Osteoradio­necrosis

Do you have pain or swelling? Numbness or tingling? Sores or ulcers on your gums, neck or outer jaw? Is your jaw so tight that it’s hard to open your mouth (trismus)? Are your teeth out of alignment (malocclusion)?

ORN can cause these symptoms and more serious ones, too, like exposed bone. It most often affects your lower jaw (mandible), but it can also damage the bones in your upper jaw (maxilla), your spine or skull.

If you’ve had radiation and start having symptoms like these, it’s time to see healthcare providers who are experts at diagnosing and treating ORN.

What to expect at your first visit

Your story plays a big part in how we confirm your diagnosis and plan your treatment. So, when you come to your first appointment, your provider will go over your health history and ask questions, including:

• What are your symptoms?
• How long have you had these symptoms?
• Have you had radiation therapy, and if so, when?
• What dose of radiation did you have?

You’ll also have a physical exam. Your provider will look for exposed bone, swelling, sores and infections. Then they’ll order imaging tests, like dental X-rays or a CT scan, to help pinpoint what’s going on. You may also have a biopsy to make sure there’s no cancer present.

All of this helps our team build the most personalized treatment plan for you.

Meet Our Osteoradionecrosis Team

When you come to Cleveland Clinic, you’ll have a care team of expert providers from different specialties on your side. They work together to plan your care, treat your condition and keep an eye on your progress. They also offer compassionate support, guiding you through your treatment. We build your team with providers based on your needs, like:

• Otolaryngologists.
• Head and neck surgeons.
• Facial plastic surgeons.
• Oncologists.
• Radiologists.
• Dentists.
• Oral surgeons.
• Oral maxillofacial prosthodontists.
• Speech-language pathologists (SLPs).

Your ORN treatment depends on many things, including your symptoms, where the bone damage is and how severe it is. Sometimes, we can manage the condition with medication. Often, though, surgery is the most effective way to treat osteoradionecrosis.

Medication

We may use a combination of pentoxifylline, vitamin E (tocopherol) and, less often, a bisphosphonate drug called clodronate. This combo treatment is often called PENTO (pentoxifylline and tocopherol) or PENTOCLO (all three drugs).

PENTO can improve blood flow to your affected bone, boost your immune system and help your bone recover. It can also help manage minor areas of ORN without you having to have surgery. We often combine these medications with antibiotics to treat infections in your bone or surrounding tissue.

Surgery

Surgery to reconstruct damaged bone and facial features is often the most effective treatment for ORN. Before surgery, your provider may recommend something called surgical debridement. This just means that we’ll remove the infected or dead bone and tissue. You’ll most likely have medications, like antibiotics, with this procedure.

Free flap surgery and reconstruction

In this procedure (also called microvascular free tissue transfer), our surgeons use techniques that bring in healthy tissue with a new blood supply to either replace the damaged bone or help the remaining bone recover.

Here’s what will happen during this surgery:

• We remove tissue (skin, muscle, fascia and/or bone) from other parts of your body where it won’t affect function (your “spare parts”). Common “spare part” areas include your thigh, hip, lower leg (fibula) or shoulder blade (scapula).
• Your surgeon will bring this tissue to the affected area and reconnect the veins and arteries.
• Then, your surgeon will transplant the healthy tissue and bone in the area that needs reconstruction. We do this reconstruction in combination with surgery to remove the damaged bone. Examples are a mandibulectomy (jawbone removal) or a maxillectomy, which removes part or all of the top jawbone.

It takes about a week and half to recover in the hospital from this type of surgery and reconstruction.

Rescue flap surgery and reconstruction

Surgery for osteoradionecrosis continues to evolve. Our surgeons did the first anterolateral thigh fascia lata rescue flap surgery for the mandible (lower jawbone).

For this surgery we remove the damaged bone and cover it with tissue and skin taken from your thigh to create a new blood supply. Sometimes, we may also use a small bone graft from your hip.

For the reconstruction, we make a small cut (incision) in front of your ear — like the ones used in facelifts. This leaves little to no visible scar on your face. In fact, the surgery usually isn’t much different from removing a wisdom tooth. We try to avoid touching good, healthy bone as much as possible.

Over 100 Cleveland Clinic patients have had this surgery, which is far less invasive than traditional free flap reconstruction. It causes very little short-term pain, takes less time (about four hours), the hospital stay is shorter (usually about two days) and recovery is faster (you’re walking and eating right away).

This surgery has been extremely effective in managing moderate or advanced ORN when there’s enough good bone left to keep your jaw stable.

Hyperbaric oxygen (HBO) therapy

Hyperbaric oxygen therapy involves roughly 30 visits to a chamber filled with pressurized air and highly concentrated oxygen. The idea is that supplying you with 100% oxygen in this special chamber can help your body grow new skin, blood vessels and connective tissues. In the past, this has been a standard treatment, but recent quality studies have failed to show its effectiveness, so we typically don’t recommend it.

Life After Osteoradionecrosis Treatment

After ORN treatment, you’ll have regular check-ins with our team and routine imaging tests. This lets us see if the reconstruction worked. We can also check for new infections or if cancer has come back (recurred). When we catch problems early, our team can start treatment quickly to slow or stop their progression.

Taking the Next Step

If you’ve had radiation therapy to your head and neck — even years ago — it’s important not to ignore pain, swelling or sores on your jaw, face, skull and neck. All of these things could be signs of osteoradionecrosis. The faster you see an experienced healthcare provider, the more effective treatment will be. Our team knows all of this can be stressful. We’re here to help you move forward. From treatments and reconstruction (if you need it) to follow-up care, we’re by your side every step of the way.