FARKHUNDA

OSTEORADIONECROSIS
OF THEFACIAL BONES:
FARKHUNDA FATIMA
IV YEAR BDS
ORN is also known as radiation OML
It is a most serious complications of therapeutic radiotherapy for head
and neck
Effects of radiation treatment in maxillofacial area

The cancers of oral and maxillofacial region are treated by
1. Radiation therapy
2. Sugery
3. Both
DEFINITION OF OSTEORADIONECROSIS
ORN of the jaw bone is an exposure of nonviable , nonhealing , non-septic lesion
in the irradiated bone , which fails to heal without intervention.
It is a sequelae of irradiation – induced tissue injury , in which hypocellularity ,
hypovascularity , hypoxia are the underlying causes .
Incidence
Incidences of involvement of the mandible ranges from 2-3%.
Second most common bone involved is Temporal bone.
Extraction of tooth causes of ORN 60 -89%
The time period between the RT and the development of ORN has been
reported as a mean of 7.5 yr and upto 20 yr.
ETIOPATHOLOGY
A. MARX 1983 -”Three H” principle of irradiated tissue:
H – hypocellularity
H- hypovascularity H- hypoxia
Comprises all the elements of bone,
including periostem, marrow &
investing soft tiissues.
B. Failure of osteoclastic activity – the hypoxic tissue when damged is unable to respond metabolically to
the injury
So the fibroblast fail to lay down new collagen and a chronic non healing develops.
• SO, DUE TO HYPOXIA  INJURED TISSUE MACROHPAGES
ARE UNABLE TO PHAGOCYTOSE BACTERIA OR DEAD TISSUE
IN WOUNDS  FIBROBLASTS FAIL TO LAY DOWN NEW
COLLAGEN & CHRONIC NON HEALING WOUND DEVELOPS.
WOUND, WHOSE 02 & METABOLIC REQ. FOR HEALING

EXCEED THE AVAILABLE SUPPLY.
MECHANIS Therapeutic doses of
M irradiation cause:
Endothelial death thrombosis hyalinization of blood

vessels
This leads to decreased Microcirculation
Periosteum undergoes Fibrosis , osteoblasts & osteocytes Are destroyed.
Marrow spaces in bone filled With fibrous tissue
Decreased cellularity of tissues and vascularity is decreased
Hypoxia in irradiated tissues

PATHOLOGICAL CHANGES:
Effects of radiation on soft and hard tissues ( M A R X –
Mnemonic ) • IN CHILDREN:
INTERFERENCE WITH NORMAL GROWTIn children:
1. Mucositis
Interfence with normal growith & dev of jaws.
2. Atrophic mucosa Irregularities in formation and eruption of teeth.
3. Radiation caries
4. xerostomia
In adults:
1. radiation caries
2. decreased salivary flow
Effects of radiation on bone depend upon: 3. mucositis
5. Quality and quantity of radiation 4. Skin – dermatitis
6. Size of portals used
• H & DEV OF JAWS.
7. Location and external of lesion
8. Condition of teeth and periosteum
• IRREGULARITIES IN FORMATION AND ERUPTION OF TEETH.
• IN ADULTS:
• 1. RADIATION CARIES
2. DECREASED SALIVARY FLOW
CLINICAL FEATURES:
• 1. PAINFUL – SEVERE, DEEP, BORING PAIN
• 2. SWELLING OF FACE
• 3. SOFT.T ABSCESSES & PERSISTENTLY DRAINING SINUSES
• 4. EXPOSED BONE ( WITH OR W/0 INTRA OR EXTRAORAL FISTULAE)
• 5.TRISMUS
• 6. FETID ODOR
• 7. PYREXIA
• 8. PATHOLOGICAL FRACTURES
9. THERE IS SLOW SEQUESTRATION, BECAUSE BOTH OSTEOBLASTIC N
OSTEOCLASTIC ACTIVITY IS DESTROYED.
SO LARGE PIECE OF BONE IS SEPARATED FROM UNAFFECTED VITAL

PART OF MANDIBLE.
10. Deep cellulitis

11. Sloughing of adjoining skin & mucosa
RADIOGRAPHIC FEATURES:
EARLY STAGE:
it may appear as radiolucent with non sclerotic borders.
Occassional areas of Radiopacity assoc with bony sequestrum.
LATE STAGE:
Sequestra and involucra occur late or not at all. ( due to severely compromised
blood supply )
TREATMENT:
THERE IS NO UNIVERSALLY ACCEPTED TREATMENT OF ORN OF JAWS.
A. CONSERVATIVE TREATMENT:
1. SYSTEMIC AB
2. SELECTIVE RINSING WITH TOPICAL ANTISEPTICS
3. SELECTIVE REMOVAL OF SEQUESTRA
4. CURETTING
5. LOCAL DEBRIDEMENT
UNTIL NORMAL BLEEDING BONE OCCURS

MANAGEMENT
•THE PROTOCOL OF MARX (IN 1983)
•MARX PROPOSED A PROTOCOL FOR MANAGEMENT OF ORN THAT COMBINES HBO THERAPY AND
SURGERY AS ITS PRIMARY TREATMENT MODALITIES .
•HBO ALONE CANT HEAL ORN WOUNDS SUGGESTING THAT HBO WITHOUT AGGRESSIVE
MANAGEMENT WOULD NOT RESOLVE THE DISEASE PROGRESS IN MORE CASES
•HBO IS A ADJUNCTIVE AND NOT A “STAND ALONE” THERAPY.
STAGE III
RECONSTRUCTION
STAGE III
HBO has a significant role to play in the management of radiation necrosis of the bone and
soft tissue
Maniosus et al 1973 were the first clinicians to suggest the use of HBO therapy for treatment of
ORN
HBO therapy : hyperbaric oxygenation is defined as a treatment where patient inhales 100%
humified oxygen in a absolute pressure chamber at 1.5 atmospheres or greater intermittently
and almost daily.
Delivered in a mono place chamber or larger multi space chamber with air –
mask , headtent/hood or endotracheal tube.
Five aspects of the action of HBO are beneficial:
1.HBO therapy enhancement of lysosomal degradation potential of polymorphonuclear
leukocytes and O2 radicals; which are major components of catabolic enzymes of macrophage
lysosome. Formation of these enzymes is decreased in hypoxic environment, as in OML and
ORN.
2. Free radicals of O2 are toxic to many pathogenic anaerobes (bactericidal).
3.Many exotoxins liberated by microorganisms are rendered inert by exposure to elevated
partial pressure of O2 .
4.Tissue hypoxia is intermittently reversed by HBO therapy mimicking tissue level during wound
healing.
5.Positive enhancement of neoangiogenesis, in the aerobic portion of proliferative phase of
wound healing
Complications :
: HBO therapy is very time consuming, and therefore expensive.
Some of the possible complications associated with HBO therapy are listed here.
(i) Eustachian tube dysfunction, (ii) Tympanic membrane rupture,

(iii) Oxygen toxicity, (iv) Ear, sinus or tooth pain,
(v) Decompression sickness, (vi) Pneumothorax,
(vii) Arterial gas embolism, (viii) Nitrogen emboli to CNS, lung or joints,
(ix) Middle ear hemorrhage, (x) Deafness
PREVENTION OF ORN:
1. PRE IRRADIATION DENTAL CARE
1. EXTARCTION OF TOOTH
2.REESTORATION OF TEETH
3. SHARP SOCKET MARIGIN SHOULD BE TRIMMED
2. DURING THERAPY:
MOUTHWASH, CLEANING OF ALL TEETH, ORAL HYGIENE
INSTRUCTIONS, AND DIETARY ADVISE.
ALSO IMPROVE GENERAL HEALTH OF PATIENT.
3. POST IRRADITAION DENTAL CARE:
AVOIDANCE OF DENTURES.
MAINTAINE ORAL HYGIENE
TOPICAL FLUORIDES
SALIVA SUBSTITUTES
EXTRACTION AS LAST RESORT
THANK
YOU

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OSTEORADIONECROSIS

Effects of radiation treatment in maxillofacial area

WOUND, WHOSE 02 & METABOLIC REQ. FOR HEALING

Endothelial death thrombosis hyalinization of blood

Periosteum undergoes Fibrosis , osteoblasts & osteocytes Are destroyed.

Marrow spaces in bone filled With fibrous tissue

Decreased cellularity of tissues and vascularity is decreased

Hypoxia in irradiated tissues

• 3. SOFT.T ABSCESSES & PERSISTENTLY DRAINING SINUSES

• 4. EXPOSED BONE ( WITH OR W/0 INTRA OR EXTRAORAL FISTULAE)

SO LARGE PIECE OF BONE IS SEPARATED FROM UNAFFECTED VITAL

10. Deep cellulitis

UNTIL NORMAL BLEEDING BONE OCCURS

(i) Eustachian tube dysfunction, (ii) Tympanic membrane rupture,

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