不同手术方法治疗双膦酸盐性颌骨坏死

Different surgical methods for the treatment of bisphosphonate-related osteonecrosis of the jaw

目的探讨不同手术方法治疗双膦酸盐性颌骨坏死(BRONJ)的临床效果。方法回顾性分析2013年1月至2019年3月,南京市口腔医院收治的行手术治疗的20例双膦酸盐性颌骨坏死患者的临床资料,对治疗方法与结果进行分析。其中男14例,女6例,发病时的平均年龄为65.4岁(48~81岁),其中男性67.4岁,女性60.7岁。处于第1阶段9例,第2阶段7例,第3阶段3例,1例患者上颌第2阶段、下颌第3阶段。对于部分处于第1阶段或第2阶段、全身情况较差、不能耐受全麻手术或手术创伤的患者,根据影像学评估的结果,若局部已形成完整的死骨,则在局麻下进行死骨摘除术;对于病变区死骨尚未完全分离患者,行颌骨部分切除术。对于发生在下颌骨且症状较重的第3阶段BRONJ患者,如形成了口内、外瘘管,发生了病理性骨折,或病变累及下颌骨下缘等颌面部骨质,在全身条件允许的情况下,通常行节段性截骨术。结果本组20例,有6例(含1例病变同时累及上、下颌骨患者)接受了死骨摘除术,11例接受了颌骨部分切除术,4例(含1例病变同时累及上、下颌骨患者)接受了下颌骨节段性截骨术。随访1~67个月,平均32.8个月,其中4例行下颌骨节段性截骨术的患者治愈,6例通过颌骨部分切除术的患者达到临床无症状,其余患者疼痛、死骨外露等症状减轻,病程明显减缓。结论死骨摘除术和颌骨部分切除术可使双膦酸盐性颌骨坏死患者症状减轻,部分患者可达到临床治愈,提高了患者的生活质量,而下颌骨节段性截骨术作为较彻底的治疗方法,可考虑作为病变为下颌骨第3阶段且全身状况较好患者的首选治疗方式。

Objective To investigate the clinical effect of different surgical methods in the treatment of bisphosphonate-related osteonecrosis of the jaw(BRONJ).Methods A total of 20 cases of BRONJ who were treated for surgical treatment from January 2013 to March 2019 were included for the retrospective analysis in this study.There were 14 males and 6 females in this study.The average age of onset was 65.4 years,including 67.4 years for males and 60.7 years for females.There were 9 patients in stage 1,7 in stage 2,3 in stage 3,and 1 patient with maxillary lesions in stage 2 and mandibular lesions in stage 3.For patients in stage 1 or stage 2 who had poor systemic conditions and could not tolerate general anesthesia or surgical trauma.Different surgical treatments should be performed according to the results of imaging evaluation.If completely dead bones were formed locally,sequestrectomy under local anesthesia was performed.For patients whose dead bones were not completely separated,partial jaw resection was performed.For stage 3 BRONJ patients with severe symptoms occurring in the mandible,such as the formation of intraoral and external fistulas,pathological fractures,or lesions involving the lower margin of the mandible,segmental osteotomy was usually performed when general conditions were stable.Results Of the 20 patients,6 cases(including 1 patient with lesions involving both maxilla and mandible)underwent sequestrectomy,11 cases partial jaw resection and 4(including 1 patient with lesions involving both maxilla and mandible)mandibular segmental osteotomy.The patients were followed up for 1-67 months(mean 32.8 months).All the patients who underwent mandibular segmental osteotomy were recovered well and discharged.6 patients were clinically asymptomatic after partial jawbone resection.The symptoms of the rest of the patients were alleviated,showing relieved pain,disappeared dead bone and so on,while the course of disease was significantly slowed down.Conclusions Sequestrectomy and partial jaw resection can relieve symptoms and improve quality of life of patients,so that some patients can achieve clinical cure.Mandibular segmental osteotomy as a more effective treatment method,can be considered as the preferred treatment for stage 3 patients with lesions in the mandible and with good systemic condition.