Dose-Informed Surgical Margin in Mandibular Osteoradionecrosis Surgery: Integrating Radiation Biology into Osteotomy Planning

Mandibular osteoradionecrosis (ORN) remains one of the most challenging late complications of head and neck radiotherapy. Although surgical resection with vascularized reconstruction is the standard treatment for advanced disease, determination of the osteotomy margin continues to rely largely on anatomical findings, intraoperative assessment, and surgical judgment. However, accumulating evidence indicates that radiation-induced mandibular injury is spatially heterogeneous and biologically dynamic. Consequently, visible necrosis, geometric distance from disease, and punctate marrow bleeding may not reliably reflect the biological competence of residual irradiated bone. This review proposes the Dose-Informed Surgical Margin (DISM) framework, a biologically informed, hypothesis-generating concept that integrates patient-specific historical radiotherapy dosimetry with conventional anatomical, radiological, intraoperative, and host-related factors to support individualized osteotomy planning. We examine the radiobiological basis of mandibular injury, current concepts of surgical margin assessment, the limitations of bleeding-guided resection, and the potential contribution of three-dimensional radiation dose mapping to identifying biologically more favorable residual bone. We further discuss technical considerations for clinical implementation, including image registration, multimodality imaging, virtual surgical planning, and integration with host-related determinants of tissue repair. Rather than advocating universal dose thresholds or replacing established surgical principles, DISM is intended as an adjunctive decision-support framework that adds biological context to conventional margin assessment. Prospective biological and clinical validation remains essential before routine clinical implementation. If validated, DISM may facilitate a transition from predominantly anatomical definitions of mandibular osteotomy toward biologically informed, patient-specific surgical planning for the management of mandibular ORN.