Surgical management of bisphosphonate induced osteonecrosis of the jaws

Recent literature contains numerous articles on osteonecrosis of the jaws (ONJ) associated with bisphosphonate treatment (BPT), with most advocating a conservative approach to management. A prospective study was designed to review the surgical management of cases of ONJ that did not respond to conservative management. Forty patients, referred with ONJ that did not respond to conservative management, were treated surgically and followed up for 6 months to 4 years. Four patients were taking i.v. BPT as part of their bone cancer management and 16 were taking oral BPT for osteoporosis. The surgical management of ONJ involved antibiotic therapy, surgical debridement of all necrotic bone and tension-free primary closure. All 40 cases healed uneventfully with no wound breakdown during follow-up. Most of the literature supports the conservative management of ONJ, but the condition leaves the patient debilitated. Many cases do not respond to conservative management and the infection and bone destruction is progressive. The conservative management of ONJ is to be supported, but this prospective study has shown that those cases that do not respond may be managed surgically. It should be recognized that while the results of this paper are encouraging, some cases will be resistant to all treatments.