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Table 1. Summary of literature evaluating the efficacy of antibiotic therapy in radiated patients receiving dental extraction or
implantation
Ref. Design n Treatment Outcomes Conclusion
[55]
Sandhu et al. Retrospective 50 Post dental extraction Amoxicillin 2% developed ORN at 18 ORN incidence was comparable with
(2020) 500 mg 3×/day for 14 days with months reported rates in the literature in
chlorhexidine 2×/day in radiated radiated patients receiving post-
patients extraction Abx
[56]
Al-Bazie et al. RCT 89 Ten days of Amoxicillin 500 mg q8h No reported cases of ORN Perioperative Abx with antibiotic
(2016) and chlorhexidine before extractions at a mean of 63 months mouthwashes are effective in
preventing ORN after extractions
Sultan et al. [15] RCT 26 Abx alone vs. Abx + HBO 1/13 from HBO + Abx No difference in outcomes between
(2017) prophylaxis in radiated patients developed ORN, 0/13 from Abx vs. Abx with HBO in radiated
receiving dental implants Abx alone developed ORN patients undergoing dental implants
No difference in implant
survival
Marx et al. [57] RCT 37 Penicillin prior to dental extraction in ORN in 5.4% of HBO group Perioperative Abx did not decrease
(1985) radiated patients vs. HBO and 29.9% of Abx group ORN incidence at 6 months following
dental extraction
RCT: Randomized control trial; Abx: antibiotics; ORN: osteoradionecrosis; HBO: hyperbaric oxygen.

Table 2. Summary of literature evaluating the efficacy of hyperbaric oxygen therapy in patients with osteonecrosis
Ref. Design n Treatment Outcomes Conclusion
[14]
Shaw et al. RCT 144 HBO vs. no HBO in radiated patients Incidence of ORN at 6 HBO for dental
(2019) requiring dental months was 6.4% extraction/implantation is
extraction/implantation (HBO) vs. 5.7% (control) unnecessary
[58]
Bennett et al. Cochrane 753 HBO vs. no HBO in patients with Improved healing of Suggest improved healing following
(2016) Review non-healing wounds radiated sockets after HBO treatment in radiated sockets
extractions in HBO after extractions
group
[59]
Teguh et al. RCT 19 Thirty sessions of HBO after Higher QOL scores in Head and neck patients receiving HBO
(2009) completing head and neck RT vs. no HBO group (swallow, after RT had higher QOL scores
HBO saliva, and pain)
[60]
D’Souza et al. Retrospective 23 HBO vs. no HBO for treatment of 12.5% cure in HBO Small sample size but minimal benefit
(2007) ORN group, 86% cure rate in from HBO in the treatment of ORN
non-HBO group
Bessereau et al. [61] RCT 68 HBO vs. no HBO for treatment of None Terminated early due to worse
(2010) ORN outcome in HBO arm
RCT: Randomized control trial; ORN: osteoradionecrosis; HBO: hyperbaric oxygen; QOL: quality of life.

patient’s symptomology and the subsequent impact on QOL. Conservative surgical measures can include
debridement, sequestrectomy, local tissue rearrangement, and marginal mandibulectomy. If conservative
medical and surgical management fails to provide resolution or symptom relief, more invasive surgical
interventions can be considered. Definitive surgery typically involves resection of the involved bone and soft
tissues. The resulting defect often requires reconstruction with vascularized non-radiated tissue, typically in
the form of a free flap [22-26] .

FREE FLAP DONOR SITES
When selecting a donor site for ORN reconstruction, one must consider the amount of soft tissue required
and the length of bone needed for continuity.

Fibula
The fibula is the donor site used most commonly for free flap reconstruction of head and neck ORN.
Advantages of the fibula free flap include a long segment of bone stock (22-25 cm), adequate pedicle length
for tension-free anastomosis in the neck, and low donor site morbidity . The fibula is harvested as a long
[27]