Surgical Challenges in the Management of Advanced Osteoradionecrosis of the Mandible

Advanced Osteoradionecrosis is a severe problem associated with complex oro-cutaneous damage and pathological fracture. The morbidity is significant, both in terms of aesthetics and function, with detrimental consequences on the quality of life. The mainstay of treatment for advanced ORN is radical surgery involving free tissue transfer. The challenging nature of such reconstructive surgery is set out in the context of a patient previously treated for cancer, whether surgergy and radiotherapy or chemoradiotherapy, and therefor significant co-morbidities. The clinician is thus presented with challenging decisions to be made with regards to conservative vs. radical treatment of these patients and the choice of reconstruction. The aim of this paper is to highlight the difficulties encountered in the decision-making process and the reconstructive challenges of ORN, reflecting on the experience of the authors at the three international centres. For the ease of description, we have divided the problems and solutions encountered into eight different sections. 1. Patient characteristics, pre-operative planning and medical optimisation. 2. Vessel depleted neck and the choice of neck vessels. 3.Soft tissues defect and management of the fistula. 4. Reconstruction of the bone. 5. Choice of plates. 6. Choice of flaps. 7. Expertise of the unit. 8. Outcomes.