Staged surgical management of advanced MRONJ in a nonagenarian with severe infection: extensive segmental mandibulectomy and reconstruction.

Introduction: The management of advanced medication-related osteonecrosis of the jaw (MRONJ) in very elderly patients remains controversial because of concerns regarding perioperative risk. This report describes the clinical course and outcome of staged surgical management in a nonagenarian patient with advanced MRONJ complicated by severe infection. Methods: A 92-year-old woman with Stage 3 MRONJ, according to the 2022 American Association of Oral and Maxillofacial Surgeons Position Paper, presented with extensive mandibular destruction and severe infection accompanied by a marked systemic inflammatory response. Initial management included airway protection, incision and drainage, and systemic infection control measures. After resolution of systemic inflammation, definitive surgical treatment was performed based on disease severity, the patient's general condition, and treatment preference. Results: A segmental mandibulectomy and reconstruction with a titanium reconstruction plate were performed under general anesthesia. The postoperative course was uneventful, and oral intake was resumed successfully. Imaging confirmed restoration of mandibular continuity. Over a 4-year follow-up period, a fracture of the reconstruction plate occurred secondary to trauma, but no recurrence of MRONJ was observed. Conclusion: Staged management with initial infection control followed by definitive surgical resection was safely performed in a carefully selected nonagenarian patient with Stage 3 MRONJ. Reports of such extensive surgical management in nonagenarian patients remain extremely limited. Surgical decision-making should be based on disease severity and systemic condition rather than chronological age alone.