Management of medication-related osteonecrosis of the jaw according to the clinical grade: An analysis of 19 cases

Abstract

Introduction: Bisphosphonates are a family of drugs used to inhibit bone resorption. One of their secondary effects is osteonecrosis of the jaws (ONJ). In 2010, scientists began to publish cases of osteonecrosis of the jaws associated with a new drug, denosumab. In 2014 it was recommended to change the name of ONJ to medication-related osteonecrosis of the jaws (MONJ). The aim of this article is to review a case series of MONJ treated in our Department, and present our experience in the different treatment options according to the clinical classification defined by the American Association of Oral Maxillofacial Surgeons (AAOMS). Materials and methods: A retrospective review was performed on 19 patients with MONJ, who were managed between 2005 and 2015. The clinical staging was according to the classification of the AAOMS and Ruggiero. The lesions were treated according to their clinical and radiological presentation. Results: The mean age was 75 years. The underlying disease was osteoporosis in 11 patients (58%), prostate cancer in 2 patients (11%), breast cancer in 2 patients (11%), and multiple myeloma in 4 patients (20%). Intravenous bisphosphonates were used in 9 (47%) patients, and oral in the remaining 4 (alendronate and ibandronate, 21%), with denosumab being administered subcutaneously. Stage 3 patients were treated in all cases with segmental mandibulectomy. Three of them were re-constructed with a microsurgical fibula flap, and onw with bar and direct closure. Sequestrectomy was used to treat 7 patients, of which 5 had stage 2, and 2 stage 1. One patient with stage 1 was treated with local debridement. Conservative treatment was applied to the rest (4) of the stage 1 patients, and 3 stage 2 patients. Discussion: Mandibulectomy is an effective treatment for stage 3, sequestrectomy for stage 2, and conservative measures for stage 1. This pathology is also associated with other drugs, such as denosumab, which is why the term had changed to medication-related osteonecrosis of the jaw. Conclusions: MONJ treatment depends on the stage of the disease, with mandibulectomy being an effective treatment in stage 3, sequestrectomy in stage 2 and stage 1 is usually controlled with conservative treatment.