一种新的放射性颌骨坏死的临床分类分期—120例临床分析

中国口腔颌面外科杂志 ›› 2014, Vol. 12 ›› Issue (3): 215-222.

一种新的放射性颌骨坏死的临床分类分期—120例临床分析

何悦¹,代天国¹,田卓炜¹,王中和²,张陈平¹,张志愿¹

1.上海交通大学医学院附属第九人民医院·口腔医学院口腔颌面-头颈肿瘤科,2.口腔放疗科,上海市口腔医学重点实验室,上海 200011

收稿日期:2013-11-08 出版日期:2014-05-10 发布日期:2014-07-15
通讯作者: 张志愿,Tel:021-23271699-5385,E-mail:zhzhy@omschina.org.cn E-mail:william5218 @126.com
作者简介:何悦(1973-),男,教授,主任医师,博士研究生导师
基金资助:
国家自然科学基金(81271112,30973341);上海市人才发展计划资助项目(201312);上海交通大学晨星计划A类(201312)

A new clinical classification and stage for osteoradionecrosis of the jaws: clinical analysis of 120 cases

HE Yue¹, DAI Tian-guo¹, TIAN Zhuo-wei¹, WANG Zhong-he², ZHANG Chen-ping¹, ZHANG Zhi-yuan¹

1.Department of Oromaxillofacial Head and Neck Oncology; 2.Department of Oral Radiology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; Shanghai Key Laboratory of Stomatology. Shanghai 200011, China

Received:2013-11-08 Online:2014-05-10 Published:2014-07-15

摘要/Abstract

摘要： 目的:探讨颌骨放射性骨坏死的临床特征、治疗方法、分类及分期。方法:采用BS分类及分期,对我院口腔颌面-头颈肿瘤科2003年1月—2013年1月10 a间收治的120例放射性颌骨坏死患者临床资料进行回顾分析。结果:下颌骨发生骨坏死的病例明显多于上颌骨及上、下颌骨,分别为99例、14例及7例。累计放疗剂量区间为35～148 Gy,中位剂量为68.1 Gy, 69(57.5%)例患者剂量大于60 Gy。大多数患者骨坏死发生在放疗后1～2 a内(64.2%),少数发生在放疗5 a以后(20.0%)。按BS分类,Stage Ⅰ期患者为0例;Stage Ⅱ期患者16(13.3%)例,主要采用单纯死骨刮治及单纯死骨扩大切除术(14例);Stage Ⅲ期患者92(76.7%)例,71例患者采用死骨扩大切除术,其中47例同期行血管化组织瓣修复;Stage Ⅳ期患者12(10.0%)例,主要采用死骨扩大切除联合同期血管化组织瓣修复(10例)。结论:放射性颌骨坏死以单侧下颌骨最多见,并以体部及部分下颌支最为好发,大多数患者骨坏死发生在放疗后1～2 a。死骨扩大切除联合同期血管化组织瓣修复是目前最好的治疗方法。

关键词: 颌骨, 放射性骨坏死, BS分类, 分期

Abstract: PURPOSE: To investigate the clinical characteristics, treatment, classification and stage of osteoradionecrosis of the jaws. METHODS: Using BS classification and Stage, we retrospectively studied the clinical data of 120 ORNJ cases treated from Jan. 2003 to Jan. 2013. RESULTS: Mandibular necrosis was significantly more than maxilla and upper-lower jaws, account for 99, 14 and 7, respectively. Cumulative radiation dose ranged from 35 to 148Gy, with a median dose of 68.1Gy, and 69(57.5%) cases received more than 60Gy. In majority of patients (64.2%), osteonecrosis occurred first to two years after radiotherapy, however, also 20.0% patients osteonecrosis occurred more than five years after radiotherapy. According to BS classification, none of patient belonged to StageⅠ; Stage Ⅱ patients accounted for 13.3% (n=16), and 14 cases were treated by sequestrum scaling and simple sequestrum extensive resection; Stage Ⅲ patients accounted for 76.7% (n=92), and 71 cases were treated by sequestrum extensive resection, and 47 cases treated with simultaneous vascularized flap; Stage Ⅳ patients accounted for 10.0% (n=12), 10 cases were treated by sequestrum extensive resection and immediately vascularized flap transplantation. CONCLUSIONS: Osteoradionecrosis occurs more easily in unilateral mandible, especially the body and partial ramus. In majority of patients, osteoradionecrosis occurred first to two years after radiotherapy. The currently best treatment methods for ORNJ are extensive sequestrum resection combined immediately vascularized flap transplantation.Supported by National Natural Science Foundation of China (81271112, 30973341), Development Foundation of Shanghai Municipal Human Resources and Social Security Bureau (201312) and SMC Rising Star-A Scholar of Shanghai Jiao Tong University (201312).

Key words: Jaw bone, Osteoradionecrosis, BS classification, Stage

中图分类号:

R739.8

何悦,代天国,田卓炜,王中和,张陈平,张志愿. 一种新的放射性颌骨坏死的临床分类分期—120例临床分析[J]. 中国口腔颌面外科杂志, 2014, 12(3): 215-222.

HE Yue, DAI Tian-guo, TIAN Zhuo-wei, WANG Zhong-he, ZHANG Chen-ping, ZHANG Zhi-yuan. A new clinical classification and stage for osteoradionecrosis of the jaws: clinical analysis of 120 cases[J]. China J Oral Maxillofac Surg, 2014, 12(3): 215-222.

参考文献

【1】Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg, 1983, 41(6): 351-357.
【2】Nabil S. Redefining osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012, 114 (3): 403-404.
【3】Meyer I. Infectious diseases of the jaws. J Oral Surg,1970,28(1): 17-26.
【4】Delanian S, Lefaix JL. The radiation-induced fibroatropic process: therapeutic perspective via the antioxidant pathway . Radiother Oncol, 2004, 73(2): 119-131.
【5】Coffin F. The incidence and management of osteoradionecrosis of the jaws following head and neck radiotherapy. Br J Radiol, 1983, 56(671): 851-857.
【6】Morton ME, Simpson W. The management of osteoradionecrosis of the jaws . Br J Oral Maxillofac Surg, 1986, 24 (5): 332-341.
【7】Clayman L. Clinical controversies in oral and maxillofacial surgery: part two. Management of dental extractions in irradiated jaws: a protocol without hyperbaric oxygen therapy. J Oral Maxillofac Surg, 1997, 55(3): 275-281.
【8】Schwartz HC, Kagan AR. Osteoradionecrosis of the mandible: scientific basis for clinical staging. Am J Clin Oncol,2002,25(2): 168-171.
【9】Glanzmann C, Grätz KW. Radionecrosis of the mandibula: a retrospective analysis of the incidence and risk factors . Radiother Oncol, 1995, 36(2): 94-100.
【10】Jereczek-Fossa BA, Orecchia R. Radiotherapy-induced mandibular bone complications. Cancer Treat Rev, 2002, 28(1): 65-74.
【11】Nabil S, Samman N. Risk factors for osteoradionecrosis after head and neck radiation: a systematic review . Oral Surg Oral Med Oral Pathol Oral Radiol, 2012, 113(1): 54-69.
【12】Lee IJ, Koom WS, Lee CG, et al. Risk factors and dose-effect relationship for mandibular osteoradionecrosis in oral and oropharyngeal cancer patients . Int J Radiat Oncol Biol Phys, 2009, 75(4): 1084-1091.
【13】Reuther T, Schuster T, Mende U, et al. Osteoradionecrosis of the jaws as a side effect of radiotherapy of head and neck tumour patients--a report of a thirty year retrospective review . Int J Oral Maxillofac Surg, 2003, 32(3): 289-295.
【14】刘习强, 黄洪章, 曾融生, 等. 368例放射性颌骨坏死的临床分析 . 中国口腔颌面外科杂志, 2007, 5(3): 176-179.
【15】Curi MM, Dib LL. Osteoradionecrosis of the jaws: a retrospective study of the background factors and treatment in 104 cases . J Oral Maxillofac Surg, 1997, 55(6): 540-544.
【16】Thorn JJ, Hansen HS, Specht L, et al. Osteoradionecrosis of the jaws: clinical characteristics and relation to the field of irradiation . J Oral Maxillofac Surg, 2000, 58(10): 1088-1093.
【17】Tsai CJ, Hofstede TM, Sturgis EM, et al. Osteoradionecrosis and radiation dose to the mandible in patients with oropharyngeal cancer . Int J Radiat Oncol Biol Phys, 2013, 85(2): 415-420.
【18】Wong JK, Wood RE, McLean M. Conservative management of osteoradionecrosis . Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1997, 84(1): 16-21.
【19】Chang DT, Sandow PR, Morris CG, et al. Do pre-irradiation dental extractions reduce the risk of osteoradionecrosis of the mandible? . Head Neck, 2007, 29(6): 528-536.
【20】Goldwaser BR, Chuang SK, Kaban LB, et al. Risk factor assessment for the development of osteoradionecrosis . J Oral Maxillofac Surg, 2007, 65(11): 2311-2316.
【21】Annane D, Depondt J, Aubert P, et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group . J Clin Oncol, 2004, 22(24): 4893-4900.
【22】McLeod NM, Pratt CA, Mellor TK, et al. Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience . Br J Oral Maxillofac Surg, 2012, 50(1): 41-44.
【23】Lubek JE, Hancock MK, Strome SE. What is the value of hyperbaric oxygen therapy in management of osteoradionecrosis of the head and neck? . Laryngoscope, 2013, 123(3): 555-556.
【24】Curi MM, Oliveira dos Santos M, Feher O, et al. Management of extensive osteoradionecrosis of the mandible with radical resection and immediate microvascular reconstruction. J Oral Maxillofac Surg, 2007, 65(3): 434-438.
【25】Baumann DP, Yu P, Hanasono MM, et al. Free flap reconstruction of osteoradionecrosis of the mandible: a 10-year review and defect classification. Head Neck, 2011, 33(6): 800-807.
【26】Oh HK, Chambers MS, Martin JW, et al. Osteoradionecrosis of the mandible: treatment outcomes and factors influencing the progress of osteoradionecrosis. J Oral Maxillofac Surg,2009,67(7):1378-1386.
【27】Zaghi S, Danesh J, Hendizadeh L, et al. Changing indications for maxillomandibular reconstruction with osseous free flaps: a 17-year experience with 620 consecutive cases at UCLA and the impact of osteoradionecrosis. Laryngoscope, 2013 Aug 14.
【28】何悦, 张志愿, 竺涵光,等. 钛重建板联合胸大肌肌皮瓣同期修复下颌骨放射性骨坏死切除术后缺损. 上海口腔医学, 2008, 17(6): 565-568.
【29】Epstein JB, Wong FL, Stevenson-Moore P. Osteoradionecrosis: clinical experience and a proposal for classification . J Oral Maxillofac Surg, 1987, 45(2): 104-110.
【30】StØre G, Boysen M. Mandibular osteoradionecrosis: clinical behaviour and diagnostic aspects . Clin Otolaryngol Allied Sci, 2000, 25(5): 378-384.

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