| Introduction: Osteoradionecrosis of Jaws(ORN)is the most serious problem after radiotherapy either primary treatment and adjuvant therapy for patients.ORN treatment has been discussed more than decade since the first radiotherapy was introduced from conservative such as antibiotics treatment,ultrasound therapy,hyperbaric oxygen therapy,to surgical treatment.Conservative management is less aggressive and not too difficult,but it takes longer time to recovery from the disease.In severe cases,surgical intervention still needed to correct the deformity from progression of the disease.Surgical managements for ORN started from debridement of dead bone and irrigate wound to remove bacteria colonization,to radical resection with or without reconstruction of tissue loss.With recently knowledge and surgical technique,microvascular reconstructive surgery with variety of free flap are using more than in the past to correct lesion and improve quality of life for patients.However,there is many factors that contribute the result of the surgery such as previous radiation in surgical area which cause trouble for surgeon to decide the area for recipient vessels in microvascular surgery method and end up with failure of free flaps.This thesis studied about ORN and its complication from the surgery by identified the type of surgery for ORN treatment in one hospital and identified type of flaps,recipient vessels side and area and immediate postoperative complication for further study.Objective: To identified patients who received surgical management for ORN in Peking university school and hospital of stomatology and identified type of surgical treatment they received during inpatient department.To show the statistic of the surgery include method of surgical treatment in ORN patients and type of flaps we use for reconstruction in patients whom suffered from radiation therapy side effects.For microvascular surgery cases identified type of flaps we use for reconstruction the necrotic tissue and identified recipient vessels include ipsilateral or contralateral side to the radiation therapy side to find the incidence of contralateral vessel use to avoid failure from free flaps surgery.Method: All the patients whom diagnosed as ORN was selected from the hospital database.All cases were reviewed and exclude the cases that not meet the criteria.67 patients whom received surgical management for ORN in Peking university school and hospital of stomatology during year 2013-2016 are studied by inpatient data record and divided into 3 group based on surgical methods.Data are collected for patient's characteristic such as age,sex,underlying disease,smoking habit and alcohol consumption.For primary tumor characteristic we collected type of primary tumor,treatment for primary tumor and area or site of primary tumor.ORN clinical finding we collected symptom of ORN and type of surgery we did to the patients include type of flaps and recipient vessels for microvascular surgery reconstruction either name of vessels and ipsilateral or contralateral side to the radiation therapy side.Immediate postoperative complications were collected and reviewed for reoperation and their finding during operative surgery.Result: Total 67 patients include male 45 and female 22 all were received surgical management in our hospital mean age of all the patients is 58.42(Standard error 1.953).All the patients are divided into 3 group by treatment method.Group1,simple surgical treatment(38.8%),patients are received debridement of dead bone and tissues.Group2 is radical resection with reconstructive surgery(52.2%).Microvascular free flap surgery in this study are fibula free flap(80%),anterior lateral thigh(11.4%)and local regional flap is pectoris major flap(5.7%),submental flap(2.9%).Group 3 is resection without reconstructive surgery(9%)in this group patients were resected the dead bone and closed the wound without any reconstruction.Treatments of primary tumor have many procedures but all of them must have at least once radiotherapy.We found four methods for primary tumor treatment in our study.They are radiation alone 13.4%(N=9/67),surgery and then radiation 52.2%(N=35/67),radiation and chemotherapy 11.9%(N=8/67)and surgery with radiation and chemotherapy 22.4%(N=15/67).Types of primary tumor in our study are squamous cell and find 41.8% of all the data and the second most common is nasopharyngeal CA 22.4%.We also found adenoid cystic CA 14.9%,lymphoma 6%,mucoepidermoid CA 1.5% and distant metastasis 3%.The median of timing after received radiation is 60 months and Q1 is 36 months,Q3 is 108 months.The shortest time after radiation is 4 months and the longest is 360 months.From all the reconstruction flap we found that the surgery was done anastomosis vessel ipsilateral to the ORN site for 85.7%(N=30/35),contralateral site 5.7%(N=2/35)and no anastomosis surgery,due to regional flap reconstruct,8.6%(N=3/35).The most common use for recipient artery is facial artery 42.9%(N=15/35),the second is lingual artery 25.7%(N=9/35),the rest of all are superior thyroid artery 17.1%(N=6/35),carotid artery 2.9%(N=1/35)and superficial temporal artery 2.9%(N=1/35).For the recipient vein are external jugular vein 48.6%(N=17/35),internal jugular vein 28.6%(N=10/35),facial vein 8.6%(N=3/35),anterior vein 2.9%(N=1/35)and superficial temporal vein 2.9%(N=1/35).Immediate postoperative complication can be found in group2 for 20%(N=7)and in group3 16.7%(N=1)whereas none in group1.In group2 for immediate postoperative complication we found it is coming from artery compromise 5.7%(N=2),vein compromise 5.7%(N=2),hypokalemia 2.9%(N=1),partial flap loss 2.9%(N=1)and facial nerve injury 2.9%(N=1).Conclusion: In early stage of ORN conservative modality treatment is still commonly used to avoid major complication from surgery.However,there are many patients whom needed to do the necrotic bone and tissue debridement more than one time and some of them needed radical resection of necrotic tissue after conservative management.Even surgical management in ORN patients have many method,fibula flap is the most common use and reliable for reconstructive surgery after radical resection especially in mandible region.Anterior lateral thigh is more using after radical resection maxilla.However,regional flaps such as pectoralis major muscle flap is the most common salvage flaps in case of free flap was failed or patients are not suitable for microvascular surgery reconstruction.Closed monitoring and identification promptly of compromise flaps are the key of prevent flap failure which can let surgeon to correct the compromise flaps. |
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