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Prediction of Osteoradionecrosis Following Radiation Therapy for Head and Neck Squamous Cell Carcinoma
Thomas Ren
*, Fares Lebbos, Richard Redett, Robin Yang, Pasha Shakoori
Plastic Surgery, Johhs Hopkins School of Medicine, Hopewell Junction, NY
Introduction: Osteoradionecrosis (ORN) of the mandible remains a debilitating complication of head and neck radiotherapy. Pre- and post-radiation dental and surgical trauma may influence ORN risk, however the current literature remains inconclusive regarding the impact of dental clearance and management. This study evaluates predictors of ORN in patients with head and neck squamous cell carcinoma (HNSCC) treated with radiation therapy. Methods: We conducted a retrospective study of patients with HNSCC who completed radiation treatment at a single tertiary center. Collected variables included demographics; dental factors (pre-radiation dental clearance, extractions, overall dental health, post-radiation dental treatment); radiation-related factors (tumor location, bone invasion, total dose); and surgical history (free fibula flap [FFF] reconstruction). The primary outcome was development of ORN. Results: A total of 462 patients were included (mean age 61±11 years, 78.4% male) and of which 47 patients (10.2%) developed ORN. Notably, pre-radiation dental clearance demonstrated no significant association with reduced ORN risk (39.3% vs. 40.4%; p=0.88). Patients with ORN were more likely to exhibit radiographic bone invasion (10.6% vs. 3.4%; p<0.05). In the multivariate model, post-radiation dental treatment (aOR 5.36, p<0.001) and smoking history (aOR 2.49, p=0.015) were independently associated with significantly increased odds. Fibula flap reconstruction was the strongest predictor, with patients being nearly 11 times more likely to develop ORN (aOR 10.70, 95% CI 4.96-23.08; p<0.001). Conclusion: This study highlights that bony invasion requiring FFF reconstruction and post-radiation dental trauma are the most potent predictors of ORN development, while pre-radiation dental clearance appears to offer minimal benefit against late-stage bony necrosis. Further prospective studies are needed to investigate a shift toward individualized, dental protocols to preserve the integrity of the vascularized bone graft and minimize long-term reconstructive morbidity.
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