# Resective Surgery versus Debridement in Stage 2 Medication-Related Osteonecrosis of the Jaw
## 4 Discussion  
MRONJ treatment is an exciting and divisive challenge since its definition in 2003 [1; 27]. Despite MASCC/ISOO/ASCO 2019 guidelines suggesting the debridement conservative treatment, a universally accepted behavior is lacking [2; 12; 15; 28; 29]. The discontinuation of therapy role before the surgical intervention was often debated since therapy suspension time was not significantly associated to post-surgical prognosis. The results described by [PERSON] et al. suggest that the interruption of bisphosphonate therapy does not represent an optimal protocol [30]. [PERSON] et al. did not show a statistically significant relation between the discontinuation of therapy and treatment outcomes [31]. Nonetheless, more studies are required to identify the optimal time when the drug should be discontinued in MRONJ patients. Conservative treatments include analgesic drugs, antispetic mouthwashes, regular dental treatments, dental and periodontal diseases treatment and antibiotic therapy and the removal of sharp bone edges that may cause soft tissue inflammation [30; 32; 33]. During a literature review, two studies did not report any significant differences in healing rate between surgical and non-surgical treatments [34; 35]. In a wide retrospective study on 337 patients, [PERSON] et al. stated that patients who underwent surgery were 28 times more likely to have a positive outcome then non-surgical patients [36]. Systematic reviews of literature confronted surgical vs. non-surgical treatments and showed better results after the surgical treatment [37; 38; 39]. Few more studies highlighted how a less aggressive surgical treatment produces better results when compared to demolitive surgery, although no statistical significance was shown [40]. [PERSON] et al. suggest a support therapy based upon antispetic mouthwash and antibiotic drugs. In their research, 91 out of 94 patients developed sequestrum that was later removed with a minimally invasive approach [41]. Pharmacologic aid was further reported to help the mucous healing above the osteeonecrosis in 50-57% of cases thanks to amoxicillin/clavulanic acid plus mouthwashes without the need for surgery [42; 43]. The 2010 Japanese position paper on the subject of matter recommended a non-surgical treatment associated, in case of need, with debridement [44]. Similarly, the AAOMS 2014 position paper suggested the same line of treatment [1]. The AAOMS 2014 recommendation, further confirmed in 2019 edition, discourage a surgical approach, suggesting to continue indefinitely a conservative treatment until disease progression [1]. Nonetheless, the necrotic bone never heals spontaneously, therefore the non-surgical treatment goal is to improve MRONJ symptoms rather than achieve complete healing. [PERSON] et al. results showed how complete healing rate was significantly higher when the patients underwent surgical treatment (94.6% of patients) rather than non-surgical treatment [31]. Therefore, the authors believe that the surgical treatment should be the first line of therapy, since long-term non-surgical treatment reduces patients' quality of life and can lead to disease progression. Published literature suggests that resective surgical treatment is more effective in MRONJ patients. Furthermore, early intervention with adequate resection margins of the necrotic areas and primary closure is strongly suggested due to a better outcome and to be preferred over less invasive but multiple surgical treatments [45; 46]. Non-responders to the conservative therapy should be addressed to surgery, including resection osteeotomies of the affected area with margins extending to macroscopically sound bone tissue. Osteotomies should be performed with piezosurgery rather than rotary burs and soft tissue suture should be tensionless and without sharp bony edges that may damage the mucosa [47; 48; 49]. [PERSON] et al. underlined how debridements and refinements attempts are usually counterproductive and lead to a further bone exposure and worsen of the symptomatology [15].