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Conservative treatment of radionecrosis of the mandible
Conservativetreatment of radionecrosis of the mandible (hotye Hahn, D.D.R.,* Da~llas, !i’tmis VETERASK
ADMISIXTRATIOX
and I). A. Corgill,
dM.D., F..~l.C.S.,**
HOSPITr\I.
A
reas of radiation necrosis of the mandible resulting from treatment of cancer of the floor of the mouth or tongue may be treated conservatively, provided such areas are small and have not completely destroyed the circulation of the mandible and its supportive tissues on either the buccal or the lingual surfaces. The effect of radiation to the mandible is not evident immrdiatcly. In fact, it. has been noted that loss of supportive tissue OCCLWS, on the average, about one year after radiation. The over-all occurr(‘nce rate for osteoradionecrosis in relat.ion to location of primary intraoral cancer is 13 per cent of 1,819 cases.’ It first appears as an erythema.tous area t.hought. to have arisen from the chewing of food or from a denture rubbing that arca. Later the area ulrerates and cxpos~s t.he bone, which has a dull appearance unlike the glossy bone area exposed when the live pcriost.eum is elevated. The a.rthaof exposure increases with the traumatic a&on of eating, and the tissue around the edges of the lesion becomes undermined and inflamed. This condition is caused primarily by the loss of circulstion to the bone, periosteum, and mucosal tissues and ma- proceed to osteomyelitis with greater destruct.ion anterior and posterior to the radiated area. The outer surfaces of the bone receive a large! portion of their nourishment. from the periosteal blood vc+~ls which enter its substance through Volknmnn’s canals. The blood vcsscls of the 1Iav(trxian canals and their nutrient arter) supply the deeper portions of the honr and marrow. This blood system forms ;I rich vascular network eneloscd in a rigid framework of bonth, the strueturc? of which makes it highly vulnerahlc to the elect. of radiation. TTp to this t.ime the generalI>- accepted mclthod of treating radionecrosis 01 the mandibla has been radica.1 removal of the radiated bone to whatever length is ncccssary to reach vital bleeding.” It, is now proposed that small radionecrotic areas he treated conservativrly, as will be described later, inasmuch as radical excision can always 1~ pcrformcd at 21 later cldc~ if tlict c0nsPITiltiW treatment is not, successful. “Jdaxillofacial Dentist, Assistant Chief of L)entist,ry, Vetcranx .hhinirtration Ronpital. **Chief, Otolaryngology Section, and Clinical AssocGatc Proftwor of Otolaryllgology, The University of Texas Southwestern Medical Hchool.
707
MANDIBULAR CROSSSECTION
Necrotic Area
mNormal Bone
ColJ.sf?Pl~cltil’c!
Fig.
3. Photograph
showing
tt’E(f tJJ1 P.Jft
proliferating
of
~l~rlrlionc~cr~osi.~
tissue through
of
mandible
709
holes and some loss of cortical
bone.
Pig. 4. One yar mueo.wl tissue.
aftrr
start
of treatment.
Note
tnwral
~urfacc
c~wmplctc~ly cwvcwd
with
the area was inflamed wposecl t)one was dull and rtmlky white; the muc:osal t.isxuo surrounding and not adhcrcnt to the lwne. This indicated that the area of radiation effwt was larger than shown. The loss of muwsal tissue owr the ~NJIWowurrc~l approximatc~ly 1 yar aftw radiation. When the patient ate, foot1 woultl pass from ttlcl mouth out through ttlr> largca firtula. I?01 palliation, the fistula was clowd wit.tl a. plug of xilicwnc 1 502. IYpon c3amination, it. was found that the tissws on the! lingual surfare of the nrandit~te werr lwalt.hy and firm in appc’aranw, which was evidence cwough that. the radiation 11~1 not twnetratell thcl lingunl surface rind that the pnriosteum hew was still vital. Holes WTP (lrillrd from t.tlca irradiated arwt to the still vital arca on the lingual side to allow gr0wt.h of healing grwmlal-ion tissue into railiatwl
bone in the hope that the eirvulation forru uew bone.
would cause au osteoclastie
aud osteoblintie
reaction
mid
h No. 8 round lmr iu a straight dental handpiew was wleetcd, and the center of tht: exposed boue was chosen as the arm in whkh to start drilling n circular pattern of holes. Thcb first hole drilled went almost through the mxndildr lreforr therr was any cvidvuw of I~tw~l
for 1d00tl. ~IlOh 011 the c?ut.tings of the surgical point. Tlw drill ~vax wamiwcl frtywntly ww clrilled from this point in a circular pattern, as shown in Pig. 2. The drilling of th holes continued until all of tlic? exposed area was perforated and each of the 1lOlW filld wit11 Ihod. It was noticed that the d(hptll of t.llc! holcw drilled was lrw at the periplierp of the wposetl arca. The pat.irnt was given autilGotiw, zuld in i days it was found that tissue Ilad proliferated through the IIO~PRjust lwlow tlw cortiaal 1,oue. Other than this, no visible progress was olwrwl for at letit a month. The tissue iu t.h holw st.aycld vital Imt appww1 to progress no farther than the iunc~r rurfaw of t,lw cwrtiea.1layws. As in an earlier (*a~, we then dec:idt!d to r(w~~v~~a small pictw of wrt~ieal iant~ arouutl oue of the 1101~. When this was dew, it was uot.td that tllcl prolifrrating tissue luul undwulinrtl t.he cortical lwue latwally ( I”&. 3 j. We now rcbaliztl that it is important uot. to rcmovo the cwrtical layer unless it is wque&attd, for it protwts tlw new eaucc!llous bone and tlw new proliferating tissues from infection and wosiou. Latw. mow cwrtil*al bone was wquw strat(d unl il the whole area was wvered with niucowal t issw. At times small sequestra appeared on tllc xurfacx! ant1 ww rt:moved. This ~~rwlw of sequestration and regeneration eon1hued for about. 1 gear ( Fig. 4). The boue loss was about the tlG.knesw of t.he cortical bone in this area. This, in turn, c~ausc!da slight depressiou. Tlwrc was still an opening from tlic oral cavity to tlw outside, and thir was ~overc~tlby means of a prbdiclr flap from t.lw rl~oultl~r ( Pigs. 5 and Ii I. CASE 2
wlt~ (lw:rilwd twatnwnt. was firrt tried in 1952 on a 44.year-old physician who had Ii c~arc.inoma in the floor of the mouth on tlw right side. The lesion was trratcd with radium ucwlles. About a year later au area of sownws drvc~loped, with c~xposuw of the maudiblc 011 the lingual surface. The lmccal tissue was intact and iu good condition. T11tt denuded area was about 1.5 (*m. in tlixnicGr and ver.v painful. wlchpaticwt wfuwcl to submit. to raclicwl wrrioval of the area. .I( was clreided that the area could always lw rwiwd IaWr am1 that the trratuwit just tlcw*ril,ed would lw tried. Tlw radiat.ed area wwted in the same manuer, with complete healing iu about. a year, lcaviug the tcc~tll iutwt am1 in good conditiou. wa 0111~wmplaiut was au owasional suquestrum that irritated t.lle tougue during the healing period. ‘E’nurtetw years later (in 1966 ) anotliw cauwr ilevc~lo~~c*iliu tlw tonsillar arw and larynx ou tlw I& side, :~ud the patient died. CONCLUSIONS I. It is possiblr to treat some casts of radiation necrosis of the mandible. where! the radiation has not estcnsivc1.v affected one side or the other, in a conservat.ive manner without loss of mandibular continuity. 2. If the tissues of both lingual and buwal awas have been lost, radical t.rcatmcnt is indicated. 3. If conscrvat.iw treatment. is successful, rcgcincration of new boric owurs in ;II)out I year. It is important to proserve the cortical bone during this period, for it prot,ccts t.hr nw prolifrratin, w cancrllous boric fwli infection and wosion. 4. Two cases have bwn presented, onne recent and one old, to illustrate the conservative management, of mandibular radioncwwis. IJour ca.scs have hcen treated successfully in this manner. 5. The tr&mcnt. described here is at. least a. start in the direction of connerVat.irc tlratment of radiation newosis, to which otlwrs may contribut.e. REFERENCES 1. Wat.uon, William L., and Scarborougl~, ;lanwH El.: Ol;tc~oradioncwosi~ in Intra-oral Cawrr, 4m. J. Hoentgenol. 40: 525-526, 1938. 2. Meyer, Irving: Osteoradionecrosis of the .Jaws, PT)M, pp. 24-i33, Nowmber, 19%.
ADMISIXTRATIOX
and I). A. Corgill,
dM.D., F..~l.C.S.,**
HOSPITr\I.
A
reas of radiation necrosis of the mandible resulting from treatment of cancer of the floor of the mouth or tongue may be treated conservatively, provided such areas are small and have not completely destroyed the circulation of the mandible and its supportive tissues on either the buccal or the lingual surfaces. The effect of radiation to the mandible is not evident immrdiatcly. In fact, it. has been noted that loss of supportive tissue OCCLWS, on the average, about one year after radiation. The over-all occurr(‘nce rate for osteoradionecrosis in relat.ion to location of primary intraoral cancer is 13 per cent of 1,819 cases.’ It first appears as an erythema.tous area t.hought. to have arisen from the chewing of food or from a denture rubbing that arca. Later the area ulrerates and cxpos~s t.he bone, which has a dull appearance unlike the glossy bone area exposed when the live pcriost.eum is elevated. The a.rthaof exposure increases with the traumatic a&on of eating, and the tissue around the edges of the lesion becomes undermined and inflamed. This condition is caused primarily by the loss of circulstion to the bone, periosteum, and mucosal tissues and ma- proceed to osteomyelitis with greater destruct.ion anterior and posterior to the radiated area. The outer surfaces of the bone receive a large! portion of their nourishment. from the periosteal blood vc+~ls which enter its substance through Volknmnn’s canals. The blood vcsscls of the 1Iav(trxian canals and their nutrient arter) supply the deeper portions of the honr and marrow. This blood system forms ;I rich vascular network eneloscd in a rigid framework of bonth, the strueturc? of which makes it highly vulnerahlc to the elect. of radiation. TTp to this t.ime the generalI>- accepted mclthod of treating radionecrosis 01 the mandibla has been radica.1 removal of the radiated bone to whatever length is ncccssary to reach vital bleeding.” It, is now proposed that small radionecrotic areas he treated conservativrly, as will be described later, inasmuch as radical excision can always 1~ pcrformcd at 21 later cldc~ if tlict c0nsPITiltiW treatment is not, successful. “Jdaxillofacial Dentist, Assistant Chief of L)entist,ry, Vetcranx .hhinirtration Ronpital. **Chief, Otolaryngology Section, and Clinical AssocGatc Proftwor of Otolaryllgology, The University of Texas Southwestern Medical Hchool.
707
MANDIBULAR CROSSSECTION
Necrotic Area
mNormal Bone
ColJ.sf?Pl~cltil’c!
Fig.
3. Photograph
showing
tt’E(f tJJ1 P.Jft
proliferating
of
~l~rlrlionc~cr~osi.~
tissue through
of
mandible
709
holes and some loss of cortical
bone.
Pig. 4. One yar mueo.wl tissue.
aftrr
start
of treatment.
Note
tnwral
~urfacc
c~wmplctc~ly cwvcwd
with
the area was inflamed wposecl t)one was dull and rtmlky white; the muc:osal t.isxuo surrounding and not adhcrcnt to the lwne. This indicated that the area of radiation effwt was larger than shown. The loss of muwsal tissue owr the ~NJIWowurrc~l approximatc~ly 1 yar aftw radiation. When the patient ate, foot1 woultl pass from ttlcl mouth out through ttlr> largca firtula. I?01 palliation, the fistula was clowd wit.tl a. plug of xilicwnc 1 502. IYpon c3amination, it. was found that the tissws on the! lingual surfare of the nrandit~te werr lwalt.hy and firm in appc’aranw, which was evidence cwough that. the radiation 11~1 not twnetratell thcl lingunl surface rind that the pnriosteum hew was still vital. Holes WTP (lrillrd from t.tlca irradiated arwt to the still vital arca on the lingual side to allow gr0wt.h of healing grwmlal-ion tissue into railiatwl
bone in the hope that the eirvulation forru uew bone.
would cause au osteoclastie
aud osteoblintie
reaction
mid
h No. 8 round lmr iu a straight dental handpiew was wleetcd, and the center of tht: exposed boue was chosen as the arm in whkh to start drilling n circular pattern of holes. Thcb first hole drilled went almost through the mxndildr lreforr therr was any cvidvuw of I~tw~l
for 1d00tl. ~IlOh 011 the c?ut.tings of the surgical point. Tlw drill ~vax wamiwcl frtywntly ww clrilled from this point in a circular pattern, as shown in Pig. 2. The drilling of th holes continued until all of tlic? exposed area was perforated and each of the 1lOlW filld wit11 Ihod. It was noticed that the d(hptll of t.llc! holcw drilled was lrw at the periplierp of the wposetl arca. The pat.irnt was given autilGotiw, zuld in i days it was found that tissue Ilad proliferated through the IIO~PRjust lwlow tlw cortiaal 1,oue. Other than this, no visible progress was olwrwl for at letit a month. The tissue iu t.h holw st.aycld vital Imt appww1 to progress no farther than the iunc~r rurfaw of t,lw cwrtiea.1layws. As in an earlier (*a~, we then dec:idt!d to r(w~~v~~a small pictw of wrt~ieal iant~ arouutl oue of the 1101~. When this was dew, it was uot.td that tllcl prolifrrating tissue luul undwulinrtl t.he cortical lwue latwally ( I”&. 3 j. We now rcbaliztl that it is important uot. to rcmovo the cwrtical layer unless it is wque&attd, for it protwts tlw new eaucc!llous bone and tlw new proliferating tissues from infection and wosiou. Latw. mow cwrtil*al bone was wquw strat(d unl il the whole area was wvered with niucowal t issw. At times small sequestra appeared on tllc xurfacx! ant1 ww rt:moved. This ~~rwlw of sequestration and regeneration eon1hued for about. 1 gear ( Fig. 4). The boue loss was about the tlG.knesw of t.he cortical bone in this area. This, in turn, c~ausc!da slight depressiou. Tlwrc was still an opening from tlic oral cavity to tlw outside, and thir was ~overc~tlby means of a prbdiclr flap from t.lw rl~oultl~r ( Pigs. 5 and Ii I. CASE 2
wlt~ (lw:rilwd twatnwnt. was firrt tried in 1952 on a 44.year-old physician who had Ii c~arc.inoma in the floor of the mouth on tlw right side. The lesion was trratcd with radium ucwlles. About a year later au area of sownws drvc~loped, with c~xposuw of the maudiblc 011 the lingual surface. The lmccal tissue was intact and iu good condition. T11tt denuded area was about 1.5 (*m. in tlixnicGr and ver.v painful. wlchpaticwt wfuwcl to submit. to raclicwl wrrioval of the area. .I( was clreided that the area could always lw rwiwd IaWr am1 that the trratuwit just tlcw*ril,ed would lw tried. Tlw radiat.ed area wwted in the same manuer, with complete healing iu about. a year, lcaviug the tcc~tll iutwt am1 in good conditiou. wa 0111~wmplaiut was au owasional suquestrum that irritated t.lle tougue during the healing period. ‘E’nurtetw years later (in 1966 ) anotliw cauwr ilevc~lo~~c*iliu tlw tonsillar arw and larynx ou tlw I& side, :~ud the patient died. CONCLUSIONS I. It is possiblr to treat some casts of radiation necrosis of the mandible. where! the radiation has not estcnsivc1.v affected one side or the other, in a conservat.ive manner without loss of mandibular continuity. 2. If the tissues of both lingual and buwal awas have been lost, radical t.rcatmcnt is indicated. 3. If conscrvat.iw treatment. is successful, rcgcincration of new boric owurs in ;II)out I year. It is important to proserve the cortical bone during this period, for it prot,ccts t.hr nw prolifrratin, w cancrllous boric fwli infection and wosion. 4. Two cases have bwn presented, onne recent and one old, to illustrate the conservative management, of mandibular radioncwwis. IJour ca.scs have hcen treated successfully in this manner. 5. The tr&mcnt. described here is at. least a. start in the direction of connerVat.irc tlratment of radiation newosis, to which otlwrs may contribut.e. REFERENCES 1. Wat.uon, William L., and Scarborougl~, ;lanwH El.: Ol;tc~oradioncwosi~ in Intra-oral Cawrr, 4m. J. Hoentgenol. 40: 525-526, 1938. 2. Meyer, Irving: Osteoradionecrosis of the .Jaws, PT)M, pp. 24-i33, Nowmber, 19%.