Surgical Management of Advanced Mandibular Osteonecrosis Utilizing a Contemporary Mandibular Reconstruction Plate in Patients Unsuitable for Free Flap Reconstruction—Preliminary Study and Case Series

TL;DR

A titanium plate system was used to reconstruct the jaw in patients unsuitable for free flap surgery, showing stable and functional results.

Contribution

This case series introduces titanium plate-only reconstruction as a viable alternative for advanced mandibular osteonecrosis in patients unfit for free flap surgery.

Findings

All patients showed stable reconstruction without plate exposure or complications.

Esthetic and functional outcomes were achieved without hardware issues.

Literature review supports plate-only reconstruction for unsuitable free flap candidates.

Abstract

Introduction: Stage three osteonecrosis of the jaw (ONJ), whether medication-related (MRONJ) or osteoradionecrosis (ORN), often necessitates aggressive surgical management due to extensive necrosis, infection, and risk of pathologic fracture. While free flap reconstruction remains the gold standard post-segmental mandibulectomy, it may not be feasible for elderly or systemically compromised patients. Objective: The presentation of our own experience with advanced mandibular ONJ on patients managed exclusively with a contemporary titanium reconstruction plate system and to evaluate the clinical outcomes of this approach in the context of the current literature. Methods: From a group of 21 patients treated for ONJ, just four patients with Stage 3 MRONJ or Grade III ORN, unfit for microvascular surgery, underwent segmental mandibulectomy followed by alloplastic reconstruction using standard titanium plating. Outcomes were assessed clinically and radiographically over a follow-up period ranging from 3 to 20 months. A focused literature review was conducted to contextualize results. Results: All patients demonstrated stable reconstruction without plate exposure, fracture, or intraoral bone exposure during follow-up. Esthetic and functional outcomes are reported. No hardware complications were reported. The review of the literature supports plate-only reconstruction as a valid alternative for patients unsuitable for free flap surgery, especially when using rigid, anatomically adaptive systems with robust soft tissue coverage. Conclusions: Titanium plate–only reconstruction following segmental mandibulectomy can provide reliable short- to mid-term outcomes in selected patients with advanced ONJ. Used titanium plating systems appears to be a promising option.

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