Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Khashayar Arianpour; Joseph B Meleca; Sara W Liu; Brandon L Prendes; Peter J Ciolek; Dane J Genther; Craig Mangie; Sagar Khanna; Michael A Fritz

doi:10.1001/jamaoto.2023.1089

. 2023 Jun 1;149(7):621–627. doi: 10.1001/jamaoto.2023.1089

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Khashayar Arianpour ¹, Joseph B Meleca ², Sara W Liu ¹, Brandon L Prendes ¹, Peter J Ciolek ¹, Dane J Genther ¹, Craig Mangie ³, Sagar Khanna ³, Michael A Fritz ^1,^✉

PMCID: PMC10236321 PMID: 37261824

Key Points

Question

What are the long-term outcomes of the anterolateral thigh fascia lata (ALTFL) rescue flap for treatment of patients with mandibular osteoradionecrosis?

Findings

In this retrospective series of 52 ALTFL rescue flap procedures to treat mandibular osteoradionecrosis in 43 patients, successful arrest was noted on clinical and radiographic findings in 96.2% (50 cases); only 3.8% (2 cases) subsequently required fibular free flap reconstruction, and the complication rate was 1.9% (1 case). Parametric estimate analysis revealed a 96.9%, 94.6%, and 93.1% success rate of the ALTFL rescue flap procedure at 1, 3, and 5 years, respectively.

Meaning

The findings of this retrospective case series indicate that in carefully selected patients, the ALTFL procedure is a highly efficacious and low-morbidity option for the long-term management of mandibular osteoradionecrosis.

Abstract

Importance

Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique’s safety, effectiveness, and long-term outcomes is needed.

Objective

To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN.

Design, Settings, and Participants

This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023.

Main Outcomes and Measures

Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals.

Results

The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm². Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months.

Conclusions and Relevance

The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

This large retrospective case series evaluates the safety, effectiveness, and long-term outcomes of the anterolateral thigh fascia lata rescue flap to treat patients with mandibular osteoradionecrosis.

Introduction

Osteoradionecrosis (ORN) of the mandible is currently defined as nonhealing irradiated bone exposure of more than 3 months duration without evidence of neoplasia.^1,2,3 This definition has been continuously modified, and the necessity for mucosal breakdown and duration of exposure has been the subject of much debate.¹ Proposed pathophysiologic mechanisms include hypocellularity, hypoxia, and/or hypovascularity,⁴ and fibroblast dysregulation; free radical production; microvascular thrombosis; and local inflammation.⁵ Bacterial inoculation and infection also play an essential role in disease progression and impaired healing.⁶ These factors may produce fibroatrophic tissue with poor vascularity and impaired wound healing, forming a chronic wound that can progress to full-thickness mandibular involvement.^2,7

The mandible is the most prevalent subsite of head and neck ORN, attributed to its relatively poor vascular supply, high density, high affinity for radiation absorption, and continuous exposure to oral contamination. Mitigation and refinement of radiation exposure through intensity-modulated radiotherapy and the routine performance of prophylactic dental extractions have substantially decreased risk for patients; however, rates of ORN after oncologic management remain as high as 8%.⁸ Symptoms are progressive and often include pain, trismus, masticatory and swallow dysfunction, and chronic flares of infection, which have substantially affected patients’ quality of life (QOL).⁸ Despite many proposed treatment modalities, consistently effective therapies in managing mandibular ORN remain elusive.

Standard treatment paradigms are based on disease stage. In early or moderate disease, treatment options include observation, early surgical sequestrectomy or saucerization, hyperbaric oxygen therapy (HBOT), and more recently, targeted medical therapies. Unfortunately, a paucity of robust, large cohort randomized clinical trials support these options as the standard-criterion therapy. In advanced mandibular ORN, the presence of cutaneous fistulas, full-thickness bone involvement, or pathologic fractures necessitates segmental resection and free osteocutaneous microvascular reconstruction. This treatment incurs substantial expense, prolonged hospital stays, and a high risk of short- and long-term complications.⁹ The combination of ineffective treatment options for early or moderate disease and an often-progressive course frequently requires this highly morbid surgery.

Our institution has highlighted the anterolateral thigh fascia lata (ALTFL) rescue flap as a surgical option that can halt ORN progression, thus obviating the need for osteocutaneous reconstruction. Previously published case series^10,11,12 have demonstrated efficacy in various head and neck subsites with low morbidity and complication rates and abbreviated hospital stays. During the past decade, we have gained substantial experience with the ALTFL rescue flap in the setting of mandibular ORN and are presenting our findings of the long-term outcomes.

Methods

Approval was obtained before study initiation from the institutional review board of the Cleveland Clinic. Informed consent was waived because of the descriptive nature of the study. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were followed.

Study Design and Participants

A retrospective medical record review was performed of all patients from March 3, 2011, to December 31, 2022, who had been diagnosed with mandibular osteoradionecrosis that met classic inclusion criteria (3 months duration of exposed bone or obvious radiographic evidence of ORN, irradiated field, and exclusion of neoplasm) and who had been treated with the ALTFL rescue flap. Patients with full-thickness mandibular involvement, fistula, and bisphosphonate-induced osteonecrosis were excluded. Variables collected include patient demographic information, initial cancer diagnosis and site, mandibular defect subsite and size, prior failed therapies, preoperative assessment, intraoperative details, and postoperative outcomes. Only patients with at least 6 months of follow-up were included.

Operative Technique

The following steps summarize the operative technique of ALTFL rescue flap surgical procedure:

Transoral marginal mandibulectomy with limited subperiosteal elevation. Debridement of necrotic bone, sequestra, and mucosa until healthy well-vascularized tissue is encountered.
Dentition or implants within the field of ORN are extracted.
Sharp edges of bone are smoothened using a burr drill to avoid injury to the free flap.
The ensuing defect is measured, and the potential for long-term stability is evaluated. If residual bone height is substantially reduced (usually >1 cm of inferior border of the mandible), then free iliac crest bone graft is harvested and packed into the defect to promote additional bone formation.
An ALTFL free flap is harvested, similarly to a pure perforator fasciocutaneous ALT; however, suprafascial dissection is performed after flap isolation based on the pedicle to separate the skin and subcutaneous fat from the fascia lata.
This flap comprises a very thin, pliable, and highly vascularized sheet that can be layered into the defect and provide complete coverage of exposed bone.
Vascular access is obtained through a 3-cm incision at the facial notch, preauricular crease, or nasolabial fold to access the facial, superficial temporal, or angular vessels, respectively.
A subcutaneous tunnel is created; the free flap pedicle is passed from the intraoral defect to the access site; and microvascular anastomosis is performed.
The ALTFL is trimmed as needed taking care to preserve the perforators and is inset into the surrounding healthy mucosa. The fascia is folded and imbricated into the defect to completely obliterate the space with vascularized tissue.
A skin graft is harvested from the previously removed cutaneous ALT paddle on the back table. This graft is inset intraorally over any exposed fascia lata as a protective barrier for the early perioperative period.

Preoperative and surgical images are available in Supplement 1, eFigures 1A-C.

Statistical Analysis

For continuously measured outcomes, means (SDs) were used. To report descriptive statistics, ie, categorical variables, frequencies and proportions were used. Time-to-event data were estimated using Kaplan-Meier method, and group comparisons were performed using a log-rank test. Weilbull profile analysis was used to provide parametric estimates of progression. To quantify differences between groups, effect-size measures were used. P values were only used in reporting the log-rank test because a feasible effect-size measure does not exist for describing this difference.

Multivariable Cox regression was used to analyze time to progression and estimate hazard ratios (HRs) for variables. Statistical analysis was performed in JMP, version 15.0 (SAS Institute, US), and Jamovi, version 2.3 (The Jamovi Project, Australia) from January 1 to March 26, 2023. A probability of < .05 was deemed to be statistically significant.

Results

General Characteristics

A total of 43 patients with mandibular ORN who underwent 52 ALTFL rescue flap procedures were identified. Their mean (SD; range) age at the time of rescue flap surgery was 66.1 (8.2; 47-80) years; 24 (55.8%) were male and 19 (44.2%), female; 8 (18.6%) patients had bilateral disease; of the remainder with unilateral disease, 21 (48.8%) had right-sided and 14 (6.0%) had left-sided disease.

The exact subsites of mandibular ORN are depicted in Figure 1, and subsite combinations are listed in the Table. Of the 52 rescue flap procedures, subsites included mandibular body (90.4%), angle (73.1%), body and angle (32.7%) or body and angle plus additional adjacent subsites (30.8%). Aside from an extracted single tooth at the site of ORN, 88.5% of 52 procedures involved mandibular bone that was dentulous in the surrounding region.

Table. Distribution of Mandibular ORN by Subsite Involvement in Patients Undergoing ALTFL Rescue Flap Procedure.

Mandibular subsite	No. (%)
Patients, No.	43 (100)
Laterality
Bilateral	8 (18.6)
Right	21 (48.8)
Left	14 (32.6)
Subsite
Ramus	17 (33.3)
Angle	37 (72.5)
Body	47 (92.2)
Parasymphysis	11 (21.6)
Symphysis	3 (5.9)
Subsite combinations
Angle only	2 (3.9)
Angle and ramus	2 (3.9)
Body only	9 (17.7)
Body and angle	17 (33.3)
Body, angle, and ramus	10 (19.6)
Body, parasymphysis, and symphysis	3 (5.9)
Parasymphysis and body	2 (3.9)
Parasymphysis, body, and angle	1 (2.0)
All subsites	5 (9.8)

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Abbreviations: ALTFL, anterolateral thigh fascia lata; ORN, osteoradionecrosis.

Most (92.3%) of the radiated tumors were of squamous cell carcinoma pathology (78.7% oropharynx, 19.1% oral cavity, and 2.1% unknown primary). The remainder of treated tumors were nonsquamous parotid cancers (7.8%) and oral cavity adenoid cystic carcinoma (2.0%). Before development or exacerbation of ORN, cases involved either recent dental extraction (50.9%), root canal or implant work (11.8%), or dental manipulation or trauma to the region (3.9%). In 25 (57.7%) of the 43 patients, HBOT had been completed on presentation (mean, 29.2 dives); retinal detachment was suspected in 2 of these patients.

Rescue Flap

All 43 patients had undergone at least 1 preoperative imaging workup, computed tomography (CT) of the face, mandible, and neck (31 patients; 72.1%), and/or panoramic radiography (31 patients; 72.1%). Preoperative Notani staging¹³ of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%) were stage II; and 14 (30.4%) were stage III. The mean (SD; range) of the defect’s length, width, and area were 5.3 (2.4; 3.0-15.0) cm, 3.8 (1.5; 2.0-8.0) cm, and 20.9 (17.6; 6.0-90.0) cm², respectively (Figure 2). Dental extraction of 1 or more teeth during ALTFL rescue flap surgery was performed in 41 (78.8%) procedures. Microvascular anastomosis was performed using superficial temporal (29 procedures; 55.7%), facial (22; 42.3%), or angular (1; 1.9%) vessels via minimally invasive access. Free iliac crest bone grafting was performed concurrently in 9 (17.3%) procedures.

Figure 2. — The difference in the probability density is the probability per unit on the x-axis. ALTFL refers to the anterolateral thigh fascia lata and ORN to osteoradionecrosis.

After undergoing ALTFL rescue flap surgery, ORN arrest was noted by both the clinical and radiographic findings of 50 (96.2%) of the 52 procedures, with subsequent fibular free flap reconstruction required in only 2 (3.8%) cases. The major complication rate was 1.9% (1 case).

The distribution of clinical and radiographic progression-free plots was assessed, and no statistically significant difference was noted between Notani staging¹³ groups (log-rank P = .43 and P = .43, respectively). That is, patients in the Notani stage III group had no significant difference in risk of clinical progression (HR, 0.866; 95% CI, 0.054-13.853) or radiographic progression (HR, 0.959; 95% CI, 0.059-15.474) compared with those in the Notani stage I group. Given that there were zero participants with Notani stage II who experienced clinical or radiographic progression (zero event), employing Cox regression for this stage yielded degenerate estimates of HRs and 95% CIs, and is therefore not reportable.

Successful mandibular ORN arrest for the 52 procedures was estimated to be 96.9%, 94.6%, and 93.1% at 1, 3, and 5 years, respectively. The only major complication was free flap vascular compromise in 1 (1.9%) procedure. Minor complications occurred in 6 (11.5%) cases, with thigh hematoma in 2 and thigh seroma in 4 cases. Additional pre- and postoperative surgical images detailing the success of this treatment are available in eFigures 2A to 3B in Supplement 1.

The mean duration (range) of hospital stay was 2.7 (0-7.0) days, with a 2-day stay being the most common (19 procedures; 36.5%). Mean (SD) radiographic follow-up was 29.3 (30.7) months; clinical follow-up was 26.3 (28.7) months.

Discussion

The management of mandibular ORN cases ranges from observation to surgical extirpation and complex reconstruction. Traditionally, treatment has leaned toward conservative measures because manipulation often exacerbates poor-healing wounds. In addition, there have been reports of 219 spontaneous resolutions in as many as 60% of localized disease cases.¹⁴ However, adopting a watch and wait policy must be practiced cautiously because delaying treatment has been associated with a greater risk of disease progression.^1,2,9 Additionally, the continuously changing definitions of ORN have produced heterogeneity within the literature with respect to diagnosis.⁹ Therefore, previously reported spontaneous resolution rates may be an overestimate. For example, if a shorter duration than 3 months is used to diagnose ORN, it may capture patients with mucosal radionecrosis without mandibular involvement. That is a separate entity from ORN and is characterized by bone exposure, often secondary to mucosal trauma, which typically resolves over weeks.^1,9 To our knowledge, no large-scale studies evaluate the efficacy of conservative management of mandibular ORN. Smaller case series, such as that reported by Wong and colleagues (n = 32), have reported resolution, improvement, or asymptomatic stabilization in 48.3%, 3.4%, and 13.8% of patients, respectively.¹⁵

In treating advanced mandibular ORN, the established standard criterion is segmental resection with osteocutaneous free flap reconstruction, most commonly with a fibular free flap.^3,9,16,17 Necrotic bone is excised and replaced with nonirradiated and well-vascularized bone. A robust blood supply to the region has been associated with improved wound healing and symptomatic resolution.^18,19 Although nearly 90% effective, the morbidity of the fibular free flap can be substantial. Therefore, osteocutaneous free flap reconstruction is often reserved for symptomatic patients with disease unresponsive to conservative therapy or in whom there is evidence of pathologic fracture or fistulization.²⁰

Patients presenting with recalcitrant disease have often been unsuccessfully treated with antibiotics; most have also undergone unsuccessful HBOT. Many patients do not have clinical or radiographic evidence of advanced full-thickness disease. Therefore, their treatment presents a dilemma. In the past, similar to many institutions, we offered highly morbid but definitive osteocutaneous reconstruction. Alternatively, patients could opt to continue with conservative therapy, frequent temporizing debridement with overall diminished QOL, while awaiting end-stage progression. More than a decade ago, we began to offer a third option, the ALTFL rescue flap technique. We previously reported on this technique and our early experiences with halting mandibular ORN progression.¹⁰ Now, with long-term outcomes, we were able to present continued success among a larger cohort.

Patient selection was based on both clinical and radiographic evaluation. Patients typically presented with pain, swelling, drainage, and/or exposed bone, despite several treatment courses of antibiotics and/or HBOT. Computed tomography imaging demonstrated disruption of cortical bone, lytic and sclerotic areas, sequestra, and possible pathologic fractures. Dental panoramic radiograph imaging revealed ill-defined nonsclerotic borders with lytic regions.²¹

At our institution, disease severity is estimated by the Notani¹³ staging system, which uses the inferior alveolar nerve canal (IANC) as a critical landmark. Stage I is confined to the alveolar bone. Stage II involves the mandibular bone above the level of IANC. In addition to pathologic fractures and cutaneous fistulas, stage III may be characterized by any mandibular involvement below the level of the IANC. The ALTFL free flap technique is reserved for symptomatic patients of any Notani stage without evidence of fracture or cutaneous fistula. Any site suggestive of cancer recurrence is biopsied, and any malignant neoplasm is definitively ruled out before proceeding with this rescue flap procedure.

It is well established that patients with ORN are at higher risk for flap complications (21%-60%) and flap loss (0%-20%).^20,22,23,24 Most recently, this was highlighted in a sizeable single-institution series of 76 patients who underwent definitive segmental mandibulectomy and reconstruction for mandibular ORN.²⁵ A total 65% of patients experienced postoperative complications, and 49% required a return to the operating room. A total of 24% of patients had more than 1 complication. Approximately 11% of patients required tracheostomy, and perioperative mortality reached 4%. These findings starkly contrast with our experience with the ALTFL rescue flap technique. Although patient-level data were unavailable from that study,²⁵ only 49% and 38% of patients had a pathologic fracture or fistula, respectively. In other words, most patients were potential candidates for an ALTFL rescue flap procedure.

The difficulty in the treatment of mandibular ORN lies in its progressive nature. Given the marked contrast concerning the invasiveness of therapy in early vs late-stage disease, conservative measures and less invasive surgery are typically exhausted before pursuing segmental resection. To this point, much effort has been devoted to developing disease-modifying interventions that delay or halt disease progression. The earliest attempts at this were founded in HBOT, which was introduced in the early 1970s.^4,9,26 The proposed primary mechanism of HBOT was an increase in local tissue oxygen tension associated with improved wound healing²⁷; those authors developed an HBOT protocol integrated with their proposed staging system that was centered entirely on HBOT. In recent years, the efficacy of HBOT for treating craniofacial ORN has been questioned. Initial trials of HBOT were unblinded, had small cohort sizes, and were nonreplicable; at best, they reported a 15% resolution rate.

Moreover, most patients required concomitant surgical intervention ranging from sequestrectomy to extensive resection.^9,22,26,27 Therefore, HBOT was intended to be an adjunct to surgery, especially in moderate to severe stages of the disease. In 2019, a randomized prospective multicenter unblinded trial in the UK²⁸ demonstrated no role for HBOT in preventing mandibular ORN after dentoalveolar surgery. In 2022, Forner and colleagues²⁹ combined data from 2 randomized clinical trials and did not find an advantage in healing outcomes after surgical debridement of ORN when comparing HBOT with standard care. Furthermore, a multidisciplinary guideline and review by Sultan and colleagues underscored the lack of consistent evidence for routine HBOT to prevent or treat mandibular ORN and recommended against it.²⁷

As our understanding of ORN pathophysiology has expanded, several targeted pharmacologic therapies have been proposed for treatment. The most common ones include pentoxifylline, tocopherol (vitamin E), and clodronate. In isolation, none of these drugs or vitamins have demonstrated curative efficacy. However, these medications act via different mechanisms and combinations, which appear to confer synergism. Pentoxifylline-tocopherol-clodronate combination therapy has been under recent investigation and has shown promising preliminary results as a nonadjunctive therapy for early stage I disease. Unfortunately, in late-stage (II or III) disease, it has failed to halt progression, and many patients developed advanced disease.^30,31

To our knowledge, the ALTFL rescue flap procedure is currently the only available treatment option with high efficacy and low morbidity for moderate stage ORN.^10,11,12 Our findings from the present study indicate a halt in ORN progression in nearly all patients postoperatively.

There are several advantages to offering the ALTFL rescue flap procedure. First, donor site morbidity is low.^{10,11,32,33,34,35,36} Also, given that patients with ORN are at high risk for advanced cancer recurrence—and may require future salvage resection and reconstruction—the ALTFL rescue flap procedure is an important option because it does not preclude future fibula free flap reconstruction. This procedure also does not render revision surgery more difficult or limit other options because the transoral approach to the mandible and the minimal access incision for vessels minimize the need for transcervical dissection.¹⁰

Overall, this de-escalation of care is of particular importance because prior studies have demonstrated marginal improvement in QOL measures in Notani stage III disease after microvascular osteocutaneous reconstruction.^8,37 Contrera and colleagues also reported that an increase in elapsed time from diagnosis of ORN to surgery was associated with higher rates of flap complications.³⁸ This may support the decision to intervene sooner with free flap reconstruction rather than await continued progression.

An additional advantage is financial; prior studies have demonstrated surgical resection and osteocutaneous reconstruction with a 7-day postoperative hospital stay are more cost-effective than conservative and hyperbaric therapies.³⁸ In addition, it was noted that nearly half of the median charges for hospitalization after osteocutaneous reconstruction were related to complications. Therefore, we would expect that the economic advantage of our ALTFL rescue flap technique must be even greater given that the average postoperative hospital stay has been just 2 to 3 days and the complication rate has been very low.

There continue to be advancements in treatment options for mandibular ORN—both surgical and nonsurgical. We are currently developing a treatment algorithm and new staging system that includes the ALTFL rescue flap technique.

Limitations

Although we report high efficacy and low complication rates with the rescue flap technique for mandibular ORN, our study had limitations. First, it was a single-institution report and was retrospective. Moreover, preoperative imaging, especially plain films, can often underestimate the extent of the disease. Therefore, patients should be prepared for more extensive resection, if necessary.

Conclusions

The findings of this retrospective case series study suggest that the ALTFL rescue flap procedure is a highly effective low-morbidity treatment option for patients with symptomatic ORN, and can successfully halt progression across the disease spectrum. The management of mandibular ORN is complex and a myriad of nonsurgical treatment options exist that have variable effectiveness. When disease progression ensues, the surgeon is faced with the difficult decision of when to intervene. The current standard criterion is osteocutaneous reconstruction, a definitive treatment when it is successful; however, it is highly morbid. Conversely, the ALTFL rescue flap procedure has been associated with low morbidity and high effectiveness. A prospective clinical trial of the ALTFL rescue flap technique, including primary resolution outcomes and secondary QOL measures, is needed.

Supplement 1.

eFigure 1A. Intraoperative image of a patient with left mandibular body ORN

eFigure 1B. Intraoperative image of the defect in left mandibular body after debridement to viable bone

eFigure 1C. Intraoperative image of the defect packed with harvested iliac crest bone graft

eFigure 2A. Intraoperative image of ATLFL rescue flap after inset for bilateral mandibular osteoradionecrosis (right shown only)

eFigure 2B. Postoperative image of same patient demonstrating integration and mucosalization of flap at 1 year (right side)

eFigure 2C. Postoperative image of same patient demonstrating integration and mucosalization of flap at 1 year (left side)

eFigure 3A. Preoperative panorex of left mandibular body ORN surrounding dental implant (pre-operative Notani II, intraoperative Notani III after debridement)

eFigure 3B. Panorex of same patient at 9 months post-operatively after rescue flap and iliac crest bone graft demonstrating viable smooth borders, adequate height and no further evidence of ORN

Click here for additional data file.^{(778.5KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(14.3KB, pdf)}

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