Fibula flap versus soft tissue flap with reconstruction plate for mandibular stage 3 medication-related osteonecrosis of the jaw: a retrospective cohort study.

Introduction

Bone-modifying agents (BMAs), including bisphosphonates (BPs) and denosumab (Dmab), are widely used to treat malignant tumor bone metastases, multiple myeloma, osteoporosis, and other conditions [ 1 ]. While effective in preventing skeletal-related events (SREs), such as hypercalcemia and pathological fractures, BMAs can lead to a serious adverse event known as medication-related osteonecrosis of the jaw (MRONJ) [ 1 – 3 ]. MRONJ most commonly affects the mandible, presenting with symptoms such as pain, purulent discharge, and exposed necrotic bone [ 2 ]. As per the updated position paper published by the American Association of Oral and Maxillofacial Surgeons (AAOMS), mandibular stage 3 MRONJ is defined not only by the aforementioned signs of infection, but also by one or more of the following: (1) exposed necrotic bone extending beyond the region of alveolar bone; (2) pathologic fracture; (3) extraoral fistula; (4) osteolysis extending to the inferior border of the mandible [ 1 ]. This condition significantly reduces oral health-related quality of life (OHRQoL) [ 3 ].

Treatment strategies for mandibular stage 3 MRONJ can be categorized into nonoperative and operative approaches [ 1 ]. Nonoperative treatment focuses on stabilizing the condition through anti-infective management, pain control, and other supportive measures. However, this approach often has limited effectiveness and may contribute to disease progression [ 4 ]. Increasing evidence supports early surgical intervention for mandibular stage 3 MRONJ [ 5 , 6 ]. Radical resection, involving the complete removal of necrotic bone and infected soft tissue, is important to reduce the risk of recurrence [ 7 , 8 ]. Following radical mandibulectomy, both fibula flap (FF) and soft tissue flap with reconstruction plate (SR) are commonly used as primary reconstruction techniques [ 9 – 11 ].

FF is a reliable method for reconstructing both hard and soft tissue defects in the mandible, restoring facial appearance. The skin paddle also helps achieve tension-free wound closure [ 12 ]. However, there are several concerns associated with FF: (1) MRONJ patients often have poor overall health, which may limit their ability to tolerate FF transplantation; (2) there is a risk of metastasis from primary malignant tumors to the grafted FF; (3) complications may arise at the donor site; and (4) the fibula may be affected by BMAs [ 13 , 14 ]. These factors have led some surgeons to prefer the SR approach. Although SR does not provide the same functional recovery as FF, it is less invasive, offers adequate stability, and may be more suitable for patients with limited life expectancy [ 14 ]. Therefore, the choice between FF and SR for mandibular stage 3 MRONJ remains controversial and requires further investigation.

With the expanding indications for BMAs and the development of new related drugs, the incidence of MRONJ is expected to rise, making it important to address this ongoing controversy [ 3 ]. This study aims to compare intraoperative and postoperative outcomes, as well as OHRQoL, between FF and SR. The findings will provide valuable evidence to guide surgeons in selecting reconstruction methods for patients with mandibular stage 3 MRONJ.

Materials and methods

Study design and patients

This retrospective cohort study included patients diagnosed with mandibular stage 3 MRONJ who received reconstructive treatment at the Department of Oral and Maxillofacial Surgery, Fujian Medical University Union Hospital, between September 2018 and May 2024 (Fig. 1 ). This study was approved by the Ethical Committee of Fujian Medical University Union Hospital (2024KY242) and was conducted in accordance with the principles of the Declaration of Helsinki. The inclusion criteria were: (1) diagnosis of mandibular stage 3 MRONJ based on the 2022 AAOMS position paper; (2) underwent reconstructive surgery; (3) a minimum follow-up period of six months. Exclusion criteria included: (1) contraindications to general anesthesia; (2) history of radiation therapy or metastatic disease involving the jaws. Fig. 1 The flow diagram of the present study

Demographic and general characteristics were obtained from patient records (Table 1 ). The choice of reconstructive method was primarily based on the extent and location of the mandibular defect, as well as the anticipated reconstructive needs. All patients were informed of the benefits and risks of both FF and SR, and the final decision was made through shared decision-making between the surgeon and patient. Table 1 Demographic and general characteristics of patients FF ( n = 17) SR ( n = 12) P value Age (yr) mean ± SD 62.6 ± 9.7 68.4 ± 9.2 a 0.115 Gender n (%) b 0.710 Male 9 (52.9) 5 (41.7) Female 8 (47.1) 7 (58.3) BMI (kg/m 2 ) median (Q1, Q3) 22.0 (19.0, 25.5) 20.5 (19.3, 23.0) c 0.607 Primary disease n (%) d 0.149 Osteoporosis - 1 (8.3) Multiple myeloma 8 (47.1) 1 (8.3) Metastatic lung cancer 3 (17.6) 3 (25.0) Metastatic breast cancer 4 (23.5) 3 (25.0) Metastatic prostate cancer 2 (11.8) 4 (33.3) Type of drugs n (%) d 0.687 Zoledronic acid 10 (58.8) 9 (75.0) Ibandronate 1 (5.9) - Denosumab 2 (11.8) - More than one drug 4 (23.5) 3 (25.0) Drug administration duration (yr) mean ± SD 2.5 ± 1.3 2.8 ± 1.9 a 0.594 Drug holiday (mo) median (Q1, Q3) 5.0 (2.4, 9.8) 6.0 (1.5, 10.5) c 0.912 Predisposing factors n (%) d > 0.999 Tooth extraction 7 (41.2) 6 (50.0) Implant 1 (5.9) - Spontaneous 9 (52.9) 6 (50.0) Past treatment history n (%) d 0.675 Antibiotic therapy 9 (52.9) 6 (50.0) Curettage 8 (47.1) 5 (41.7) None - 1 (8.3) ASA classification n (%) b > 0.999 Ⅰ-Ⅱ 13 (76.5) 10 (83.3) Ⅲ 4 (23.5) 2 (16.7) FF Fibula flap, SR Soft tissue with reconstruction plate, yr year, mo month, SD Standard deviation, BMI Body mass index, Q1 Quartile 1, Q3 quartile 3, ASA American Society of Anesthesiologists a Independent-sample t-test b Fisher’s exact test c Non-parametric Mann–Whitney test d Fisher-Freeman-Halton exact test

Surgical treatment

For patients planned for FF reconstruction, single-photon emission computed tomography (SPECT) was used to exclude fibular involvement by malignant tumors, as indicated by the absence of 99mTc-methylene diphosphonate (99mTc-MDP) accumulation in the fibula (Fig. 2 ). Fig. 2 Preoperative SPECT revealed accumulation of 99mTc-MDP in the MRONJ area (red arrows), while no accumulation of 99mTc-MDP was observed in the fibula (blue arrows)

All surgeries were performed by the same surgical team under general anesthesia with nasotracheal intubation. Osteolysis was initially evaluated with CT imaging to assess the extent of MRONJ, and intraoperative resection margins were confirmed based on bone bleeding and color. Necrotic bone and inflamed soft tissue were completely removed, and a reconstruction plate was placed to restore mandibular continuity and provide mechanical stability.

In the FF group, the flap was prepared using conventional methods to repair the mandibular defect, followed by microvascular anastomosis. In the SR group, depending on the extent of the defect, either a local flap or a free flap was used to fill dead space.

Perioperative intravenous cefuroxime sodium and ornidazole were administered. The intraoral wound was cleaned daily with normal saline. Enteral nutrition via nasogastric tube was initiated on the second postoperative day. Early ambulation was encouraged. Intraoral sutures and the nasogastric tube were removed 14 days post-surgery. The specific details of management can be referred to the article published by our group [ 15 ].

Preoperative and postoperative panoramic radiographs of representative cases are shown in Figs. 3 and 4 , with clinical photographs of Case 1 in Figs. 5 and 6 . Fig. 3 Panoramic radiographs of the FF group Fig. 4 Panoramic radiographs of the SR group Fig. 5 Clinical photographs of Case 1 in the FF group A Intraoral image showing exposed necrotic bone in the left mandible (pointed by red arrow). B Extraoral image showing erythema and swelling in the left submandibular skin. C Exposure of the affected bone. D Complete excision of the affected mandible and inflamed skin and mucosa. E Design and harvesting of the fibula flap. F Shaping and reconstruction of the fibula flap for the mandibular defect, with the skin paddle placed extraorally (pointed by white arrow) Fig. 6 Clinical photographs of Case 1 in the SR group A Intraoral image showing exposure of necrotic bone in the left mandible (pointed by red arrow). B Extraoral image showing a skin fistula on the left submandibular region. C Adequate exposure of the pathological tissue. D Removal of the pathological mandible. E Design and harvesting of the anterolateral thigh flap. F Reconstruction of the defect using the anterolateral thigh flap with a reconstruction plate. Anastomosis was performed using microvascular technique (pointed by cyan arrow)

Intraoperative and postoperative outcomes and OHRQoL

Intraoperative outcomes included defect size, defect area, and operative time. Size of defect was expressed by the maximal diameter [ 16 ]. Area of defect was categorized into lateral and anterior defects [ 17 ]. Postoperative outcomes included hospital stay, plate-related complications (plate exposure, plate fracture, screw loosening), wound-related complications (wound infection, wound fistula), recurrence, survival status. Recurrence was defined as the presence of necrotic bone exposed or intraoral/extraoral fistula at the original surgical site persisting for more than eight weeks [ 15 ]. Postoperative OHRQoL was assessed using the Chinese version of oral health impact profile-14 (OHIP-14), with scores ranging from 0 to 56, where lower scores indicate better OHRQoL. The English version of this questionnaire has demonstrated good reliability and validity [ 18 ]. The Chinese version of OHIP-14 has been translated, cross-culturally adapted, and validated [ 19 ]. The questionnaire was administered at six months postoperatively. Patients who had died were excluded from the questionnaire collection.

Microsurgical outcomes of the FF group

Microsurgical outcomes included total flap loss, partial flap loss, non-union, second flap procedure, donor site complications (delayed healing, wound infection, wound dehiscence, tibial fracture), lower extremity function. Postoperative lower extremity function was assessed using the Chinese version of lower extremity functional scale (LEFS), ranging from 0 to 80, with higher scores indicating better function. The English version of this questionnaire has demonstrated strong reliability and validity [ 20 ]. The Chinese version of LEFS has been translated, cross-culturally adapted, and validated [ 21 ]. The questionnaire was administered at six months postoperatively. Patients who had died or had motor diseases were excluded from the questionnaire collection.

Statistical analysis

Statistical analyses were performed using SPSS (IBM SPSS Statistics 27.0). Normal distribution of continuous variables was assessed with the Shapiro–Wilk test. Normally distributed data were expressed as mean ± standard deviation (SD) and comparison between two groups using independent-sample t-test. Non-normally distributed data were expressed as median (quartile 1 [Q1], quartile 3 [Q3]) and comparison between two groups using non-parametric Mann–Whitney test. Categorical variables in 2 × 2 contingency tables were evaluated using Fisher’s exact test. For contingency tables larger than 2 × 2, the Fisher-Freeman-Halton exact test was used. Kaplan–Meier analysis and log-rank test were performed to assess plate-related complication-free survival and overall survival. A P value < 0.05 was considered statistically significant.

Results

Demographic and general characteristics of patients

The study initially included 30 patients, but one was lost to follow-up, resulting in a final analysis of 29 patients. Based on the type of reconstruction, 17 patients were assigned to the FF group and 12 to the SR group (Fig. 1 ). No statistically significant differences were observed between the two groups regarding age, gender, body mass index (BMI), or types of primary disease ( P > 0.05). Zoledronic acid (ZA) was the most commonly used BMA in both groups. ZA and ibandronate were administrated intravenously, whereas Dmab was given subcutaneously. The drug administration duration and drug holiday showed no significant differences between the two groups ( P > 0.05). The proportions of MRONJ triggered by tooth extraction (41.2% vs. 50.0%) or occurring spontaneously (50.0% vs. 50.0%) were comparable. Only one patient in the SR group had no history of past treatment, while the others had received either antibiotic therapy or curettage ( P > 0.05). In addition, no significant differences were noted in the American Society of Anesthesiologists (ASA) classification between the two groups ( P > 0.05) (Table 1 ).

Intraoperative and postoperative outcomes and OHRQoL

The intraoperative and postoperative outcomes of the two groups are shown in Table 2 . The median defect size in the FF group was 5.5 cm (4.8, 6.3 cm), while in the SR group it was 5.2 cm (4.2, 5.6 cm). No statistically significant differences were observed between the two groups regarding defect size or area. In the SR group, reconstruction options included mucoperiosteal flaps in five patients, submental island flaps in six patients, and an anterolateral thigh flap in one patient, selected according to the extent of the defect. The operative time was significantly longer in the FF group compared to the SR group (225.0 [179.5, 270.0] minutes vs. 131.0 [115.0, 160.0] minutes, P < 0.001). Table 2 Intraoperative and postoperative outcomes of two groups FF ( n = 17) SR ( n = 12) P value Intraoperative Size of defect (cm) median (Q1, Q3) 5.5 (4.8, 6.3) 5.2 (4.2, 5.6) a 0.199 Area of defect n (%) b 0.683 Lateral 13 (76.5) 8 (66.7) Anterior 4 (23.5) 4 (33.3) Operative time (min) median (Q1, Q3) 225.0 (179.5, 270.0) 131.0 (115.0, 160.0) a < 0.001 * Postoperative Hospital stay (d) median (Q1, Q3) 14.0 (10.0, 18.0) 11.0 (8.0, 18.0) a 0.257 Plate-related complications n (%) Plate exposure - 5 (41.7) b 0.007 * Plate fracture - - - Screw loosening 1 (5.9) - b > 0.999 Wound-related complications n (%) Wound infection 4 (23.5) 5 (41.7) b 0.422 Wound fistula 3 (17.6) 5 (41.7) b 0.218 Recurrence n (%) 2 (11.8) 2 (16.7) b > 0.999 Survival status n (%) b 0.622 Live 15 (88.2) 9 (75.0) Dead 2 (11.8) 3 (25.0) FF Fibula flap, SR Soft tissue with reconstruction plate, Q1 Quartile 1, Q3 Quartile 3, min minute, d day a Non-parametric Mann–Whitney test b Fisher’s exact test * P value is significant

The median hospital stay was longer in the FF group (14.0 [10.0, 18.0] days) than in the SR group (11.0 [8.0, 18.0] days), although the difference was not statistically significant ( P > 0.05). Compared to the FF group, the rate of plate exposure was significantly higher in the SR group (0.0% vs. 41.7%, P = 0.007). Among the five patients with plate exposure in the SR group, two underwent plate removal. One patient healed well after direct wound closure. The other received a reduced-profile plate, but plate re-exposure developed postoperatively. This patient was unwilling to undergo additional surgical treatment, and the condition eventually progressed to recurrence. Two additional patients were managed with bedside debridement and suturing combined with compression bandaging. One of them healed well, whereas the other showed persistent poor wound healing and later died due to cardiac arrest. The remaining patient with plate exposure was unwilling to receive further surgery. Prolonged dressing changes were performed, but the response was unsatisfactory and ultimately resulted in recurrence (Table 3 ). No plate fractures occurred in either group. In the FF group, one patient experienced screw loosening and wound fistula due to total flap loss. Plate-related complication-free survival was significantly better in the FF group (HR = 0.12, 95% CI = 0.02–0.62, P = 0.019) (Fig. 7 A). Regarding wound-related complications, the rates of wound infection and wound fistula were lower in the FF group, although the differences were not statistically significant (23.5% vs. 41.7%, P > 0.05; 17.6% vs. 41.7%, P > 0.05). Two patients in the FF group developed persistent extraoral fistulae and were diagnosed with recurrence. One patient was unwilling to receive further surgical intervention, and the other showed poor healing after reoperation but remained clinically stable under conservative management. The number of recurrences was the same in both groups, with two cases in each group, and the difference was not statistically significant ( P > 0.05). During the follow-up periods, no significant difference was observed in overall survival between the two groups (HR = 0.74, 95% CI = 0.13–4.31, P = 0.712) (Fig. 7 B). Table 3 Clinical data of patients with plate-related complications in SR group Sex Primary disease Comorbid diagnoses Type of BMAs Other drugs Type of soft tissue flaps Time of onset (mo) Managements Outcomes Female Metastatic lung cancer None ZA Icotinib Osimertinib Anlotinib MF 1.0 Plate removal Debridement and suturing Healed well Male Metastatic lung cancer Postobstructive pneumonia Hypertension ZA Bevacizumab Carboplatin Pemetrexed Lenvatinib SIF 9.3 Dressing changes Recurrence ‡ Male Metastatic prostate cancer None ZA Abiraterone acetate Prednisolone acetate Bicalutamide SIF 1.5 Plate removal Reduced-profile plate implantation Recurrence ‡ Female Osteoporosis Rheumatoid arthritis Anemia Electrolyte disorders Hypoproteinemia ZA Dmab Methotrexate Methylprednisolone Hydroxychloroquine sulfate SIF 0.5 Bedside debridement and suturing Compression bandaging Plate exposure ‡‡ Male Metastatic prostate cancer Anemia Diabetes Hypertension ZA Leuprorelin acetate Prednisolone acetate Bicalutamide MF 0.7 Bedside debridement and suturing Compression bandaging Healed well BMAs Bone-modifying agents, ZA Zoledronic acid, Dmab Denosumab, MF Mucoperiosteal flap, SIF Submental island flap, mo month ‡ Unwilling to receive additional surgery ‡‡ Died due to cardiac arrest Fig. 7 A Kaplan–Meier curve of the plate-related complication-free survival of two groups (Log-rank P = 0.019). B Kaplan–Meier curve of the overall survival of two groups (Log-rank P = 0.712)

Excluding deceased patients, OHIP-14 scores were obtained for 15 patients in the FF group, with a mean score of 17.0 ± 9.8, and for 9 patients in the SR group, with a mean score of 22.3 ± 9.1. The difference between the two groups was not statistically significant ( P = 0.198). The frequency distribution histogram of postoperative OHIP-14 score is shown in Fig. 8 . Fig. 8 The frequency distribution histogram of postoperative OHIP-14 score of the two groups. The blue dashed line represents the mean score of the FF group. The red dashed line represents the mean score of the SR group

Microsurgical outcomes of the FF group

The microsurgical outcomes of FF group are summarized in Table 4 . Table 4 Microsurgical outcomes of FF group FF (n = 17) Total flap loss n (%) 1 (5.9) Partial flap loss n (%) - Non-union n (%) 1 (5.9) Second flap procedure n (%) 1 (5.9) Donor-site complications n (%) Delayed healing 2 (11.8) Wound infection 1 (5.9) Wound dehiscence 1 (5.9) Tibial fracture -

At the recipient site, FF survival was achieved in 16 patients with successful bone healing. Only one patient experienced non-union due to total flap loss. A second surgery was performed to remove the necrotic FF, and the defect was reconstructed using a pectoralis major myocutaneous flap, resulting in successful wound healing.

At the donor site, primary healing was observed in 15 patients. Two patients experienced delayed healing. One of these cases involved wound dehiscence with infection. Both patients recovered within three months following regular dressing changes. No severe complications, such as tibial fractures, were observed. Excluding patients who had died or had motor diseases, LEFS scores were collected from 14 patients, with a mean score of 60.2 ± 7.0. These patients exhibited significant difficulties with running and jumping. The frequency distribution histogram of postoperative LEFS score is shown in Fig. 9 . Fig. 9 The frequency distribution histogram of postoperative LEFS score of the FF group. The blue dashed line represents the mean score

Discussion

For mandibular stage 3 MRONJ, the choice between FF and SR remains controversial. Prior studies have primarily focused on descriptive statistics of individual surgical techniques, without meaningful comparative analysis [ 9 – 11 ]. This study compared the outcomes and OHRQoL between FF and SR in mandibular stage 3 MRONJ and provided evidence to inform the selection of reconstruction methods. The findings indicate that patients who received FF reconstruction had better plate-related complication-free survival, while overall survival was comparable between the FF and SR groups.

MRONJ often exceeds the areas of osteolysis observed on imaging, complicating the delineation of surgical boundaries [ 22 ]. To achieve clear surgical borders, surgeons typically perform radical resections for mandibular stage 3 MRONJ, resulting in significant defects in both soft and hard tissues [ 7 ]. Reconstruction aims to enhance mandibular mechanical stability, restore continuity, and prevent malocclusion [ 23 ]. However, the healing process is complicated by BMAs, which inhibit proliferation and promote apoptosis in oral keratinocytes and fibroblasts, thereby impairing mucosal healing [ 24 , 25 ]. The MRONJ microenvironment is also characterized by immunosuppression and insufficient vascularization, further increasing the risk of complications such as recurrent infections [ 7 , 26 ]. Our findings suggest that the choice of reconstruction method influences clinical outcomes, as the SR group demonstrated a higher rate of plate-related complications.

In this study, no statistically significant differences were observed between the FF and SR groups in terms of defect size or area. Plate-related complication-free survival was worse in the SR group, and all plate-related complications manifested as plate exposure, most of which occurred within three months postoperatively. Compared with studies including broader patient populations reconstructed using soft tissue flaps and plates, the incidence in our study is similar to the 45.8% reported by Molteni et al., but complications occurred earlier than the 8.6-month mean reported by Bauer et al. [ 12 , 17 ]. The affected SR cases shared several features that may have contributed to these outcomes. Some patients had long-term exposure to BMAs or antiangiogenic medications together with multiple systemic illnesses, which can collectively compromise wound healing. Structurally, SR reconstruction does not provide vascularized bone beneath the plate, resulting in an underlying dead space that is not fully filled, and in some cases the soft-tissue envelope over the plate was relatively thin. These combined conditions make it more difficult to maintain stable and durable plate coverage once inflammation or delayed healing develops [ 27 ].

In the SR group, several patients with plate exposure required additional surgical interventions, including plate removal, bedside debridement and suturing. Although some wounds healed after secondary treatment, others experienced recurrent exposure or progression to disease recurrence, consistent with previous studies that SR carries a higher likelihood of requiring secondary surgery [ 12 ]. Multiple surgical interventions may further delay wound healing and increase surgical complexity, especially in advanced MRONJ cases.

Huang et al. reported that, compared with FF reconstruction, the use of reconstruction plates alone is associated with a higher rate of screw loosening, which can lead to mandibular displacement and malocclusion [ 27 ]. This may be attributable to the absence of fibular support in distributing occlusal forces. Although no instances of screw loosening were observed in the SR group in this study, BMAs inhibit bone remodeling, causing metabolic disruptions and microcracks in the jaw, potentially increasing susceptibility to screw loosening [ 28 ]. Thus, surgeons should exercise caution when opting for SR in patients with MRONJ.

Osteoradionecrosis is a known risk factor for plate-related complications [ 29 ]. To the best of our knowledge, MRONJ has not been reported as an independent risk factor for plate-related complications. The preliminary findings of this study suggest that SR in MRONJ patients is associated with a higher rate and earlier onset of plate-related complications. These observations merit careful consideration and more extensive exploration.

Proponents of the SR technique argue that it is suitable for patients whose expected overall survival is shorter than the time typically required for long-term complications to develop [ 12 ]. However, as demonstrated in our study, patients undergoing SR still face the risk of plate-related complications occurring before their expected demise, which may prevent complete resolution of MRONJ. Additionally, SR did not offer a longer overall survival than FF. With advancements in medical science, patients with bone metastases from malignant tumors have seen improved 5-year survival rates and median survival [ 30 , 31 ]. As a result, the indications for FF reconstruction may be expanded for mandibular stage 3 MRONJ patients. However, SR does offer a shorter operative time, which translates into reduced anesthesia time and surgical burden [ 32 ]. This may make SR a suitable option for MRONJ patients with unstable general conditions [ 10 , 33 ]. Even if complete healing is not achievable, SR may still help reduce the stage of MRONJ [ 6 ].

The FF effectively reconstructs both soft and hard tissue defects, which leads to improved functional outcomes, and the skin paddle facilitates tension-free closure [ 12 , 34 ]. Opponents of FF argue that the fibula may carry a risk of transferring primary malignant tumor metastasis to the jaw [ 13 , 14 ]. In this study, SPECT imaging was used to exclude fibular involvement, thereby avoiding this potential risk. Additionally, some studies have expressed concern about the impact of BMAs on the fibula and tibia, which may lead to complications at both the recipient and donor sites [ 13 , 35 ]. At the recipient site, complications such as flap necrosis or non-union may occur. At the donor site, there is a risk of severe complications, such as fractures of the tibia due to inadequate resistance following fibula transplantation, as reported by Raguse et al. [ 35 ]. In this study, FF survival was achieved in 16 cases, with successful bone healing. Only one patient experienced non-union due to total flap loss. Complications at the donor site were observed in only two cases, both involving delayed wound healing, likely due to factors such as excessive tension, malnutrition, or advanced age. Repo et al. and Miles et al. reported mean LEFS scores of 74.4 and 75.0, respectively, in patients receiving FF reconstruction [ 36 , 37 ]. In our study, the mean LEFS score was 60.2 ± 7.0, a difference potentially attributable to the younger average age (below 50 years) and inclusion of pediatric patients in previous studies, whereas our cohort consisted of older population with more complex systemic diseases. Nevertheless, most patients were able to manage daily activities, with difficulty only in running and jumping, indicating satisfactory functional recovery.

In addition to MRONJ, atypical femoral fractures (AFF) represent another serious adverse effect of BMAs and are defined as non-traumatic fractures in the subtrochanteric region and along the femoral diaphysis [ 38 ]. The pathogenesis of AFF is thought to involve suppressed bone remodeling, increasing bone brittleness, making fractures more likely under high mechanical stress [ 38 – 40 ]. However, unlike the mandible, which may be affected by odontogenic infections, or the femur, which experiences high mechanical stress, the tibia and fibula do not face the same challenges. Thus, even though BMAs target the entire skeletal system, their impact on FF and tibia is likely limited, with a low probability of severe complications [ 35 , 41 ]. The favorable outcomes and functional recovery observed at the donor site in our study support this hypothesis.

This study focuses on OHRQoL rather than overall quality of life because of the influence of the primary disease on general health status. Hoene et al. and Moll et al. used the OHIP-14 to evaluate improvements in OHRQoL among patients with MRONJ following surgical treatment [ 42 , 43 ]. However, previous studies have rarely compared different surgical techniques based on OHRQoL, which is one of the strengths of the present study [ 14 , 44 ]. The results showed that the mean postoperative OHIP-14 score in the FF group was 17.0 ± 9.8, compared with 22.3 ± 9.1 in the SR group, indicating better OHRQoL in the FF group. Although this difference was not statistically significant, it may be related to the higher rate of plate-related complications observed in the SR group.

This study has several limitations. First, as a retrospective study, it is subject to selection bias and lacks randomization, so prospective trials are needed in the future. Second, the sample size was small due to the rarity of the condition, necessitating further evaluation in larger cohorts. Third, the questionnaire was administered only once, at six months postoperatively, which may not fully represent the patients' postoperative OHRQoL and lower extremity function. Nevertheless, this study is the first to comprehensively compare the effects of FF and SR on the prognosis of mandibular stage 3 MRONJ, providing valuable reference for clinical practice.

Conclusion

Favorable surgical outcomes were observed in the FF group for mandibular stage 3 MRONJ, with better plate-related complication-free survival compared with the SR group, which exhibited a higher rate and earlier onset of complications. After excluding fibular involvement due to primary disease, surgeons may consider FF based on the patient's wishes and overall health status. However, as this is a preliminary study, further validation in larger-scale research is need.

Abbreviations

Fibula flap

Soft tissue flap with reconstruction plate

Medication-related osteonecrosis of the jaw

Oral health-related quality of life

Bone-modifying agents

Bisphosphonates

Denosumab

Skeletal-related events

American Association of Oral and Maxillofacial Surgeons

Atypical femoral fracture

Single-photon emission computed tomography

99MTc-methylene diphosphonate

Body mass index

American Society of Anesthesiologists

Oral health impact profile-14

Lower extremity functional scale

Zoledronic acid

Standard deviation

Quartile 1

Quartile 3

Mucoperiosteal flap

Submental island flap

Publisher’s Note

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Yuhan Lin and Yihong Fang contributed equally to this work.

Acknowledgements

Not applicable.

Authors’ contributions

YL, YF conducted the data analysis and wrote the initial draft of the manuscript. YL, CM, CW provided revisions to the manuscript. ML, JW, QO were responsible for data collection. WC conceptualized and designed the study, critically reviewed the final manuscript. All authors read and approved the final manuscript.

Funding

No financial support with regards to this research.

Data availability

The original contributions presented in this study are included in the article. Further data and materials are available from the corresponding author upon request.

Declarations

Ethical approval and consent to participate

This study was approved by the Ethical Committee of Fujian Medical University Union Hospital (2024KY242) and was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was waived because of the anonymity of the data and the retrospective nature of our study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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