Maxfacts

Bone necrosis (osteonecrosis) in the head & neck region often occurs in combination with necrosis of adjacent soft tissues such as the skin or the lining of the mouth (mucosa).

The treatment options for hard tissue necrosis include:

• Conservative treatment of small lesions, relying on meticulous oral hygiene, aseptic mouthwashes (including chlorhexidine as the active ingredient), and elimination of all potential irritants, such as ill-fitting dentures. A course of systemic antibacterial medication may be part of the treatment plan. Most small such lesions heal over a period of 6 to 12 months with this kind of management regime.
• Slightly more extensive necrotic bone lesions with more significant exposure of necrotic bone require local débridement (removal of the necrotic bone piece(s) (called a sequestrum)) and application of a pack to the defect to support healing. Suitable such packs may be fleece soaked with an antibacterial agent or simple gauze soaked in an antiseptic agent (usually iodine based) such as bismuth iodoform paraffin paste (BIPP), iodine solution or variations thereof.
• Complicated (and controversial) medication schemes (PENTOCLO; consisting of a cocktail of pentoxifylline (a drug to improve tissue oxygen supply by improved blood flow), tocopherol (a vitamin E derivative with antioxidative properties) and clodronate (a bisphosphonate, an antiresorptive agent to reduce bone resorption – which itself is known to increase the risk of bone necrosis)) have been suggested for the conservative treatment of osteoradionecrosis, ORN.
• More extensive surgical débridement with water tight (and thus saliva tight) seal may be necessary. If suitable (vascularised) local soft tissue is available, a local flap may provide such a seal. If no suitable local soft tissue can be used, depending on the individual case, a regional or a free soft tissue flap may be suitable.
• For the treatment of persistent and extensive osteonecrosis of the jaws, mostly the mandible, the strategies may have to be escalated to major surgical resection of all necrotic bone sections and appropriate reconstruction with free bone flaps.

The most appropriate treatment scheme(s) for osteonecrosis are not only dictated by the extent and location of the lesion(s) as the above list of escalating treatment options may suggest. The underlying cause is another important factor for choosing the best possible treatment scheme, alongside considerations of general fitness for major surgery and, in some circumstances, life expectancy.

At the time of writing (2018), the most common causes of bone necrosis in the maxillofacial region are radiotherapy applied to the head & neck region (osteoradionecrosis, ORN), and various medication-treatment schemes with antiresorptive agents for the management of various bone conditions such as osteoporosis, bone metastases, or primary bone malignancies (medication-related osteonecrosis of the jaws, MRONJ). With these two risk factors well documented and severe osteonecrosis being a debilitating condition, any (improved) prevention is the preferred option whenever possible.