studies are needed to reduce nosological ambiguity and optimize clinical decision-making in this emerging post-viral condition. Full article

Background and Objectives: Orbital exenteration performed for advanced malignancies often results in complex defects that are difficult to reconstruct, particularly in patients treated with adjuvant radiotherapy who subsequently develop osteoradionecrosis. This study describes the preliminary results of a surgical technique for secondary orbital reconstruction using a combined scalp flap and temporalis muscle flap (TMF), referred to as the “Pacman flap with tongue,” performed prior to prosthetic rehabilitation. Materials and Methods: Five elderly patients with multiple comorbidities and osteoradionecrosis following orbital exenteration and radiotherapy underwent secondary orbital reconstruction using the “Pacman flap with tongue” technique. The clinical outcomes, flap viability, complications, and feasibility of subsequent prosthetic rehabilitation were assessed. After stabilization of healing, digitally planned ocular epitheses were fabricated using cone-beam computed tomography (CBCT), computer-aided design, and three-dimensional printing. Results: Healing was uneventful in all patients. No flap necrosis, wound dehiscence, or recurrent bone exposure was observed. The reconstructed orbital sockets provided a stable, well-vascularized prosthetic bed, enabling satisfactory prosthetic rehabilitation. Conclusions: The “Pacman flap with tongue” may be considered a feasible option for secondary orbital reconstruction in selected high-risk patients, particularly in the setting of osteoradionecrosis. Full article

Segmental mandibular resection may be indicated as a treatment in, for example, advanced stages of oral squamous cell carcinoma (OSCC). Osseous reconstruction of these defects is a fundamental part of static and dynamic masticatory rehabilitation, particularly when dental implants are required. The Segmental Mandibular Defect Reconstruction (SMDR) Registry aims to generate real-world evidence on SMDR through an international, prospective, multicentre case series designed as a registry. While OSCC is a common indication for segmental mandibular resection, the SMDR Registry also aims to capture outcomes for rarer mandibular conditions and the increasing number of collateral damage cases resulting from systemic medication therapies (antiresorptive drugs, immunotherapeutics) or irradiation, which may likewise lead to medication-related osteonecrosis of the mandible (MRONJ) or osteo(radio)necrosis with tumour-like segmental resection of the mandible, highlighting the value of an international database for these less frequent pathologies. Primary objectives are to describe the patient population and current treatment modalities, describe the outcomes and adverse events (AEs) for different treatment modalities, and identify potential predictors for successful autologous reconstruction of SMDs. Approximately 300 patients with a mandibular lesion resulting from bisphosphonate- and immunomodulatory drug-induced osteonecrosis of the mandible, ameloblastoma or osteosarcoma of the mandible, oral metastases related mandibular lesions indicated for segmental resection, or OSCC undergoing SMDR or intending to undergo one- or two-stage reconstruction will be prospectively recruited over a 36-month period. Baseline information, treatment details, and outcome measures will be documented. All treatments will be per the usual practice at participating sites. Outcome measures include clinical, patient-reported, and radiological outcomes; AEs related to the condition and/or treatment with a possible influence on the outcome will be recorded. Full article

Background: Oral complications are common in cancer patients, especially those with head and neck cancers. Patients who have been exposed to radiotherapy for their head and neck cancers endure considerable short- and long-term complications. Methods: A scoping review following the ScR and OSF registries protocol was conducted in MEDLINE/PubMed, Embase, Cochrane, Scopus, LILACS, and Web of Science to identify relevant articles from 1993 to 30 June 2025. Inclusion criteria covered clinical trials, case series, prospective and retrospective studies, and diagnostic investigations. Figures were taken from the treated patients after their consent. Results: Radiotherapy-induced oral complications include, but are not limited to, periodontitis, oral mucositis, xerostomia, fibrosis and trismus, dental caries, oropharyngeal candidiasis, burning mouth syndrome, and osteoradionecrosis. Conclusions: An integrated, collaborative, multidisciplinary approach to managing these patients should be implemented to reduce these toxicities and their impact on patients’ vitality and quality of life. This review discusses the main oral complications of radiotherapy in patients with head and neck cancers and summarizes the updated management approaches for these complications. Full article

Introduction: Stage three osteonecrosis of the jaw (ONJ), whether medication-related (MRONJ) or osteoradionecrosis (ORN), often necessitates aggressive surgical management due to extensive necrosis, infection, and risk of pathologic fracture. While free flap reconstruction remains the gold standard post-segmental mandibulectomy, it may not be feasible for elderly or systemically compromised patients. Objective: The presentation of our own experience with advanced mandibular ONJ on patients managed exclusively with a contemporary titanium reconstruction plate system and to evaluate the clinical outcomes of this approach in the context of the current literature. Methods: From a group of 21 patients treated for ONJ, just four patients with Stage 3 MRONJ or Grade III ORN, unfit for microvascular surgery, underwent segmental mandibulectomy followed by alloplastic reconstruction using standard titanium plating. Outcomes were assessed clinically and radiographically over a follow-up period ranging from 3 to 20 months. A focused literature review was conducted to contextualize results. Results: All patients demonstrated stable reconstruction without plate exposure, fracture, or intraoral bone exposure during follow-up. Esthetic and functional outcomes are reported. No hardware complications were reported. The review of the literature supports plate-only reconstruction as a valid alternative for patients unsuitable for free flap surgery, especially when using rigid, anatomically adaptive systems with robust soft tissue coverage. Conclusions: Titanium plate–only reconstruction following segmental mandibulectomy can provide reliable short- to mid-term outcomes in selected patients with advanced ONJ. Used titanium plating systems appears to be a promising option. Full article

Background: Osteoradionecrosis (ORN) following head and neck radiotherapy has been demonstrated to induce structural and functional alterations of the upper airway, with the potential to complicate the process of tracheal intubation. Despite its clinical relevance, there is a paucity of systematic evidence on airway characteristics in ORN and reliable predictors of difficult tracheal intubation. This study compares preoperative airway parameters and tracheal intubation outcomes in irradiated patients with and without ORN and introduces a novel preoperative ORN-Difficult-Airway Score for risk stratification. Methods: In this retrospective cohort study, airway assessments, tracheal intubation methods, and perioperative visualization parameters were evaluated in 105 patients following head and neck radiotherapy. Group differences between non-ORN and ORN were analyzed using chi-square tests. A preoperative ORN-Difficult-Airway Score was constructed using exclusively bedside parameters, based on statistically and clinically relevant predictors. Results: Patients with ORN showed significantly restricted mouth opening (p < 0.001), higher Mallampati classes, particularly Mallampati IV, and a greater need for fiberoptic tracheal intubation (p < 0.01). Direct laryngoscopy (DL) was significantly less feasible in ORN, while hyperangulated videolaryngoscopy (VL) yielded consistently positive visualization (first-pass success (FPS) 100% in both groups). Under DL, FPS was lower in ORN (54.2% vs. 79.5%), resulting in an odds ratio of 0.305. Based on observed predictors, ORN status, mouth opening <3 cm, Mallampati class, restricted neck reclination, and history of difficult intubation, a preoperative ORN-Difficult-Airway Score was developed. Conclusions: ORN has been associated with distinct alterations in airway anatomy and visualization, resulting in increased tracheal intubation complexity after head and neck radiotherapy. The proposed ORN-Difficult-Airway Score presents a clinically practical, bedside-applicable approach to stratifying the risk of tracheal intubation in this population. Prior to clinical implementation, prospective validation in larger cohorts is warranted. Full article

Survival rates for children treated for malignant diseases continue to improve, yet many survivors face persistent late oral complications that affect function, aesthetics, and quality of life. Oncological therapy, especially at a young age and following head and neck radiotherapy or intensive chemotherapy, can disrupt dental and craniofacial development, resulting in dental developmental disorders, enamel defects, salivary gland dysfunction, caries susceptibility, periodontal problems, trismus, and osteoradionecrosis of the jaw. Although these effects are partially known, they are frequently underrecognized in routine practice, and many children do not receive adequate long-term dental follow-up. A key challenge highlighted in the recent literature is the absence of structured, evidence-based guidelines for monitoring and managing late oral effects. The article emphasizes the need for clearer recommendations, better communication of oncological treatment histories, and stronger integration of dental professionals within survivorship care. Developing standardized follow-up protocols will be essential to ensure timely detection, consistent management, and improved oral health outcomes for childhood cancer survivors. This article is intended as a narrative review, synthesizing available evidence from key publications to highlight clinically relevant late oral complications and gaps in current survivorship care. Full article

Background: Hyperbaric oxygen therapy (HBOT) is considered a potential adjunctive modality to enhance tissue regeneration in oral and maxillofacial surgery. By increasing tissue oxygen availability, HBOT may support bone and soft-tissue repair under hypoxic and chronically inflamed conditions. Aim: This narrative review evaluates current experimental and clinical evidence regarding HBOT in high-risk dental indications, including osteoradionecrosis (ORN), medication-related osteonecrosis of the jaw (MRONJ), chronic osteomyelitis, poorly healing postoperative wounds, and procedures in patients with systemic comorbidities. Methods: A structured search of PubMed, Web of Science, and the Cochrane Library identified 123 relevant English-language publications (from 1 January 2000–September 2025) addressing HBOT mechanisms and clinical applications in oral and maxillofacial surgery, including clinical trials, observational studies, preclinical models, and systematic reviews. Results: Available evidence suggests that HBOT may improve healing outcomes and reduce complication rates in early-stage ORN and MRONJ when used as an adjunct to surgery and systemic therapy. However, findings in implantology—particularly in irradiated or diabetic patients—and in periodontal therapy remain limited, heterogeneous, and methodologically inconsistent. Conclusions: HBOT may be considered in selected clinical scenarios, particularly where healing is impaired by hypoxia or systemic disease. Nevertheless, current evidence remains insufficient to support routine use. Standardized, high-quality studies with clearly defined endpoints and uniform therapeutic protocols are needed to determine its clinical effectiveness and optimal indications. Full article

Background: Osteoradionecrosis (ORN) of the jaw is a severe, progressive complication of radiation therapy for head and neck malignancies. ORN features radiologically overlaps osteomyelitis and tumor recurrence. This study analyzes jaw ORN imaging characteristics and progression and proposes an ORN CT-based grading system that builds on current ClinRAD grades. Materials and Methods: A retrospective cohort study of 35 patients with biopsy-proven or clinically diagnosed ORN following radiation therapy. Initial and follow-up imaging were assessed to evaluate the radiological evolution of ORN. The imaging findings were statistically analyzed using IBM SPSS v26, and literature comparisons were made. Results: The median onset of ORN post-radiotherapy was 27–28 months (range: 2–119 months). The most common clinical presentations included non-healing ulcers (49%), pain (34%), and discharging sinuses (31%). Mandibular involvement was predominant (51%), with focal bone alterations being more frequent (63%). CT findings at clinical suspicion of ORN included resorption (100%), erosions (100%), sclerosis (86%), and fragmentation (83%). Follow-up imaging showed increased bone erosion (77%), fragmentation (92%), and sclerosis (92%). A CT-based grading system is proposed to classify ORN progression. Conclusions: ORN follows a predictable radiological progression, beginning with trabecular resorption and cortical erosion, leading to fragmentation and sequestrum formation. The proposed grading system provides a structured approach for early diagnosis. The proposed grading system provides a structured approach for diagnosis. Larger studies of imaging analyses are required to validate these findings and refine diagnostic criteria. Full article

Radiotherapy is a fundamental component in the management of head and neck malignancies, but its non-selective effects on surrounding normal tissues can result in significant oral complications. The oral cavity and oropharynx contain several radiosensitive structures, including mucosa, salivary glands, and alveolar bone, which are susceptible to both acute and late toxicities resulting in mucositis, xerostomia, and osteoradionecrosis. Although dentomaxillofacial diagnostic imaging, such as intraoral radiography, panoramic imaging and cone-beam computed tomography (CBCT), delivers radiation doses several orders of magnitude lower than therapeutic exposures, its biological impact on previously irradiated tissues remains underexplored. Even low-dose X-rays may act as secondary stressors, reactivating oxidative and inflammatory pathways in tissues with compromised repair capacity. In this review, we examine the radiobiological and dosimetric implications of using diagnostic ionizing imaging in patients undergoing or recently having completed head and neck radiotherapy. We summarize current evidence on potential additive effects of low-dose imaging, emphasizing the importance of justification, timing, and protocol optimization. Finally, we discuss radioprotective strategies (e.g., dose modulation, field limitation, and integration of modern low-dose imaging technologies) designed to reduce unnecessary exposure, thus enhancing tissue preservation and ensuring diagnostic safety in this vulnerable patient population Full article

Background: Oral squamous cell carcinoma (OSCC) is the most common malignancy of the oral cavity, often necessitating extensive surgical resection. Such interventions may result in complex intraoral defects requiring immediate reconstruction to restore function and aesthetics. Objective: This case report highlights the surgical management of a patient with OSCC involving the tongue, floor of the mouth and mandibular ridge, reconstructed using a radial forearm free flap (RFFF). Case report: A 51-year-old male with a history of heavy smoking presented with a necrotic lesion affecting the left mandibular alveolar ridge, floor of the mouth, and tongue. Methods: Histopathological examination confirmed a diagnosis of moderately differentiated keratinizing OSCC (G2). After oncologic resection and selective neck dissection, the defect was reconstructed using an RFFF harvested from the left forearm. The facial artery and anterior jugular vein served as recipient vessels for microvascular anastomosis. A split-thickness skin graft (STSG) was used to close the donor site. Results: The postoperative course was generally favorable. Minor complications, including a localized hematoma and neck wound dehiscence, were conservatively managed. Functional outcomes such as oral intake and wrist mobility were successfully restored with rehabilitation. The RFFF provided durable, well-vascularized coverage over exposed mandibular bone, critical for minimizing the risk of osteoradionecrosis in the context of planned adjuvant radiotherapy. Conclusions: The radial forearm free flap remains a reliable reconstructive option for complex oral defects post-OSCC resection. Multidisciplinary collaboration and meticulous surgical technique are essential to achieve optimal oncologic, functional, and aesthetic outcomes. Full article

Objective: This study aims to evaluate the management and outcomes over 14 years at a tertiary maxillofacial surgery unit. Methods: Retrospective cohort study of patients from a Portuguese tertiary center of maxillofacial surgery with histopathologically confirmed diagnoses of chronic osteomyelitis of the jaws between January 2010 and December 2023. Demographic and clinical characteristics, treatment, and progression of the disease were evaluated. Results: Fifty-three patients were included—28 women (52.8%), mean age 55 (95% CI 5–90) years. The mandible was affected in 84.9% (n = 45) of cases. Secondary chronic osteomyelitis was diagnosed in 88.7% (n = 47), with medication-related osteonecrosis of the jaw (MRONJ) being the most common etiology (38.3%). Bacteriological samples were contributory in 52% (n = 13) and 46.1% (n = 6) were resistant to amoxicillin. All received antibiotics for a median time of 27.3 days. Surgical treatment included sequestrectomy (n = 40, 75.5%), marginal (n = 5, 9.4%), and segmental mandibulectomy (n = 8, 15.1%). Clinical remission was achieved in 77.4% (n = 41) of cases with higher success in MRONJ (n = 15, 83.3%) than ORN (n = 4, 57.1%). Conclusions: Almost half of the isolates were amoxicillin-resistant, reinforcing the need for susceptibility testing. Surgical management guided by etiology and disease stage remains essential, with more extensive resection needed in MRONJ and ORN. Full article

Background: Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a functional imaging modality that can quantify tissue permeability and blood flow. Due to vasculature changes resulting from radiation therapy (RT), DCE-MRI quantitative parameters should be significantly different in regions receiving a high radiation dose compared to regions receiving a low radiation dose. This study sought to determine whether a significant difference exists in post-head-and-neck-cancer (HNC)-RT DCE-MRI quantitative parameters (K^trans and v_e) between regions of the mandible receiving a high radiation dose and regions of the mandible receiving a low radiation dose. Methods: DCE-MRI was acquired from HNC subjects post-RT. The DCE-MRI quantitative parameters K^trans and v_e were obtained through Tofts model fitting. Four mandible sections (left ramus, left body, right ramus, and right body) were delineated on subject mandible contours. Two Friedman tests comparing the mean K^trans and v_e in low-dose (≤60 Gy) areas of the four mandible regions were computed. If the Friedman test determined that a significant difference for a parameter between mandible regions exists, post hoc Wilcoxon signed-rank tests were completed comparing the four mandible regions. If the Friedman test determined that there was no significant difference between mandible regions, a Wilcoxon signed-rank test was used to determine whether a significant difference exists in the parameter between high-dose (>60 Gy) and low-dose (≤60 Gy) mandible regions. Results: 48 HNC subjects were included in the analysis. The Friedman tests showed no significant difference in v_e means between mandible regions (${\chi }_{\left(3\right)}^2$ = 1.63, p = 0.44) and a significant difference in K^trans means between mandible regions (${\chi }_{\left(3\right)}^2$ = 10.29, p = 0.005). Post hoc testing between K^trans mandible regions found that the left body and right body differed significantly from the left ramus and right ramus. The Wilcoxon signed-rank test comparing the mean v_e between high- and low-dose mandible regions found a significant difference (W = 214, p = 0.00013). Conclusions: no inherent difference in the DCE-MRI quantitative parameter v_e was observed within subject mandibles, but a significant difference was observed between v_e means in high- and low-radiation-dose mandible regions. These results provide evidence of the utility of DCE-MRI to monitor mandible vasculature changes resulting from head and neck cancer radiation therapy. Monitoring post-HNC-RT mandible vasculature changes is important to initiate earlier toxicity management and ultimately improve HNC survivors’ quality of life. Full article

Background: Radiation-induced lower motor neuron syndrome (LMNS) represents a rare but significant delayed complication of oncologic treatment. Methods: We present the case of a 56-year-old female who developed LMNS, myokymia, and osteoradionecrosis of the hip nearly two decades after receiving pelvic radiation therapy for cervical carcinoma. To the best of our knowledge, no previous reports have described this particular triad of neurological and tissue changes following radiation therapy. This clinical presentation is analyzed within the framework of a systematic review encompassing 58 documented cases, including our own. Results: The database searches yielded 530 records. In total, 32 studies were included in the qualitative synthesis, reporting 57 unique cases of post-radiation LMNS. With the addition of our present case, the final analysis comprised 58 cases. The majority of analyzed patients were male (77.2%), and the most frequent primary malignancies were germ cell tumors (57.9%). The mean age of the analyzed patients at symptom onset was 40.5 ± 13 years, with radiotherapy administered at a mean age of 30.3 ± 12.5 years. The latency period between radiation exposure and the emergence of neurological symptoms averaged 10.2 ± 8.7 years. The mean cumulative radiation dose was 49.0 ± 14.0 Gy. Myokymic discharges were identified in 6 patients (10.3% of cases). Comparative analysis revealed no significant clinical or radiological differences across malignancy subtypes in the manifestation of post-radiation LMNS. Conclusions: These findings highlight the need for long-term surveillance of irradiated patients. Full article