AbstractBackground.An increasing number of cases of osteonecrosis of the jaws (ONJ) in patients treated with bisphosphonates has been reported in the literature. ONJ significantly affects the patients' quality of life and its management is still extremely difficult.Methods.A woman with ONJ secondary to therapy with zoledronic acid came to our attention for recurrent oral infections and orocutaneous fistula unresponsive to antibiotic therapy combined with minor surgical debridements. The patient underwent major surgery to remove the fistula and clean the necrotic bone and soft tissues; a lobed skin platysma flap was used to close the defect. The treatment outcome was good.Conclusion.When ONJ fails to respond to antibiotic therapy and surgical debridements, a more invasive surgical approach may be necessary to guarantee a better quality of life for the patient. © 2009 Wiley Periodicals, Inc. Head Neck, 2009