Introduction
The Role of Surgical Resection in the Management of Bisphosphonate-Related Osteonecrosis of the Jaws

https://doi.org/10.1016/j.joms.2009.01.006Get rights and content

Purpose

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a poorly understood pathologic entity from the standpoints of its nomenclature, frequency, pathogenesis, and best method of treatment. In particular, numerous recommendations have been made for treatment involving nonsurgical therapy. It is the purpose of this article to specifically examine the success of resection of the necrotic bone in the mandible and maxilla in these patients.

Patients and Methods

We identified 103 sites of BRONJ in 82 patients. Of these sites of osteonecrosis, 32 were in the maxilla and 71 were in the mandible. Of the patients, 30 were taking an oral bisphosphonate medication whereas 52 were taking a parenteral bisphosphonate medication. Resection was performed in 95 sites of osteonecrosis in 74 patients, whereas 8 sites diagnosed in 8 patients were not resected. A total of 27 sites of BRONJ were resected in patients treated with oral bisphosphonates, and 68 sites of BRONJ were resected in patients treated with parenteral bisphosphonates.

Results

Of the 95 resected sites, 87 (91.6%) healed in an acceptable fashion with resolution of disease. Of 27 resected sites in patients taking an oral bisphosphonate medication, 26 (96.3%) healed satisfactorily, with refractory disease developing in 1 site. Of 68 resected sites in patients taking a parenteral bisphosphonate medication, 61 (89.7%) healed satisfactorily, with refractory disease developing in 7 sites. All 29 patients (100%) undergoing resection of the maxilla related to either an oral or parenteral bisphosphonate healed acceptably. The 8 patients who had the development of refractory disease did so with a range of 7 to 250 days postoperatively (mean, 73 days). Of the 8 sites of refractory disease, 6 developed after a marginal resection of the mandible for BRONJ. Three sites of new primary disease developed in 2 patients postoperatively. Both patients were taking a parenteral bisphosphonate medication. Histologic examination of the resected specimens identified malignant disease in 4 specimens in 3 patients.

Conclusion

Resection of BRONJ permits acceptable healing in patients taking an oral bisphosphonate medication. In addition, resection of BRONJ of the maxilla in patients taking an oral or parenteral bisphosphonate medication follows a predictable course with regard to healing. Resection of BRONJ of the mandible in patients taking a parenteral bisphosphonate medication follows a variable postoperative course, although a high degree of success is realized. Surgeons should consider resection of necrotic bone of the maxilla and mandible that develops in patients taking bisphosphonate medications. In addition, refractory disease can be successfully managed with a more aggressive resection, specifically, a segmental resection of the mandible after a marginal resection of the mandible where refractory disease developed.

Section snippets

Patients and Methods

This prospective analysis involves a review of patients with a clinical and radiographic diagnosis of BRONJ. A total of 103 sites of osteonecrosis were identified in 82 patients who were referred to the senior author (E.R.C.) for management (Table 1). Of the patients examined, 24 were men and 58 were women. Of the patients, 25 were taking Fosamax; 2 were taking Fosamax followed by Actonel; 3 were taking Actonel; 29 were taking Zometa; 10 were taking Aredia; 10 were taking Aredia followed by

Results

Of the 95 sites resected, 87 sites (91.6%) healed in a satisfactory fashion with resolution of disease, including 26 of 27 sites (96.3%) in patients taking an oral bisphosphonate medication and all 29 sites (100%) in patients undergoing resection of the maxilla. Resolution of disease was defined as maintenance of the mucosal closure without signs of residual infection or exposed bone at the time of evaluation. Of the 68 sites resected in patients who had been treated with Aredia or Zometa, 61

Discussion

This study indicates that resection of necrotic bone associated with bisphosphonate medications is effective in resolving this disease process. In particular, the striking revelation is that bisphosphonate-related osteonecrosis of the mandible and maxilla associated with oral bisphosphonates is very responsive to properly performed resection surgery. In addition, resection of the maxilla in patients with BRONJ associated with either oral or parenteral bisphosphonates is met with significant

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    Dr Carlson is a paid consultant for Novartis. Dr Basile states no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this article.

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    Copyright © 2009 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.