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Journal of Peking University(Health Sciences) >

2026 , Vol. 58 >Issue 1: 107 - 114

DOI: https://doi.org/10.19723/j.issn.1671-167X.2026.01.014

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

  • Ebrahimi Farin 1 ,
  • Zhiqiang FENG 2 ,
  • Ebrahimi Faraz 3 ,
  • Weihua HAN 4 ,
  • Ziyang YU 4 ,
  • Kuankuan JIA 1 ,
  • Jingang AN , 1, *
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  • 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
AN Jingang, e-mail,

Received date: 2025-10-04

  Online published: 2025-12-12

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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

Cite this article

Ebrahimi Farin , Zhiqiang FENG , Ebrahimi Faraz , Weihua HAN , Ziyang YU , Kuankuan JIA , Jingang AN . Surgical treatment outcomes of different stages of maxillary medication-related osteonecrosis of the jaw[J]. Journal of Peking University(Health Sciences), 2026 , 58(1) : 107 -114 . DOI: 10.19723/j.issn.1671-167X.2026.01.014

药物相关性颌骨坏死(medication-related osteonecrosis of the jaw, MRONJ)是骨质疏松症及恶性肿瘤患者在接受抗骨吸收药物(如双膦酸盐、地舒单抗)或抗血管生成靶向药物治疗后发生的一种严重并发症，严重影响患者的口腔功能和生活质量，并为患者原发病的持续治疗带来挑战[1]。目前，针对不同分期和部位的MRONJ，临床治疗的理念和策略存在差异且持续更新。有研究指出，手术联合药物治疗相较于单纯的非手术治疗，在MRONJ各分期患者的长期随访中表现出了更可预测的疗效，早期手术治疗也更有利于黏膜愈合、病变降级及生活质量改善[2-3]。
MRONJ好发于下颌骨，上颌骨受累相对少见，约占全部颌骨病变的1/4~1/3，针对其临床特点及手术治疗的报道较少，上颌骨独特的解剖结构亦使其治疗策略具有一定特殊性。Aljohani等[4]回顾了72例上颌MRONJ，建议对于Ⅰ、Ⅱ期病变者，死骨清除后采用黏骨膜瓣关闭创口，对于Ⅲ期病变，则可采用颊脂垫瓣修复，范围广泛者可配合阻塞器封闭口腔上颌窦瘘。Park等[5]报道了62例上颌MRONJ，对部分Ⅲ期病变的患者，同期实施功能性内窥镜鼻窦手术(functional endoscopic sinus surgery, FESS)处理伴发的上颌窦炎，结果提示其治疗效果优于未行FESS的患者。Okuyama等[6]的多中心回顾性研究显示，54例手术患者的术后愈合率为85.2%(46/54)，多因素分析提示，死骨清除不彻底与复发相关。Otsuru等[7]的研究报道了34例患者，其中约半数伴发上颌窦炎，强调治疗应涵盖对上颌窦炎的处理。国内田美等[8]总结了28例上颌MRONJ，亦提出应依据分期制定相应的治疗策略。
本研究通过回顾性分析上颌MRONJ患者的临床资料，总结其手术治疗经验，以期为临床MRONJ的诊治提供参考。

1 资料与方法

本研究为回顾性研究，经北京大学口腔医院生物医学伦理委员会批准(PKUSSIRB-2019-49119)，患者均签署知情同意书。

1.1 研究对象

选取2014年4月至2024年2月于北京大学口腔医院口腔颌面外科住院并接受手术治疗的上颌MRONJ患者作为研究对象。
参照文献[7]中提到的标准对患者进行诊断及分期：Ⅰ期：有死骨暴露或可探及骨面的瘘管，但无明显症状或感染；Ⅱ期：有死骨暴露或可探及骨面的瘘管，病灶区有疼痛、感染或红斑，伴或不伴溢脓；Ⅲ期：有死骨暴露或可探及骨面的瘘管，病灶区有疼痛、感染及超过牙槽骨的死骨暴露范围，病理性骨折，口外瘘管，口鼻腔相通或延伸至下颌骨下缘或上颌窦底的溶骨范围。
纳入标准：(1)符合美国口腔颌面外科医师协会(American Association of Oral and Maxillofacial Surgeons, AAOMS) 2022年发布的上颌MRONJ的诊断标准；(2)临床分期为Ⅰ~Ⅲ期；(3)接受手术治疗且临床资料完整；(4)术后随访时间≥1年。
排除标准：(1)有头颈部放疗史；(2)合并颌面部转移癌；(3)无法完成随访者。

1.2 病例及资料收集

通过电子病历系统收集患者的以下资料：(1)基本信息：性别、年龄；(2)临床资料：病程、吸烟和饮酒史、用药史、原发疾病、全身基础疾病、病变范围、手术方式；(3)手术资料：手术记录与麻醉记录，包括手术名称、部位及过程；(4)影像学资料：术前、术后及复查时的曲面体层片与CT；(5)实验室检查：血常规、血液生化、血糖等；(6)随访资料：门诊记录及电话随访记录的治疗效果与随访时间。

1.3 手术治疗方案

依据临床及影像学检查确定病变范围，制定死骨切除和创口关闭方式。

1.3.1 局部病变切除联合直接缝合

适用于Ⅰ期或Ⅱ期病变，范围局限且未侵犯上颌窦底骨质。彻底清除死骨及感染的软组织后，适当松解颊腭侧黏膜，无张力直接关闭创口(图 1、2)。
图1 45岁女性患者右侧上颌MRONJ Ⅰ期病变

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.

图2 75岁女性患者右侧上颌MRONJ Ⅱ期病变

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.

1.3.2 上颌骨病变切除联合颊脂垫修复

适用于Ⅲ期或范围较大的Ⅱ期病变，累及较广泛的牙槽骨或上颌窦底。彻底清除死骨及坏死软组织，累及上颌窦者彻底清除窦内炎性组织并冲洗，尽量保留窦底黏膜，游离患侧颊脂垫填塞骨缺损区，在此基础上无张力缝合颊腭侧黏膜(图 3)。
图3 56岁女性患者左侧上颌MRONJ Ⅲ期病变以颊脂垫修复

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.

1.3.3 上颌骨病变切除联合碘仿纱条填塞

适用于病变广泛的Ⅲ期患者。行上颌骨次全或全切除术，彻底清理上颌窦内炎性组织，尽量保留窦底黏膜，以碘仿纱条填塞窦腔，末端经患侧鼻前庭开窗引出，口内创口无张力缝合。术后3周撤出纱条，多数患者口内创口未愈，经瘘口更换碘仿纱条，每3周更换1次，重复1~2次(图 4)。
图4 71岁男性患者右侧上颌MRONJ Ⅲ期病变以碘条填塞

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.

1.4 术后随访及疗效评价

随访时间为1年，终点事件为MRONJ复发或患者死亡。疗效分为短期(术后3个月)和长期(术后1年)，参照《药物相关性颌骨坏死临床诊疗专家共识》[9]分为治愈与复发(表 1)。
表1 本研究的治疗效果评价标准

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
本研究将符合以下情况的患者也定义为“治愈”：黏膜完全愈合，无疼痛，无骨暴露，无临床感染征象，影像学显示为正常骨结构、无死骨；或虽存在口腔上颌窦瘘，但瘘口小、无脓性分泌物，患者可通过调整漱口及进食方式避免呛咳，对生活无显著影响，且影像学显示为骨质正常、上颌窦无炎症表现。
参考Rak等[10]和Ren等[11]的研究中提出的标准，基于CT软组织窗测量上颌窦黏膜厚度，对上颌窦炎症进行评分，分别为：正常(黏膜厚度 < 2 mm，0分)、轻度(2~4 mm，1分)、中度(>4~10 mm，2分)、重度(>10 mm或窦腔消失，3分)。上颌窦炎改善程度=术前评分-复查时评分。

1.5 统计学分析

采用SPSS 20.0软件进行统计分析，比较直接缝合、颊脂垫修复和碘条填塞3组在黏膜愈合及上颌窦炎改善方面的疗效，分类资料采用卡方检验或Fisher-Freeman-Halton检验，计量资料采用t检验。显著性水平取α=0.05(双侧)。

2 结果

2.1 患者的基本情况和疾病特征

本研究共纳入136例上颌MRONJ患者，其中男性60例，女性76例，男女比例为1 ∶ 1.27；年龄范围30~83岁，平均(62.80±10.25)岁。合并糖尿病者20例(14.7%)，合并高血压者43例(31.6%)，最常见的原发病为恶性肿瘤(117/136，86.0%)。
在病变局部特征方面，Ⅰ、Ⅱ、Ⅲ期患者病变在左、右侧的分布比例相近。Ⅲ期患者平均累及牙位数为(4.8±1.7)个，略多于Ⅰ期[(4.6±1.7)个]和Ⅱ期[(3.6±1.2)个]的患者。Ⅲ期患者术前上颌窦炎评分为(2.70±0.70)分。

2.2 患者用药情况分析

患者用药以双膦酸盐类为主，在Ⅰ、Ⅱ、Ⅲ期患者中分别占比62.5%、60.0%和52.0%。给药途径方面，口服给药者占比较低，以静脉或静脉联合口服的给药途径为主(Ⅰ期75.0%，Ⅱ期83.4%，Ⅲ期92.9%)。此外，少数患者联用糖皮质激素，约半数患者曾接受化疗。
用药时长方面，多数患者累计用药时间超过12个月，而停药时间不足12个月。

2.3 实验室检查结果

在Ⅰ、Ⅱ、Ⅲ期患者中，贫血的患病率随分期升高而增加，分别为25.0%、36.7%、39.8%，低白蛋白血症的比例分别为25.0%、10.0%、35.7%，低钙血症的比例分别为37.5%、20.0%、28.6%。

2.4 手术治疗效果评价

总体治愈率：术后3个月总体治愈率为91.2%(124/136)，术后1年提升至94.9%(129/136)。不同分期的治愈率分别为：Ⅰ期，100.0%(8/8)；Ⅱ期，96.7%(29/30)；Ⅲ期，93.9%(92/98)。
上颌窦炎症改善情况：Ⅰ期患者术前上颌窦均无炎症；Ⅱ期患者术前有10.0%存在轻度上颌窦炎，复查时均好转；Ⅲ期患者术前均伴有上颌窦炎，其中93.9%为中重度，复查时80.6%的患者炎症消退至正常或轻度水平(表 2、图 3~5)。
表2 上颌MRONJ不同分期患者手术治疗后的上颌窦炎症改善情况

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

MRONJ, medication-related osteonecrosis of the jaw.

图5 57岁女性患者右侧上颌MRONJ Ⅲ期病变以碘条填塞

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.

2.5 Ⅲ期病变不同手术方式的疗效比较

Ⅲ期患者共98例，其中，碘条填塞组64例，颊脂垫修复组34例，两组患者在基线资料、原发病及用药模式上均具有可比性(P>0.05)。
两种术式均能有效改善临床症状并减轻上颌窦炎症。碘条填塞组短期(术后3个月)和长期(术后1年)治愈率分别为93.8%和95.3%，颊脂垫修复组分别为94.1%和91.2%，两组间差异无统计学意义，两组的疼痛与软组织肿胀均显著缓解。
在消除口腔上颌窦瘘方面，颊脂垫修复组的效果优于碘条填塞组，在短期(P < 0.001)和长期(P=0.002)随访中，两组差异均有统计学意义。在上颌窦炎改善程度上，碘条填塞组则表现出优势，其短期(P=0.029)和长期(P=0.014)改善效果均更显著(表 3)。
表3 两组Ⅲ期上颌MRONJ患者短期和长期疗效的对比

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

* P < 0.05, ** P < 0.01, *** P < 0.001. MRONJ, medication-related osteonecrosis of the jaw; ISP, iodine strip packing; BFPT, buccal fat pad transfer.

3 讨论

上颌MRONJ患者的早期症状多较轻微，可尝试保守治疗以缓解症状，一旦出现疼痛、经久不愈的瘘口或上颌窦炎等表现，手术治疗则成为必要选择[12]。然而，目前对上颌MRONJ的手术治疗尚缺乏统一的疗效评价标准，导致不同研究报道的治愈率差异较大，难以直接比较。本研究通过分析不同分期上颌MRONJ患者的手术预后，并比较Ⅲ期病变不同术式的疗效差异，希望为临床治疗方案的选择提供参考。
MRONJ的总体治疗目标是保障患者在抗骨吸收治疗连续性的前提下，通过患者教育、疼痛管理、控制继发感染及预防病变进展等措施，改善患者的生活质量[1]。目前，关于MRONJ的治疗策略主要有两种观点：一种是依据AAOMS 2014年发布的指南，主张对Ⅰ、Ⅱ期病变采取非手术治疗(如抗生素、特立帕肽、高压氧等)，手术仅适用于Ⅱ期保守治疗无效和Ⅲ期的患者，但非手术治疗可能无法完全控制感染，导致部分无症状患者的病变仍持续进展(“静默性进展”)；另一种认为积极的手术干预可以通过切除病灶有效终止疾病进程，且术后病理组织检查有助于排除颌骨转移癌。因此，手术被视为一种对各分期均有效的治疗手段，早期手术成功率更高，有助于黏膜愈合，实现骨坏死区域的生物学愈合，并为尽早重启抗骨吸收治疗创造条件。近年来，越来越多的研究支持对各期MRONJ患者均采取积极的手术治疗[4, 6]。
手术治疗在Ⅱ期和Ⅲ期MRONJ患者中的疗效已得到广泛证实。近期，有研究也支持对Ⅰ期病变进行手术干预。Giudice等[2]的研究纳入了57例Ⅰ期和72例Ⅱ期患者，发现早期手术可提高治愈率并缩短疗程。其他研究同样建议早期手术，以清除感染组织、控制病变进展、实现长期软组织愈合[6, 13]。也有研究显示，晚期病变治疗失败的风险显著高于早期病变，提示越早手术治愈率越高[6, 14]。
手术治疗的首要关键是彻底清除死骨，术前应依据影像学检查初步判断范围，术中则根据骨色泽与出血情况确定边界，但这很大程度上依赖术者的经验[15]。近年来，荧光引导技术逐渐应用于MRONJ手术，有助于客观界定死骨范围，减少经验性切除的不足[15-16]。次要关键是软组织创口的可靠关闭，上颌MRONJ的创口关闭方式包括直接缝合、碘仿纱条填塞、颊脂垫瓣、局部带蒂皮瓣及游离皮瓣修复等。早期病变的范围局限，常可直接无张力缝合，但局部血供不良可能导致缝合失败率较高[17]，且部分病例软组织量不足，难以实现无张力对合，易致术后裂开，因此，广泛切除后采用游离皮瓣修复可获得更高的黏膜愈合率[18-19]。然而，临床患者多为晚期恶性肿瘤患者，游离皮瓣并非首选，对此，学者们进行了多种术式改良，对于病变局限于牙槽突的早期患者，可采用双层软组织缝合技术。鼻唇沟瓣作为局部带蒂皮瓣，其治愈率虽高于局部黏骨膜瓣，但会遗留面部瘢痕[20]。颊脂垫瓣则因其血运丰富、取材邻近、操作简便而被用于辅助关闭创口。
Ⅰ、Ⅱ期早期病变未累及上颌窦底，伴发的上颌窦炎多为窦底黏膜反应性增厚，通常无需特殊处理；而Ⅲ期病变累及上颌窦，常并发不同程度的上颌窦炎，需同期处理。以往文献报道，约35.8%~61.3%的上颌MRONJ可累及上颌窦并引发上颌窦炎[4-5]。对于Ⅲ期上颌MRONJ而言，死骨清除后会遗留较大缺损，采用颊脂垫或碘仿纱条填塞是相对简便的关闭方法。颊脂垫血供丰富、抗感染能力强、位置邻近，适用于关闭创口[21]，在适应证合适时能有效闭合创面并减少并发症[22]，但其体积有限，通常用于修复直径小于5 cm的后牙区缺损[23]。碘仿纱条填塞则更有利于上颌窦引流，尤其适用于伴发上颌窦感染者，有助于控制炎症。本研究结果显示，碘条填塞法凭借其机械引流作用，在上颌窦炎控制方面的表现更优；而颊脂垫法则依靠其血运优势，在长期创面稳定性方面更具潜力。
本研究中，碘条填塞法术后口腔上颌窦瘘的发生率高于颊脂垫法，但保留的瘘口有助于上颌窦分泌物引流，从而促进上颌窦炎消退。通过定期更换碘条，30例患者的瘘口近乎完全闭合，27例患者在1年随访时虽存在小瘘口(图 5)，但黏膜愈合良好，无感染或死骨暴露，且瘘口小至不影响生活。因此，两种术式在治疗Ⅲ期上颌MRONJ中各有侧重，临床应根据个体情况选择。
Ⅲ期上颌MRONJ的治疗需结合患者全身状况与局部病变特点进行个体化决策。上述方法虽能取得较好疗效，但部分患者术后仍可能出现上颌窦炎或口腔上颌窦瘘[24]。对于术后瘘口，赝复体修复是有效的封闭手段。有研究表明，采用赝复体封闭Ⅲ期术后口腔上颌窦瘘，随访期间未见复发[4]。本研究中，部分术后瘘口通过手术修补成功闭合。对于较大瘘口，亦可考虑赝复体修复，因此术中应注意为后续修复创造条件[21]。
既往研究多将上下颌MRONJ合并分析，且主要聚焦于下颌骨，专门针对上颌MRONJ手术治疗效果的研究较少。本研究单独以上颌MRONJ为研究对象，系统分析了不同分期的手术疗效，并比较了Ⅲ期病变不同术式的差异，为此类疾病的临床诊疗提供了针对性依据。
综上所述，本研究发现手术治疗均适用于Ⅰ~Ⅲ期上颌MRONJ患者，针对Ⅲ期病变，碘仿纱条填塞法凭借其良好的引流作用，更有利于短期上颌窦炎症的控制，颊脂垫修复法则通过血供重建，在维持创面长期稳定方面更具优势，临床应根据患者全身状况与局部病变特点，个体化选择适宜的手术方案。

利益冲突  所有作者均声明不存在利益冲突。

作者贡献声明  Farin Ebrahimi、冯志强：收集整理分析数据，撰写论文；Faraz Ebrahimi、韩玮华：文献检索；于子杨、贾宽宽：论文修改；安金刚：设计研究方案，审定论文。所有作者均参与论文修改，并对最终文稿进行审读和确认。

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