Medication-related osteonecrosis of the jaw (MRONJ) remains one of the most challenging conditions for oral and maxillofacial surgeons, often leading to complex surgical interventions and prolonged healing times. Over the past two decades, the understanding of MRONJ has deepened, allowing for advancements in both preventative and surgical treatment approaches. The goal has shifted from merely managing symptoms to achieving more predictable and successful surgical outcomes through regenerative therapies, improved surgical techniques, and enhanced post-operative care. David Webb oral surgeon has observed the integration of new technologies such as platelet-rich plasma (PRP) therapy, bone grafting strategies, and growth factors that are redefining how MRONJ is treated today.
From Conservative Management to Surgical Innovation
Historically, MRONJ treatment has focused on conservative management, including antimicrobial rinses, pain control, and careful monitoring. While these approaches remain essential, they often fail to fully resolve the necrotic bone lesions, especially in advanced cases. Surgical resection of affected bone has long been the gold standard for more severe cases, but traditional surgical techniques have sometimes resulted in unpredictable healing patterns and an increased risk of complications.
Recent innovations in surgical management aim to improve predictability by reducing the extent of tissue damage and enhancing the body’s natural ability to heal. New treatment modalities focus on cellular regeneration and optimized surgical planning, which have been shown to increase the success rate of MRONJ interventions.
Platelet-Rich Plasma (PRP) Therapy and Tissue Regeneration
One of the most promising developments in MRONJ treatment is the use of platelet-rich plasma (PRP) therapy. PRP is derived from the patient’s own blood and is rich in growth factors that promote tissue repair, angiogenesis, and bone regeneration. By concentrating these biologically active molecules, PRP enhances wound healing and has shown potential in reducing post-surgical complications.
When used in conjunction with surgical debridement, PRP has been observed to accelerate soft tissue healing and improve the integration of bone grafts. The application of PRP to surgical sites has also demonstrated reduced infection rates, which is particularly beneficial for MRONJ patients, who often present with compromised immune responses due to underlying medical conditions such as osteoporosis or cancer.
The Role of Bone Grafts in MRONJ Surgery
Bone grafting techniques have evolved significantly in MRONJ treatment, allowing for more predictable structural and functional outcomes. Autologous bone grafts, taken from the patient’s own body, remain the gold standard due to their high biocompatibility and osteogenic potential. However, advancements in alloplastic and allograft materials have expanded the options available for reconstruction.
Alloplastic grafts, including bioactive ceramics and hydroxyapatite-based materials, provide a scaffold for new bone growth while minimizing the need for additional surgical sites. These synthetic materials are designed to integrate with existing bone while promoting the gradual formation of new tissue. Meanwhile, allografts, derived from donor bone, have improved in terms of processing techniques that ensure better graft incorporation and reduced immune response risks.
The combination of bone grafting with biologic agents, such as bone morphogenetic proteins (BMPs) and PRP, further enhances the likelihood of successful reconstruction by stimulating bone regeneration at the cellular level.
Growth Factors and Enhanced Bone Healing
Growth factors have emerged as a pivotal component in advancing MRONJ surgical outcomes. These proteins play a crucial role in regulating cell differentiation, migration, and tissue regeneration. The introduction of recombinant human bone morphogenetic proteins (rhBMPs) has opened new possibilities for MRONJ treatment by actively promoting osteoblast differentiation and accelerating bone formation.
Beyond rhBMPs, other biologic agents such as fibroblast growth factors (FGFs) and vascular endothelial growth factors (VEGFs) are being explored for their potential to enhance vascularization and improve healing response. The lack of blood supply in necrotic bone has been a primary challenge in MRONJ treatment, and the use of these growth factors has shown promise in restoring proper circulation to affected areas.
Studies have suggested that the combined use of PRP, bone grafting, and growth factors can significantly improve the predictability of MRONJ surgery by reducing the risk of non-healing defects and infection recurrence. The controlled application of these agents allows for a more strategic approach to surgical intervention, resulting in better long-term stability of treated bone.
Minimally Invasive Surgical Techniques and Their Impact
Traditional MRONJ surgery often involved large resections, leading to significant bone loss and functional impairments. However, with the introduction of minimally invasive techniques, surgeons can now approach MRONJ with greater precision and less disruption to surrounding tissues.
One such advancement is piezosurgery, which utilizes ultrasonic vibrations to selectively cut necrotic bone while preserving healthy structures. This method reduces thermal damage and minimizes post-operative inflammation, leading to a faster recovery process. Similarly, laser-assisted debridement has gained traction for its ability to remove necrotic tissue while promoting antimicrobial effects, further reducing the likelihood of infection.
The Shift Toward Patient-Specific Treatment Plans
With a growing understanding of MRONJ pathophysiology, treatment is becoming increasingly tailored to individual patients. Factors such as the underlying condition requiring anti-resorptive medication, the extent of necrosis, and the patient’s overall systemic health are now considered when formulating a surgical plan.
Pre-operative imaging, including CBCT and MRI, has enhanced the ability to assess the extent of disease involvement and plan for surgical resection with greater precision. The integration of digital planning tools and intraoperative navigation systems ensures that bone removal is as conservative as possible while still effectively addressing the necrotic tissue.
Additionally, advancements in post-operative care protocols are helping to improve outcomes. The use of hyperbaric oxygen therapy (HBOT) has shown potential in promoting angiogenesis and reducing infection rates, while optimized nutrition and systemic health management contribute to better healing.
Future Directions in MRONJ Surgical Management
The future of MRONJ treatment lies in the continued refinement of regenerative therapies and the integration of personalized medicine approaches. Stem cell therapy is emerging as a potential game-changer in MRONJ management, with research focusing on the ability of mesenchymal stem cells (MSCs) to promote bone regeneration. Clinical trials are also exploring the use of gene therapy to enhance the expression of specific proteins involved in bone and tissue repair.
As surgical techniques become more sophisticated and biologic agents continue to evolve, the goal is to move toward a treatment paradigm where MRONJ is no longer associated with unpredictable outcomes. With the combination of improved imaging, targeted surgical strategies, and enhanced regenerative therapies, the potential for achieving consistent, predictable healing is becoming a reality.
The evolution of MRONJ treatment highlights the ongoing progress in oral and maxillofacial surgery. As research continues to shape the way surgeons approach this condition, the emphasis remains on reducing morbidity, improving quality of life, and ensuring that each patient receives the most effective and least invasive treatment possible.