上颌骨药物相关性颌骨坏死的手术治疗效果初探

Effect of the surgical treatment of maxillary medication-related osteonecrosis of the jaw

目的探讨上颌骨药物相关性颌骨坏死(medication-related osteonecrosis of the jaw,MRONJ)手术治疗的方法和疗效。方法纳入2013年1月至2020年10月就诊于南京大学医学院附属口腔医院·南京市口腔医院口腔颌面外科行手术治疗的28例上颌骨MRONJ患者,回顾性分析患者的临床资料(性别、发病时的年龄、病变阶段、治疗方法和预后等)。其中男性20例,女性8例,发病时年龄为(65.6±11.1)岁。根据美国口腔颌面外科协会的指南,将患者的病变分成2、3阶段,第2阶段的病变10例,进行颌骨部分切除术后严密缝合,其中直接拉拢缝合4个病灶,邻近瓣覆盖4个病灶,颊脂垫瓣和邻近瓣联合使用覆盖2个病灶;第3阶段的病变18例,采用死骨摘除术,并形成引流通道。术后定期随访,并根据患者的临床表现、口腔局部检查、影像学检查等评价手术疗效。结果第2阶段的病变患者在切除坏死骨后,随访12~52个月,患者术后疼痛评分[(1.20±2.53)分]显著低于术前[(6.70±0.95)分](P<0.05)。8例患者的病变区黏膜完全愈合,无新的死骨形成;2例患者术后复发,再次就诊时发展为第3阶段。首次就诊的18例第3阶段病变患者,在摘除死骨后术后随访2~67个月,患者感染症状均明显缓解,术后疼痛评分[(3.40±0.51)分]显著低于术前[(7.06±1.00)分](P<0.05)。结论颌骨部分切除彻底去除病变骨质后软组织瓣封闭创口是针对上颌骨MRONJ第2阶段病变的一种有效治疗方法,而上颌骨第3阶段病变在采用死骨摘除术建立通畅的引流后,能快速消除临床症状,提高患者生命质量。

Objective To explore the methods and clinical effects of the surgery for treating maxillary medication-related osteonecrosis of the jaw(MRONJ).Methods The clinical data including gender,age,stage of lesion,treatment method and prognosis of 28 patients with maxillary MRONJ who underwent surgical treatment in the Department of Oral and Maxillofacial Surgery of Medical School of Nanjing University from January 2013 to October 2020 were retrospectively analyzed.There were 20 males and 8 females.The mean age at onset was(65.6±11.1)years old.According to the guidelines of American Association of Oral and Maxillofacial Surgeons,the patients′lesions were divided into 2 or 3 stages.Ten cases of stage 2 lesions were tightly sutured after partial jaw resection.Among them,4 lesions were sutured directly with mucoperiosteal flaps,4 lesions were covered by adjacent flaps and 2 lesions was covered by buccal fat pad flaps and adjacent flaps.Eighteen cases of stage 3 lesions were treated with sequestrectomy and drainage channels were formed.Patients were followed up regularly after the surgery,and the effect of surgical treatment was judged according to the clinical criteria such as clinical manifestations,local oral examination,imaging examination etc.Results After follow-up for 12 to 52 months,the postoperative pain score(1.20±2.53)was significantly lower than preoperative pain score(6.70±0.95)(P<0.05)in stage 2 patients.Eight patients′mucosa healed completely without new dead bone formed.Two patients had recurrence and developed to stage 3 at the time of revisit.There were 18 cases of stage 3 lesions,which formed drainage channels after removal of the dead bone.The postoperative follow-up time was 2 to 67 months,and the symptoms of inflammation and infection disappeared.Postoperative pain score(3.40±0.51)was significantly lower than preoperative pain score(7.06±1.00)(P<0.05).Conclusions Soft tissue flap closure of wound after partial maxillectomy is an effective approach for the treatment of maxillary MRONJ stage 2 lesions,while maxillary stage 3 lesions could be treated for eliminating clinical symptoms and improving the quality of life when establishing unobstructed drainage after dead bone extraction.