Having a special interest in bisphosphonate-related osteonecrosis of the jaw (BRONJ), we came across the paper by Biglioli and Pedrazzoli. First of all, we would like to express our gratitude to the authors for their creativity and hard work on the modified surgical technique. However, we have some concerns that we would like to bring to the authors’ attention.

The 2009 update of the American Association of Oral and Maxillofacial Surgeons (AAOMS) position paper on BRONJ proposes that those with stage 3 BRONJ undergo surgical debridement for long-term palliation of infection and pain. We agree with this minimally invasive management for medically compromised patients. However, rigid internal fixation of a titanium plate without removal of the nidus of infection and sequestrum will not actually halt the disease progression, and osteogenesis will not occur. Although the authors report that the titanium plate is not in contact with the infected area, progression of a chronic infection will cause loosening of the internal fixation. The presence of a foreign object such as a titanium plate will lead to disease deterioration and will accelerate a vicious cycle. The development of an extraoral fistula would be expected. Likewise, a thick reconstruction plate fixed beneath the subcutaneous tissue will be prone to wound dehiscence and eventually plate exposure. Ultimately, the final defect will involve not just the bone, but also the soft tissue. This is actually adding an extra challenge to future reconstruction. We worry that a continuing chronic infection within the necrotic bone of the bilateral parasymphysis could lead to the development of Ludwig’s angina, which would rapidly compromise the airway.

Taking a general look at the patient, rigid internal fixation of an edentulous jaw does not improve feeding ability. Maintaining complete nutrition of a cancer patient is possible with the use of a nasogastric tube or percutaneous gastrostomy feeding.

Withdrawal of bisphosphonate does not appear to be beneficial. A temporary suspension of bisphosphonate offers no short-term benefit, as relapse will occur after such a ‘drug holiday’. The long-term discontinuation of bisphosphonate may be beneficial in stabilizing the BRONJ area and in reducing clinical symptoms if the patient’s systemic condition allows this. Nevertheless, there is always a need to balance benefits against harm, especially when handling cancer patients.

Referring to the updated AAOMS guidelines of 2009, resection of the affected bone seems to be a better option, since the adjacent vital soft tissue will still allow a primary closure. The mobile segment of the bony sequestrum can be removed without exposing the adjacent uninvolved bone. Resection in combination with antibiotic therapy will benefit stage 3 subjects with regard to long-term palliation, providing resolution of both the acute infection and the pain. Furthermore, a histological examination of the particular mandibular segment can be performed if distant metastasis occurs, which might interfere with the palliative treatment plan.

If the patient can undergo major surgery, with a condition that distant metastasis has been ruled out, immediate reconstruction with a vascularized flap is an option. Some authors have reported the potential problem of the presence of a remnant of necrotic bone at the resection margin, which may prevent healing between the donor and recipient sites. However, modern technology can overcome this. Bone scintigraphy is significant in showing early abnormalities of bone density and this would allow determination of the exact resection margin. Tetracycline bone fluorescence has been proposed to better visualize the osteonecrosis margin, given that fluorescence-guided bone resection can improve the surgical therapy of osteonecrosis.

The points mentioned above are important from the standpoint of potential complications and treatment options. Thank you.