Systematic Review: Are Vascularised Soft Tissue Flaps Superior to Conservative Management for Patients With Osteoradionecrosis (ORN) of the Mandible or Maxilla Without Clear Indications for Resection and Complex Reconstruction?

BACKGROUND

Osteoradionecrosis (ORN) of the mandible or maxilla is a significant complication of head and neck radiotherapy. Conservative management often fails, necessitating major composite reconstruction. Vascularised soft tissue flaps represent an intermediate surgical option for nonadvanced disease (Notani stages I-II), yet their outcomes remain incompletely characterized.

METHODS

A PICO-structured systematic search of MEDLINE, Embase, Web of Science, the Cochrane Database, and major trial registries was conducted (initial search: March 2022; rerun: May 2025). Two reviewers independently screened records using Rayyan software. Study quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for case series. Given the absence of direct comparative studies, a narrative synthesis was performed, and pooled proportions with Wilson 95% CIs were calculated for binary outcomes. The review is registered on PROSPERO (CRD420250295833).

RESULTS

No randomized controlled trials or direct comparative studies were identified. Fourteen retrospective case series (207 patients, 212 flaps) met the inclusion criteria. Pooled ORN resolution was 95.2% (95% CI: 91.3-97.4), flap failure was 3.4% (95% CI: 1.6-6.8), secondary surgery was 5.0% (95% CI: 2.7-8.9), minor complication rate was 7.4%, and mean length of stay was 4.5 days. All proportions are per patient. Periosteal flaps demonstrated osteoinductive capacity, with radiologic new bone formation confirmed in 2 studies.

CONCLUSIONS

Vascularised soft tissue flaps achieve high ORN resolution rates with low morbidity, reduced trismus, and short hospitalization for refractory nonadvanced disease. Indirect evidence supports a clinically meaningful benefit over continued conservative management and a substantial reduction in the eventual need for composite osseous reconstruction. These interventions provide meaningful patient choice when conservative management has failed or is unlikely to succeed. Randomized controlled trials are needed to establish definitive superiority.