# Fat Graft in Surgical Treatment of Medication-Related Osteonecrosis of the Jaws (MRONJ)
## 2 Materials and Methods
### Treatment Protocol  
Patients included in both groups were treated with the same systemic antibiotic therapy with amoxicillin 1.75 g, clavulanic acid 250 mg, and metronidazolezole 1.5 g daily, starting from the first visit, for at least 8 weeks. All of them suspended the BMA therapy before surgery. All surgical procedures were conducted under general anesthesia. In both groups, a sequestrectomy was performed achieving vital bone margins. Sharp bone edges were removed to minimize the trauma to the overlying soft tissues. Patients included in group B received an advancement mucosal flap taken from the surrounding areas and sutured above the surgical site, while patients included in group A also received an autologous fat graft, which was introduced in the surgical site before the advancement mucosal flap was sutured.  
The adipose tissue graft was harvested from the abdominal subcutaneous compartment, similarly to the technique described by [PERSON] [23; 24; 25]: through a 3 mm cutaneous incision, the subcutaneous adipose compartment was infiltrated with a tumescent solution (lidocaine 1000 mg/L, epinephrine 1 mg/L, and sodium bicarbonate 10 mEq/L in 1 L of saline 0.9% NaCl). Then, the adipose tissue was aspirated manually with a 3 mm cannula connected to a 60 mL syringe, under moderate negative pressure (Figure 1). In contrast with [PERSON]'s technique, the harvested fat was not processed by centrifugation but drained  
\begin{table}
\begin{tabular}{c c l} \hline \hline \multirow{4}{*}{Inclusion criteria} & \(\bullet\) & Confirmed MRONJ diagnosis \\  & \(\bullet\) & Confirmed administration of BMAs \\  & \(\bullet\) & Unresponsiveness after 8 weeks of systemic antibiotic therapy and oral hygiene \\  & \(\bullet\) & Performed surgical treatment \\  & \(\bullet\) & Available follow-up: at least 1-year \\  & \(\bullet\) & History of radiation therapy to the head and neck region \\ Exclusion criteria & \(\bullet\) & Surgical treatment refused or not permitted \\  & \(\bullet\) & Incomplete follow-up \\ \hline \hline \end{tabular}
\end{table}
Table 1: Inclusion and exclusion criteria.  
of oil and liquid by gravity (Figure 2) and transferred to a 5 mL syringe. This procedure has been demonstrated to not affect the outcomes of patients receiving fat autografts [26]. Finally, it was introduced in the surgical site before the closure of the mucosal flap or through the wound margins after the mucous lining was sutured (Figure 3).  
The same postoperative protocol was administered (amoxicillin 1.75 g, clavulanic acid 250 mg, and metronidazoleacole 1.5 g daily, oral rinses with 0.2% chlorhexiidine solution) for at least two weeks. In those cases where the surgical treatment determined the complete healing of the surgical wound, the antibiotic therapy was suspended 2 weeks after surgery (continued until suture removal). On the other hand, it was extended until at most 8 weeks in case of postoperative dehiscence or relapse of bone exposure.  
Figure 1: Fat harvesting technique. The adipose tissue is aspirated under moderate manual negative pressure, using a 60 mL syringe connected to a 3 mm cannula.  
Figure 2: The harvested fat is drained by gravity.