# MRONJ Treatment Strategies: A Systematic Review and Two Case Reports
## 4 Discussion
### Fluorescence-Guided Bone Surgery  
Successful therapy should aim to eliminate bone exposure and restore mucosal integrity. MRONJ should be removed even if only small bone areas are affected because the infected necrotic and exposed bone will not be revitalized and resurrected. As a result, the goal of surgical therapy should be to remove the necrotic bone completely [42]. However, even among those who support surgical therapy, there is disagreement about which surgical technique is more effective. Indeed, one of the challenges and limitations of MRONJ therapy is that the margins of the osteonecrosis cannot be precisely determined, making clear demarcation of the necrotic bone difficult, if not impossible. Fluorescence-guided bone surgery has yielded promising results in the surgical management of MRONJ. This technique may help to define the transitions between necrotic and non-nerotic bone during the surgical procedure by providing a controllable therapeutic approach. Because this surgical approach is simple and reproducible, it may help to objectify surgical MRONJ therapy, implying an improvement in treatment [42]. It is difficult to differentiate between viable and necrotic bone, and intraoperative visualization of fluorescent patterns of viable and nonviable bone (fluorescence-guided surgery) may improve surgical outcomes. Viable bone has bright greenish fluorescence during this examination, whereas necrotic bone has no or only pale fluorescence [52]. Regarding this procedure, [PERSON] et al. conducted a study in which patients were randomly assigned to undergo fluorescence-guided surgery for medication-related osteonecrosis of the jaw [42]. The first surgical intervention, using fluorescence-guided bone surgery, resulted in complete mucosal healing in 87% of the evaluated patients, and 86.2% of the lesions had no bone exposure and no complaints at the time of the last follow-up. In total, 3.7% of the patients had no complaints, no bone exposure, and complete mucosal coverage of the bone. When the first and second surgeries were combined, 94.4% of the patients and 95.4% of the lesions showed complete mucosal healing and no bone exposure. They concluded that fluorescence-guided bone resection is a safe surgical treatment option for patients with medication-related osteonecrosis of the jaw [42]. Similarly, [PERSON] et al. performed a monocentric reevaluation of MRONJ surgical therapy. The fluorescence of tetracycline antibiotic bound in bone tissue was used to distinguish between viable and necrotic bone during intraoperative exposure to VEL scope (visually enhanced lesion scope) light of 400-460 nm wavelength. In all patients (100%), complete healing (complete mucosal closure) was achieved by secondary intention in 9.4% of the cases (\(n=3\)) in a mean period of 6 weeks [52]. There was no need for a second surgery to achieve complete healing. Therefore, they stated that the surgical therapy protocol, which includes fluorescence-guided bone surgery, is effective in managing all MRONJ stages. The surgery should preserve as much viable bone and soft tissue as possible, with no preventive extension with safety margins required [52,72]. Platelet-Rich Plasma (PRP), Platelet-Rich Fibr (PRF), Concentrated Growth Factor (CGF), and Piezsurgery (PZ)  
The literature indicates high recurrence/dehiscence rates in patients with MRONJ after surgical resection, with increased hospitalization and reoperation [73]. As a result, many techniques for optimizing therapy have been undertaken, such as flap design modification or intraoperative imaging with fluorescence-guided bone surgery, but have yet to be transferred into clinics [35,74].