Surgical Management of Advanced Mandibular Osteonecrosis Utilizing a Contemporary Mandibular Reconstruction Plate in Patients Unsuitable for Free Flap Reconstruction—Preliminary Study and Case Series

<b>Introduction:</b> Stage three osteonecrosis of the jaw (ONJ), whether medication-related (MRONJ) or osteoradionecrosis (ORN), often necessitates aggressive surgical management due to extensive necrosis, infection, and risk of pathologic fracture. While free flap reconstruction remains the gold standard post-segmental mandibulectomy, it may not be feasible for elderly or systemically compromised patients. <b>Objective:</b> The presentation of our own experience with advanced mandibular ONJ on patients managed exclusively with a contemporary titanium reconstruction plate system and to evaluate the clinical outcomes of this approach in the context of the current literature. <b>Methods:</b> From a group of 21 patients treated for ONJ, just four patients with Stage 3 MRONJ or Grade III ORN, unfit for microvascular surgery, underwent segmental mandibulectomy followed by alloplastic reconstruction using standard titanium plating. Outcomes were assessed clinically and radiographically over a follow-up period ranging from 3 to 20 months. A focused literature review was conducted to contextualize results. <b>Results</b>: All patients demonstrated stable reconstruction without plate exposure, fracture, or intraoral bone exposure during follow-up. Esthetic and functional outcomes are reported. No hardware complications were reported. The review of the literature supports plate-only reconstruction as a valid alternative for patients unsuitable for free flap surgery, especially when using rigid, anatomically adaptive systems with robust soft tissue coverage. <b>Conclusions</b>: Titanium plate-only reconstruction following segmental mandibulectomy can provide reliable short- to mid-term outcomes in selected patients with advanced ONJ. Used titanium plating systems appears to be a promising option.