There is no widely accepted gold standard for the treatments of bisphosphonate-related osteonecrosis (BRONJ). Whereas the lesser stages of this BRONJ seem to respond well to conservative and minimal invasive therapies there is controversy regarding the treatment of the later stages, especially for stage 3 BRONJ. This is defined as exposed bone with pain and or infection and at least one of the following: pathological fracture, extra oral fistula or osteolysis extending to the inferior border. The authors present a systematic review of the literature and present their own series. Twenty-seven papers were analysed and eight papers fulfilled the selection criteria of academic publications, clinically and histologically confirmed diagnosis, reconstruction with vascularised free osseous transfer and minimal follow-up of 12 months. There is a school of surgeons against microvascular reconstruction of BRONJ. The main concerns appear to be higher surgical risk, corruption of the donor site by bisphosphonates and induction of necrosis of donor bone. This paper goes some way to promote free flap vascular transfer and suggests the possibility of good results. However, the numbers are limited and the authors acknowledge that additional studies from a larger case series or case controlled series are necessary.