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Journal of Peking University (Health Sciences) ›› 2026, Vol. 58 ›› Issue (1): 107-114. doi: 10.19723/j.issn.1671-167X.2026.01.014

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Surgical treatment outcomes of different stages of maxillary medication-related osteonecrosis of the jaw

Ebrahimi Farin1, Zhiqiang FENG2, Ebrahimi Faraz3, Weihua HAN4, Ziyang YU4, Kuankuan JIA1, Jingang AN1,*()   

  1. 1. Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, China
    2. Department of Stomatology, Hebei Medical University Third Hospital, Shijiazhuang 050051, China
    3. Department of Prosthodontics, Peking University School and Hospital of Stomatology, Beijing 100081, China
    4. Department of Stomatology, Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Beijing 100730, China
  • Received:2025-10-04 Online:2026-02-18 Published:2025-12-12
  • Contact: Jingang AN

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Abstract:

Objective: To evaluate the surgical outcomes of maxillary medication-related osteonecrosis of the jaw (MRONJ) at different disease stages and to analyze the comparative efficacy of different surgical techniques on the prognosis of stage Ⅲ patients. Methods: A detailed retrospective analysis was conducted on the clinical data of 136 patients with maxillary MRONJ who underwent surgical treatment in the Department of Oral and Maxillofacial Surgery of Peking University School and Hospital of Stomatology from April 2014 to February 2024. All patients were rigorously classified according to the 2022 American Association of Oral and Maxillofacial Surgeons (AAOMS) staging criteria: Stage Ⅰ (n=8), stage Ⅱ (n=30), and stage Ⅲ (n=98). The surgical interventions included local lesion resection with primary direct closure, buccal fat pad packing, and iodoform gauze packing. The patients were systematically followed up for a period of 1 year postoperatively to comprehensively assess several key outcome measures: Complete mucosal healing, resolution of pain, effective infection control, and radiological improvement of maxillary sinus inflammation based on serial computed tomography scans. Statistical analysis was performed using SPSS version 20.0. Continuous variables were expressed as mean±standard deviation and compared using the t-test, while categorical variables were expressed as numbers and percentages and compared using the χ2 test or Fisher' s exact test as appropriate. A P-value < 0.05 was considered statistically significant for all analyses. Results: The overall short-term (3 months) cure rate was 91.2% (124/136), which improved to a long-term (1 year) cure rate of 94.9% (129/136). A stage-stratified analysis revealed excellent long-term cure rates: 100.0% (8/8) for stage Ⅰ, 96.7% (29/30) for stage Ⅱ, and 93.9% (92/98) for stage Ⅲ, with no statistically significant difference in outcomes across the different stages (P=0.611). Among the 98 stage Ⅲ patients, 34 were treated with buccal fat pad transfer (BFPT group) and 64 with iodine strip packing (ISP group), with no significant differences in baseline demographic or clinical characteristics between the two groups, ensuring comparability. The BFPT group demonstrated a statistically significant superior performance in achieving oroantral fistula closure both at the short-term (79.4% vs. 23.4%, P < 0.001) and long-term (85.3% vs. 54.7%, P=0.002) follow-up assessments. In contrast, the ISP group showed a markedly greater degree of improvement in maxillary sinus inflammation, as quantified by a standardized radiographic scoring system, with significantly greater reductions in inflammation scores at both the 3-month (P=0.029) and 12-month (P=0.014) follow-up intervals. Conclusion: Surgical management of maxillary MRONJ results in high rates of success with a favorable complication profile. For advanced (stage Ⅲ) disease, the choice of surgical technique entails a strategic trade-off: The buccal fat pad procedure is more conducive to achieving reliable soft tissue closure and oroantral fistula resolution, whereas iodoform gauze packing provides superior management and resolution of concomitant maxillary sinusitis. Consequently, the selection of surgical technique should be individualized, based on a careful consideration of the patient's specific anatomical defect, the extent of sinus involvement, and their overall clinical condition.

Key words: Osteonecrosis, Maxilla, Surgical procedures, operative, Treatment outcome, Disease progression

CLC Number: 

  • R782

Figure 1

A 45-year-old female with stage Ⅰ MRONJ in the right maxilla A and B, CT scan revealing ill-defined margins of the necrotic bone in the alveolar process (red arrow); C and D, postoperative CT scans demonstrating the alveolar process (red arrow); E and F, follow-up CT scans demonstrating normal bone architecture without abnormalities one year postoperatively (red arrow). MRONJ, medication-related osteonecrosis of the jaw."

Figure 2

A 75-year-old female with stage Ⅱ MRONJ in the right maxilla A, preoperative clinical view showing exposed necrotic bone at the alveolar process; B, axial CT scan revealing ill-defined margins of the necrotic bone in the alveolar process; C, coronal CT scan demonstrating inflammatory changes with mucosal thickening at the floor of the maxillary sinus; D, intraoperative view following mucoperiosteal flap reflection, exposing the necrotic lesion; E, extraction of the involved tooth and complete removal of the necrotic bone; F, aproximation and suturing of the wound for tight closure; G, postoperative view at 3 months shows a well-healed mucosal site with no evidence of dehiscence or fistula; H and I, follow-up CT scans showing normal bone architecture without abnormalities. MRONJ, medication-related osteonecrosis of the jaw."

Figure 3

A 56-year-old female with stage Ⅲ MRONJ in the left maxilla using buccal fat pad A, oral fistula observed in the left posterior maxilla; B, coronal CT scan revealing ill-defined osteolytic lesion in the left maxilla with associated radiographic signs of maxillary sinusitis; C, 3D CT image reconstruction confirming the poorly demarcated bony lesion; D, intraoperative view after soft tissue incision, exposure, and resection of the necrotic bone, resulting in an oroantral communication; E, mobilization and transposition of the buccal fat pad to obliterate the defect, followed by tight wound closure; F, postoperative coronal CT scan showing the buccal fat pad positioned to seal the oroantral communication; G, clinical view at 3 months postoperatively demonstrating complete mucosal healing; H and I, follow-up CT images showing normalized bone architecture and resolution of maxillary sinus inflammation. MRONJ, medication-related osteonecrosis of the jaw."

Figure 4

A 71-year-old male with stage Ⅲ MRONJ in the right maxilla using iodine strip packing A, 3D CT image reconstruction scan showing a large area of necrotic bone in the right maxilla; B, coronal CT scan demonstrating sequestrum separation and maxillary sinusitis; C and D, postoperative CT images after a period of iodine strip packing, shows normalized bone architecture and resolution of the maxillary sinus inflammation; E, clinical view at 1 year postoperatively demonstrating complete mucosal healing. MRONJ, medication-related osteonecrosis of the jaw."

Table 1

Therapeutic efficacy evaluation criteria in this study"

Outcome Wound condition Pain Infection Image findings
Healing Healed, no bone exposure No pain No signs of inflammation or infection Normal trabeculation, no sequestrum, clear maxillary sinus
Recurrence No improvement or worsened No improvement or worsened No improvement Presence of sequestrum or osteolytic changes, signs of maxillary sinusitis

Table 2

Postoperative maxillary sinusitis improvement by stages in maxillary MRONJ"

Maxillary sinusitis Stage Ⅰ (n=8) Stage Ⅱ (n=30) Stage Ⅲ (n=98)
Pre-surgery 3 moths post-surgery 1 year post-surgery Pre-surgery 3 months post-surgery 1 year post-surgery Pre-surgery 3 months post-surgery 1 year post-surgery
Normal 8 8 8 27 29 29 4 17 38
Mild 3 1 2 34 41
Moderate 1 13 42 16
Severe 79 5 3

Figure 5

A 57-year-old female with stage Ⅲ MRONJ in the right maxilla using iodine strip packing A and B, CT scans reveal sequestrum separation (red arrow) and maxillary sinusitis (blue arrow); C and D, one-year postoperative CT scans demonstrate that while a small fistula (red arrow) still remains present, the maxillary sinus inflammation has resolved. MRONJ, medication-related osteonecrosis of the jaw."

Table 3

Comparison of short term and long term treatment efficacy between the two groups of stage Ⅲ maxillary MRONJ patients"

Items Short term (3 months) Long term (1 year)
ISP (n=64) BFPT (n=34) P value ISP (n=64) BFPT (n=34) P value
Clinical efficacy, n (%) 0.656 0.415
  Recovery 60 (93.8) 32 (94.1) 61 (95.3) 31 (91.2)
  Recurrence 4 (6.2) 2 (5.9) 3 (4.7) 3 (8.8)
Pain, n (%) 0.656 0.415
  No 60 (93.8) 32 (94.1) 61 (95.3) 31 (91.2)
  Yes 4 (6.3) 2 (5.9) 3 (4.7) 3 (8.8)
Soft tissue swelling, n (%) 0.570 0.415
  No 61 (95.3) 32 (94.1) 61 (95.3) 31 (91.2)
  Yes 3 (4.7) 2 (5.9) 3 (4.7) 3 (8.8)
Sequestrum, n (%) 0.576 0.415
  No 63 (98.4) 33 (97.1) 61 (95.3) 31 (91.2)
  Yes 1 (1.6) 1 (2.9) 3 (4.7) 3 (8.8)
Oral antral fistula, n (%) < 0.001*** 0.002**
  No 15 (23.4) 27 (79.4) 35 (54.7) 29 (85.3)
  Yes 49 (76.6) 7 (20.6) 29 (45.3) 5 (14.7)
Maxillary sinusitis score, ${\bar x}$±s 0.029* 0.014*
  Pre-surgery 2.80±0.59 2.53±0.85 2.80±0.59 2.53±0.85
  Post-surgery 1.33±0.77 1.41±0.91 0.78±0.78 0.94±0.84
  Degree of improvement 1.47±0.81 1.12±0.83 2.02±0.86 1.59±1.00
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