The objective was to trial the use of the Integra skin regeneration system intraorally to promote healing of an intraoral defect in osteoradionecrosis (ORN), thereby avoiding the necessity for mucosal flaps, free flaps, or skin grafts. A 54-year-old male patient presented with a pathological mandibular fracture at the angle, related to previous radiotherapy for tonsillar carcinoma, after the development of ORN. The fracture site was debrided and fixed with a reconstruction plate and the intraoral defect was dressed with the Integra two-layer system and an overlying pack. Three weeks later, the pack and silicone layer of the regeneration system were removed, showing early granulation over the previously exposed bone. At 8 weeks postoperative, the defect had healed completely with no need for further reconstruction. Using the method described, excellent healing was seen with the Integra skin regeneration system. A new use for the Integra skin regeneration system has been identified in the authors’ unit. This method is minimally invasive and resulted in good healing in the case presented. The need for further reconstruction with associated increased patient morbidity was avoided in this case.
Osteoradionecrosis (ORN) is a condition that can develop following radiotherapy for the treatment of cancer. It is known to affect between 2% and 22% of patients who have received radiation therapy to the head and neck region. Radiation therapy reduces the vascularity of both bone and the surrounding soft tissue, and the resulting sequelae can be difficult to manage. ORN has been defined as a potentially severe, delayed radiation-induced injury, characterized by bone tissue necrosis, failure to heal, and exposed bone for at least 3 months. Bone becomes devitalized, necrosed, and exposed, with associated failure to heal in the absence of tumour recurrence, and has previously been classified by Epstein and Marx to guide treatment planning. However, ORN can occur without bone being exposed, which this classification does not address, therefore a new classification of ORN has been proposed by Lyons et al. to include this parameter.
ORN causes a significant amount of patient morbidity and associated pain, recurrent infection, and disturbance in function and aesthetics. It may cause a pathological fracture of the bone. The treatment of ORN of the mandible, and any associated fracture, may require reconstruction with a free vascularized bone graft from the fibula, pelvic bone plus the deep circumflex iliac artery (DCIA), or scapula, and fixation with titanium reconstruction plates. If conservative management is required due to associated comorbidities, long-term antibiotics with or without the use of hyperbaric oxygen has been used with success, and these also have their place as adjunctive therapies.
The principal problem is usually eradicating the communication between the affected bone and the oral cavity, thereby preventing contamination with oral bacteria. Reconstruction with the use of vascularized bone flaps with a paddle of skin, free tissue flaps, e.g. radial forearm or rectus abdominis, or, to fill smaller defects, a local mucosal flap such as a tongue flap , has been used with varying degrees of success. However, these additional procedures may enhance patient morbidity by increasing scarring and creating a further wound at the donor site.
The use of a skin regeneration system (Integra; Integra Life Sciences Corp, Plainsboro, NJ, USA) has previously been reported to provide good healing for defects of the head and neck. More recently, Singh et al. demonstrated its use in the management of ORN communicating with extraoral wounds. The authors decided to trial the Integra skin regeneration system intraorally on a small to moderate-sized mandibular defect following the debridement of necrotic bone and placement of an extraoral reconstruction plate. The aim was to eradicate the oral communication with the bone and promote full bony healing in a closed environment.
Integra is made of a combined bovine type I collagen and shark chondroitin-6-sulphate glycosaminoglycan bound to a silicone pseudoepidermis. The bovine dermal collagen component allows fibroblasts to be incorporated into the Integra matrix, resulting in the formation of a neodermis. It then facilitates graft placement onto the neodermis. A one-stage Integra procedure with subsequent healing by secondary intention has been shown to be successful in other areas of the head and neck. Thus, it was aimed to trial a one-stage procedure using Integra to gain healing in an intraoral mandibular defect arising in ORN.
A 54-year-old male presented to the department of oral and maxillofacial surgery with pain, difficulty eating, and a foul taste in his mouth that he had experienced with increasing severity over the previous 3 months. He also had anaesthesia of his right inferior dental nerve. His medical history included a left-sided tonsillar carcinoma treated with surgical excision and radiotherapy 5 years previously. He had not had a dental health assessment before treatment. He was fit and well, taking no regular medication.
Clinical examination revealed a 2.4 × 1.5 cm intraoral defect with exposed and visibly necrotic bone associated with an active draining infection ( Fig. 1 A). Radiographic and histological examination confirmed ORN surrounding his lower right first and second molar teeth and a pathological fracture of the mandibular angle. The two teeth involved in the area of ORN were extracted and the patient was placed on antibiotics prior to a second-stage procedure.