药物相关性颌骨坏死不同阶段治疗方法述评

doi:10.3969/j.issn.1005-4979.2022.03.001

《口腔颌面外科杂志》 ›› 2022, Vol. 32 ›› Issue (3): 135-143. doi: 10.3969/j.issn.1005-4979.2022.03.001

• 专家论坛 • 下一篇

药物相关性颌骨坏死不同阶段治疗方法述评

孙国文(), 田美

南京大学医学院附属口腔医院，南京市口腔医院口腔颌面外科，江苏南京 210008

收稿日期:2022-02-15 修回日期:2022-04-19 出版日期:2022-06-28 发布日期:2022-06-29
通讯作者: 孙国文，E-mail: 238957@sina.com

作者简介:

孙国文（1972—），男，吉林人，博士，主任医师.
[专家介绍]孙国文，医学博士、主任医师、硕士生导师，南京大学医学院附属口腔医院（南京市口腔医院）一病区主任。目前担任中华口腔医学会牙与牙槽外科专业委员会常务委员、中国整形美容协会精准与数字医学分会颅颌面整复专业委员会常务委员、江苏省抗癌协会头颈肿瘤专业委员会副主任委员、江苏省整形美容协会颌面整形分会副主任委员、江苏省口腔医学会口腔颌面外科专业委员会常务委员、江苏省康复医学会修复重建专业委员会常务委员等职务。获江苏省“333高层次人才” 、江苏省第一批“卫生拔尖人才”、南京地区“十佳医生”等多项荣誉称号。曾获江苏省科技进步二等奖2项、江苏省医学新技术引进一等奖4项、江苏省医学新技术引进二等奖1项。先后发表论文70余篇，其中SCI收录论文30余篇。

基金资助:
南京市科技发展计划（医疗卫生与国际合作）项目(201503038)

A comment on the treatment approaches of medication-related osteonecrosis of the jaw at different stages

SUN Guowen(), TIAN Mei

Department of Oral and Maxillofacial Surgery, Nanjing Stomatology Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China

Received:2022-02-15 Revised:2022-04-19 Online:2022-06-28 Published:2022-06-29

摘要/Abstract

摘要：

药物相关性颌骨坏死（medication-related osteonecrosis of the jaw, MRONJ）是一种使用抗骨吸收、抗血管生成等药物后，出现在颌骨的严重并发症。目前该病已经有大量的文献报道，并探讨了MRONJ的治疗方法，从保守治疗到不同侵袭程度的手术治疗，以及辅助治疗。但是当疾病处于不同阶段时，具体应采用何种治疗方法并没有定论。本文总结了近年相关的文献报道并结合笔者的临床经验，对不同阶段的治疗方法进行述评，以期为临床工作者提供参考。

关键词: 述评, 药物相关性颌骨坏死, 治疗方法, 不同阶段

Abstract:

Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication of jaw caused by the use of anti-bone resorption and anti-angiogenesis drugs. A large amount of literature has been reported about different treatment approaches of MRONJ, ranging from conservative treatment to surgical treatment, and sometimes adjuvant therapy. However, there is no definite conclusion which specific treatment approaches should be adopted at different stages of MRONJ. This paper comments the treatment approaches at different stages of MRONJ through reviewing the related references in recent years and combining the authors′ clinical experience, thus providing a reference for clinicians.

Key words: comment, medication-related osteonecrosis of the jaw, treatment, different stages

孙国文, 田美. 药物相关性颌骨坏死不同阶段治疗方法述评[J]. 《口腔颌面外科杂志》, 2022, 32(3): 135-143.

SUN Guowen, TIAN Mei. A comment on the treatment approaches of medication-related osteonecrosis of the jaw at different stages[J]. 《Journal of Oral and Maxillofacial Surgery》, 2022, 32(3): 135-143.

https://journal06.magtech.org.cn/Jweb_joms/CN/Y2022/V32/I3/135

图/表 4

表1 美国口腔颌面外科协会（American Association of Oral and Maxillofacial Surgeons, AAOMS）关于MRONJ的分期及相应治疗方案

Table 1 Stages and corresponding treatment plans of MRONJ of American Association of Oral and Maxillofacial Surgeons (AAOMS)

分期	临床表现	治疗方案
有危险倾向	口服或静脉注射相关药物的患者，颌面部无任何异常症状	无需治疗，进行口腔健康教育
0期	颌面部未发现坏死骨，但伴有非特异性临床症状，如非牙源性疼痛、下颌骨疼痛或麻木、上颌窦疼痛、感觉神经功能变化	对症治疗，包括应用止痛药控制疼痛及密切随访等，进行口腔健康教育
1期	颌面部存在暴露的坏死骨或可以触及骨面的瘘管，但患者无明显临床症状，不伴感染	非手术治疗，包括使用抗生素和漱口水等，随访，进行口腔健康教育
2期	暴露的坏死骨并伴有感染，表现为暴露的死骨周围组织红肿、疼痛，伴或不伴口内瘘口形成	手术清创和非手术治疗结合，控制疼痛和感染，缓解软组织刺激，随访，进行口腔健康教育
3期	暴露的死骨长期不愈，伴有剧烈疼痛和感染，并至少有1种以下表现：病理性骨折、口内外瘘、口鼻瘘、上颌窦瘘、累及颧骨等其他骨质、骨质溶解破坏至下颌下缘或上颌窦窦底	手术清创或手术切除，辅以非手术治疗，控制疼痛和感染，随访，患者口腔健康教育

图1 左下颌骨2期MRONJ患者（63岁男性）行颌骨部分切除术的术前和术后图像 A. 左下颌升支前缘牙龈红肿，颊侧稍膨隆，挤压溢脓，周围黏膜红肿；B. 螺旋CT重建全景片示左下颌骨骨质破坏，其内可见团块样游离状高密度影，但未及下颌骨下缘；C. 术中切除病变至有新鲜血液流出，无张力缝合关闭创口；D. 术后2周，左下牙龈黏膜愈合良好，无红肿溢脓；E. 术后 3个月，全景片示左下颌骨呈术后改变，骨缺损区域界线清晰，无新的死骨形成。

Figure 1 Images of a 63-year-old man with MRONJ stage 2 before and after partial resection of left mandible

图2 右下颌骨3期MRONJ患者（67岁男性）行右下颌骨节段性截骨术的术前和术后图像 A、B. 术前螺旋CT见右下颌骨死骨形成，不规则骨质破坏至下颌骨下缘，伴病理性骨折；C. 术中翻起黏骨膜瓣，完全暴露病变；D. 在正常骨质范围内截断下颌骨，尽量保留残留骨段的骨膜附着（箭头所示）；E. 术中截除的右下颌骨；F、G. 术后螺旋CT见截骨边缘清晰，无新的死骨形成；H. 术后6个月随访，创口愈合良好；I. 术后6个月随访，患者咬合关系基本正常。

Figure 2 Images of a 67-year-old man with MRONJ stage 3 before and after right mandibular segmental osteotomy

图3 右上颌骨3期MRONJ患者（81岁男性）行死骨摘除术的术前和术后图像 A. 右侧上颌骨大块死骨形成，周围黏膜红肿；B. 螺旋CT示右侧上颌骨大块死骨游离，右上颌窦窦底骨质不完整，窦壁骨质硬化，上颌窦与口腔相通；C. 术中仅摘除游离的死骨，不做扩大切除；D. 术后 27个月，口内无大块死骨，口腔黏膜无明显红肿，引流通道愈合；E. 术后 27个月，螺旋CT示剩余骨质光整，无新的大块死骨形成，右上颌窦内充斥软组织影。

Figure 3 Images of a 81-year-old man with MRONJ stage 3 before and after right maxillary sequestrectomy

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[56]	田美, 王丹妮, 罗舒艳, 等. 上颌骨药物相关性颌骨坏死的手术治疗效果初探[J]. 中华口腔医学杂志, 2021, 56(5): 447-451.

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