Early-onset osteoradionecrosis following adjuvant volumetric-modulated arc therapy to an osteocutaneous free fibula flap with customized titanium plate

J Stomatol Oral Maxillofac Surg. 2022 Oct;123(5):e454-e457. doi: 10.1016/j.jormas.2021.12.004. Epub 2021 Dec 11.


Background: Computerized surgical planning (CSP) in osseous reconstruction of head and neck cancer defects has become a mainstay of treatment. However, the consequences of CSP-designed titanium plating systems on planning adjuvant radiation remains unclear.

Methods: Two patients underwent head and neck cancer resection and maxillomandibular free fibula flap reconstruction with CSP-designed plates and immediate placement of osseointegrated dental implants. Surgical treatment was followed by adjuvant intensity modulated radiation therapy (IMRT).

Results: Both patients developed osteoradionecrosis (ORN), and one patient had local recurrence. The locations of disease occurred at the areas of highest titanium plate burden, possibly attributed to IMRT dosing inaccuracy caused by the CSP-designed plating system.

Conclusion: Despite proven benefits of CSP-designed plates in osseous free flap reconstruction, there may be an underreported risk to adjuvant IMRT treatment planning leading to ORN and/or local recurrence. Future study should investigate alternative plating methods and materials to mitigate this debilitating outcome.

Keywords: Computerized surgical planning; Fibula flap; Osteoradionecrosis; Radiation.

Publication types

  • Case Reports

MeSH terms

  • Dental Implants*
  • Fibula / surgery
  • Free Tissue Flaps*
  • Head and Neck Neoplasms*
  • Humans
  • Mandible / surgery
  • Osteoradionecrosis* / etiology
  • Osteoradionecrosis* / surgery
  • Radiotherapy, Intensity-Modulated* / adverse effects
  • Titanium / adverse effects


  • Dental Implants
  • Titanium