(66) Treatment of Stage 3 Maxillary Medication-Related Osteonecrosis of the Jaw With Concurrent Debridement and Functional Endoscopic Sinus Surgery: A Retrospective Analysis

Abstract: Stage 3 Medication Related Osteonecrosis of the Jaw (MRONJ) of the maxilla commonly involves the maxillary sinus (~40% of cases), often leading to chronic sinusitis and oroantral fistulas that complicate management [1;2]. Standard treatment for stage 3 MRONJ is surgical removal of necrotic bone (sequestrectomy or partial maxillectomy) with primary closure and systemic antibiotics. However, if sinus disease is left untreated, infection may persist. A combined approach incorporating functional endoscopic sinus surgery (FESS) during resection may improve healing in advanced maxillary MRONJ [3]. We evaluated this approach in a case series of stage 3 maxillary MRONJ patients treated with concurrent FESS.

A retrospective cohort analysis of patients with stage 3 MRONJ of the maxilla treated with combined maxillofacial surgery and FESS between 2017 and 2023 was conducted. Data collected included patient demographics, primary diagnosis, type of antiresorptive therapy, extent of maxillary necrosis, surgical interventions performed, preoperative radiographic assessment, and postoperative outcomes including presence or absence of oroantral communication (OAC), resolution of pain and sinus symptoms, and need for long term antibiotic treatment (defined as greater than two weeks postoperatively).

Data was summarized using descriptive statistics.

A total of nine patients (3 male, 7 female) were identified with a mean age of 70 years (range 59-88 years). All had received intravenous bisphosphonate or denosumab therapy (for malignancy in 8 cases, osteoporosis in 1). All patients presented with exposed bone in the maxilla and radiographic evidence of maxillary sinusitis (Figures 1,2). All underwent single-stage surgery combining MRONJ debridement/resection with endoscopic maxillary antrostomy. All 9 patients had a maxillary antrostomy; 7 also underwent ethmoidectomy, 1 had a frontal sinusotomy, and 1 had bilateral FESS. All patients achieved mucosal healing by 4 months postoperatively (Figure 3). Healing was maintained in all cases through final follow-up (up to 24 months). Two patients had persistent OAC, one of which underwent obturator insertion at the time of surgery due to the extent of the defect. No patients had persistent pain (all were pain-free at last follow-up) and none required long-term antibiotic therapy. All patients displayed complete resolution of sinus symptoms by 4 months (sinus pain, congestion, drainage). No patients had recurrence of exposed bone or sequestrum after healing (Table 1).

By 4 months postoperatively, all patients had resolution of MRONJ and sinusitis without recurrence of exposed bone, infection, or pain. Seven patients (78%) achieved full mucosal closure (no oroantral communication), and 2 (22%) had a residual oroantral fistula despite otherwise successful healing. No patient required prolonged antibiotic therapy.

Combining maxillary MRONJ surgery with concurrent FESS could be an effective approach to stage 3 MRONJ with sinus involvement. In this series, symptomatic resolution was achieved in all patients. Another study is currently ongoing with a control group to determine the efficacy of this approach in a larger cohort of patients.

1. Mast, G., Otto, S., Mücke, T., Schreyer, C., Bissinger, O., Kolk, A., Pautke, C. (2012). Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw. Journal of Cranio-Maxillofacial Surgery, 40(7), 568–571. https://doi.org/10.1016/j.jcms.2011.10.012
2. Park, J.-H., Alfafara, A. M., Park, Y. L., Bae, J.-H., & Kim, S.-J. (2021). Medication-related osteonecrosis of the maxilla: Prognosis of oral surgery combined with endoscopic sinus surgery. Oral Diseases, 27(4), 962–969. https://doi.org/10.1111/odi.13615
3. Ruggiero, S. L., Dodson, T. B., Aghaloo, T., Carlson, E. R., Ward, B. B., & Kademani, D. (2022). American Association of Oral and Maxillofacial Surgeons' position paper on medication-related osteonecrosis of the jaws—2022 update. Journal of Oral and Maxillofacial Surgery, 80(5), 920–943. https://doi.org/10.1016/j.joms.2022.02.008
Figure 1. Pre-Operative Cone Beam Computed Tomography scan showing bony sequestrum of right maxilla with right maxillary and ethmoid sinus opacification Figure 2. Pre-operative photo displaying area of exposed bone of right posterior maxilla Figure 3. Post-operative photo demonstrating mucosalized right maxillary posterior surgical site. Area of granulation tissue present at site #11 secondary to extraction for unrelated reason