Stage III ORN is defined by full thickness devitalization of bone,
resorption of the inferior border of the mandible, fistula or a pathological
fracture. These patients are treated with an aggressive surgical
extirpation of all diseased hard and soft tissue, and then
immediate reconstruction is performed using a free tissue transfer.The ability to transplant tissue allows the extirpative surgeon to
more aggressively resect the diseased hard and soft tissue rather
than leaving residual areas of unhealthy tissue. Bony continuity
is re-established immediately and patients can undergo a functional
dental rehabilitation in a timely manner (implants are
placed in the primary setting in non-irradiated well-vascularized
bone, reducing the need for multiple surgeries and a prolonged
period of functional impairment). This aggressive surgical treatment
is often performed without using HBO therapy (pre- or
post-operatively) or debridement. It has been our experience, and
that of others, that patients who present with advanced disease
do not benefit from HBO.31 It has been speculated that this method
of reconstruction enhances the viability of the remaining bone
even in residual areas partially involved with ORN.33,37 This approach
markedly differs from Marx’s treatment protocol in that
he advocates for HBO therapy pre- and post-operatively, the reconstruction
is staged and does not involve the use of vascularized
bone flaps.