A 70-year-old woman came to her reference hospital for a tumor on the right lateral face of the tongue with clinical stage T2N0M0.
Biopsy was reported as epidermoid carcinoma.
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The therapeutic modality implemented in the hospital was external radiotherapy divided into 30 cases (2 Gy/fraction), totaling 60 Gy for both cervical fields.
Treatment was completed with brachytherapy with four Iridium 196 needles, a total of 50 Gy.
The disease remitted completely and the patient was free of it for a year, when she returned to the specialist presenting inflammatory symptoms in the radiated area, with pain and fistula in right mandibular angle.
The physical examination and the orthopantomography image were diagnostic of ENT of the right mandibular body, and it was decided to refer the patient to the Oral and Maxillofacial Surgery Service of the University Hospital La Paz.
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Initial treatment consisted of curettage, bone voiding, and treatment with hyperbaric oxygen (Militaire de Zaoza, 17 sessions with 100% hyperbaric oxygen: 2.5 ATA-60 minutes).
Despite attempts to resolve conservatively, the patient developed a pathological fracture, which led to right segmental mandibulectomy and reconstruction with free microvascularised fibular flap.
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The limits of bone resection were determined from changes showing necrotic bone along with intraoperative macroscopic image.
The affected tissue was resected with a bone margin of 0.5-1 cm up to bleeding bone, with en bloc excision of the intraoral mucosa and skin circumscribed to the extraoral fistula.
Bone defect after mandibulectomy was 8 cm.
During the postoperative follow-up, teeth 33 to 38 carious and periodontal and periapical disease were removed, producing pain and recurrent local infections.
After an asymptomatic period of 8 months, the patient came to consultation for a fistulized inflammatory episode in the left hemimandible, which radiologically corresponded to an ORN of the left mandibular body.
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After attempts to conservatively treat the new condition, symptoms persisted and the disease progressed poorly to a second intervention with left mandibulectomy and a second fibula microvascularized with cutaneous island.
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In the early evolution, the patient developed a midline fistula, which was resolved by removing the osteosyntesis plaque, which was located at the anterior end of the first but with the right parasymphyseal region.
The final evolution of the disease has been satisfactory, with adequate intra and extraoral healing and resolution to date.
