Osteochemonecrosis after Mandible Reconstruction: NEJM case
The diagnosis of osteochemonecrosis is currently accepted if necrotic jawbone exposure lasts more than 8 weeks along with a history of related antiresorptive therapy and no irradiation of the area.

A 56-year-old woman who underwent radical nephrectomy and lymph-node resection for clear-cell renal-cell carcinoma in February 2012. During subsequent follow-up, a single metastasis of the body of the left mandible was detected. Because the primary tumor had been removed, the patient was referred for resection of the mandibular metastasis and a fibular free-flap reconstruction.

The initial outcome was good, with complete resection of the lesion followed by normal healing. Two months later, fibular viability was assessed by means of bone scintigraphy, which revealed good vascularization of the flap, although additional bone metastases to the right humerus and the pelvis were detected.

Antiresorptive treatment was initiated in April 2013 — denosumab (120 mg per month, administered subcutaneously) along with sunitinib (50 mg per day) and calcium and vitamin D. The patient did not receive glucocorticoids or bisphosphonates at any time. No radiotherapy to the head and neck was given at any time.

In January 2014, the patient was noted to have visible bone in the area of the graft with inflammation of the surrounding tissues. It was initially thought that the findings represented a recurrence of the tumor, but biopsies were negative. Over a period of days, there was an increase in the extent of bone exposure and necrosis without evidence of acute secondary infection.

CT revealed increased bone density, periosteal bone apposition, and bone sequestration — all characteristic findings of osteonecrosis of the jaw.It was inferred that osteonecrosis of the fibular bone graft was probably present. Subsequently, the patient herself extracted the bone sequestrum. Unfortunately, at the end of 2014, the patient died from progression of her cancer.

Read more here: https://www.nejm.org/doi/full/10.1056/NEJMc1509760
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