晚期药物相关性颌骨坏死的手术治疗

doi:10.7518/hxkq.2023.01.006

华西口腔医学杂志 ›› 2023, Vol. 41 ›› Issue (1): 43-51.doi: 10.7518/hxkq.2023.01.006

晚期药物相关性颌骨坏死的手术治疗

冯志强¹^,²^,³(), 安金刚¹^,²(), 张益¹^,², 贺洋¹^,²

^1.北京大学口腔医学院·口腔医院口腔颌面外科，北京 100081
^2.国家口腔医学中心国家口腔疾病临床医学研究中心口腔生物材料和数字诊疗装备国家工程研究中心口腔数字医学北京市重点实验室，北京 100081
^3.河北医科大学第三医院口腔颌面外科，石家庄 050051

收稿日期:2022-09-11 修回日期:2022-12-27 出版日期:2023-02-01 发布日期:2023-02-21
通讯作者: 安金刚 E-mail:kqfzq@hotmail.com;anjingang@126.com
作者简介:冯志强，主治医师，硕士，E-mail：kqfzq@hotmail.com

Surgical treatment of severe medication-related osteonecrosis of the jaw

Feng Zhiqiang¹^,²^,³(), An Jingang¹^,²(), Zhang Yi¹^,², He Yang¹^,²

^1.Dept. of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing 100081, China
^2.National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices ＆ Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
^3.Dept. of Oral and Maxillofacial Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang 050051, China

Received:2022-09-11 Revised:2022-12-27 Online:2023-02-01 Published:2023-02-21
Contact: An Jingang E-mail:kqfzq@hotmail.com;anjingang@126.com

摘要/Abstract

摘要：

目的总结晚期（2、3期）药物相关性颌骨坏死（MRONJ）的手术治疗效果。方法纳入2013年7月—2021年5月就诊于北京大学口腔医学院·口腔医院口腔颌面外科且采用手术治疗的晚期MRONJ患者。回顾性分析患者的临床资料，包括患者的原发疾病、用药情况、病变情况、手术治疗和随访结果等。结果本研究共纳入104例患者（123处病变），男性42例，女性62例，平均年龄（64.6±9.1）岁。原发疾病为恶性肿瘤91例，非肿瘤性疾病13例。2期病变43处（35.0%），3期病变80处（65.0%）。39处（31.7%）病变位于上颌骨，84处（68.3%）病变位于下颌骨。使用唑来膦酸89例（85.6%），阿仑膦酸钠10例（9.6%），帕米膦酸钠10例（9.6%），抗血管生成药物62例（59.6%）。平均药物治疗时长（34.7±25.8）月，平均停药时长（10.1±10.7）月。全部患者均在全麻下完成手术。手术去净死骨后，2期病变以局部黏骨膜瓣关闭创口，3期病变根据具体情况分别采用重建钛板联合下颌下腺转位、血管化腓骨瓣修复、碘仿纱条填塞、带蒂颊脂垫瓣修复等关闭创口。术后随访3个月至6年，81.3%（100/123）病变在末次随访时实现黏膜愈合，18.7%（23/123）病变术后复发。结论晚期MRONJ可以通过手术治疗实现黏膜愈合；对于合适的患者，可以考虑血管化软硬组织修复重建以提高生命质量。

Abstract:

Objective This study aimed to summarize the clinical outcomes of surgical treatment for severe medication-related osteonecrosis of the jaw (MRONJ, stages 2 and 3). Methods A retrospective cohort study was conducted to review the patients with severe MRONJ from July 2013 to May 2021. All patients were treated surgically. The characteristics and clinical variables were recorded and analyzed. Results A total of 104 patients (123 MRONJ lesions) were included, including 42 males and 62 females, aged 64.6±9.1 years. The primary disease was malignant in 91 cases and benign in 13 cases. Forty-three cases (35.0%) were stage 2 lesions, and 80 (65.0%) were stage 3 lesions. Thirty-nine (31.7%) lesions were located in the maxilla, and 84 (68.3%) lesions were located in the mandible. The most commonly used bisphosphonates were zoledronic acid (n=89; 85.6%), followed by alendronate (n=10; 9.6%), and pamidronate (n=10; 9.6%). Antiangiogenic agents were administered in 62 (59.6%) patients. The mean duration of bisphosphonate therapy was 34.7±25.8 months, and the mean duration of drug holiday was 10.1±10.7 months. All operations were performed under general anesthesia. For stage 2 lesions, debridement and saucerization were performed to completely resect the lesions, and the wounds were closed without tension through local mucoperiosteum flaps. For stage 3 lesions, after the lesions were completely resected, the bone defect was covered by reconstruction plate fixation and ipsilateral submandibular gland translocation, iodoform gauze, and buccal fat pad accordingly. The follow-up period ranged from 3 months to 6 years; 81.3% (100/123) of the lesions reached mucosal healing at the last follow-up, whereas wound infection and dehiscence occurred in 18.7% (23/123) of the lesions postoperatively. Conclusion Severe MRONJ lesions could be surgically treated to achieve mucosal healing. Vascularized flap reconstruction could be considered if the patient’s general condition could tolerate it.

Key words: medication-related osteonecrosis of the jaw, bisphosphonate-related osteonecrosis of the jaw, osteonecrosis, surgery

中图分类号:

R 782.05

冯志强, 安金刚, 张益, 贺洋. 晚期药物相关性颌骨坏死的手术治疗[J]. 华西口腔医学杂志, 2023, 41(1): 43-51.

Feng Zhiqiang, An Jingang, Zhang Yi, He Yang. Surgical treatment of severe medication-related osteonecrosis of the jaw[J]. West China Journal of Stomatology, 2023, 41(1): 43-51.

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特征		数值
性别	女性	62/59.6%
	男性	42/40.4%
年龄/岁		64.6±9.1
原发疾病，恶性		91/87.5%
乳腺癌		31/29.8%
肺癌		24/23.1%
肾癌		12/11.5%
多发性骨髓瘤		10/9.6%
前列腺癌		8/7.7%
大肠癌		3/2.9%
软组织肉瘤		1/1.0%
阴道癌		1/1.0%
肝癌		1/1.0%
原发疾病，良性		13/12.5%
骨质疏松症		5/4.8%
类风湿性关节炎		5/4.8%
天疱疮		2/1.9%
朗格汉斯细胞增生症		1/1.0%
药物危险因素*	唑来膦酸	89/85.6%
	阿仑膦酸钠	10/9.6%
	帕米膦酸钠	10/9.6%
	抗血管生成药物	62/59.6%
	BPs继以抗血管生成药物	59/56.7%
给药方式	静脉给药	93/89.4%
	口服给药	9/8.7%
	口服+静脉给药	1/1.0%
	皮下注射+静脉给药	1/1.0%
BPs治疗时长/月		34.7±25.8
停药时长/月		10.1±10.7
发病潜伏期/月		33.9±25.3
术前MRONJ持续时间/月		11.9±9.7
糖尿病		22/21.2%
激素治疗		51/49.0%
化疗		61/58.7%
病变分期	2	43/35.0%
	3	80/65.0%
上下颌分布	上颌	39/31.7%
	下颌	84/68.3%
解剖部位	颌骨前部（前牙区、前磨牙区）	19/15.4%
	颌骨前部（前牙区、前磨牙区）
	颌骨后部（磨牙区）	104/84.6%
局部诱因	牙周/种植体周围疾病	95/77.2%
	拔牙/义齿创伤	22/17.9%
	无明确诱因	6/4.9%

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晚期药物相关性颌骨坏死的手术治疗

Surgical treatment of severe medication-related osteonecrosis of the jaw

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