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Case Conference Medically Compromised Patients Oncology Oral Medicine Oral Surgery Supporting Your Practice

What’s your diagnosis of this case?

This case is presented by: 

  • Dr. Eric T. Stoopler, D.M.D., FDS RCSEd, FDS RCSEng
  • Dr. Juan M. Bugueno, D.D.S.
  • Dr. Kevin Sweeney, D.D.S.
  • Dr. David C. Stanton, D.M.D., M.D., F.A.C.S 

Click here to view the BRONJ Case Diagnosis and Treatment

Case Presentation

  • A 64-year-old Caucasian female presented for evaluation of symptomatic exposed bone of a two-year duration post extraction of maxillary teeth with immediate placement of four dental implants.
  • Medical history:
    • Is at stage IV breast adenocarcinoma treated with surgery and trastuzumab.
    • Received intravenous zoledronic acid (ZA) 4 mg monthly for approximately two years for metastatic bone disease.
    • Underwent dental surgery approximately four months after initiation of ZA therapy.
    • Onset of pain, suppuration, malodor and bony sequestration in the maxilla occurred after the dental procedure.
    • Was treated with multiple courses of antibiotics and chlorhexidine rinses without improvement of symptoms or resolution of her condition.

Clinical Evaluation

  • Significant exposure of necrotic maxillary alveolar bone with four dental implant abutments remaining, accompanied by mucosal erythema and oral malodour (Fig1).
  • Panoramic imaging and cone beam computed tomography (CBCT) revealed extensive radiographic changes to the maxillary alveolus and maxillary sinuses, as well as sequestration of necrotic bone in the anterior maxilla (Figs 2 and 3).
Figure 1

Fig 1. Initial clinical presentation of the maxilla in a 64-year-old Caucasian female

Figure 2

Fig 2. A reconstructed panoramic view from cone-beam computed tomography (CBCT) demonstrated a “moth-eaten” appearance to the maxillary alveolar ridge in addition to significant soft tissue thickening of the maxillary sinuses bilaterally

Figure 3

Fig 3. CBCT reveals sequestration of necrotic bone in the anterior maxilla
on sagittal view (arrow)

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  1. Jonathan Mayer August 6, 2014

    I would diagnose this as Bisohosphonate induced osteonecrosis

  2. Choukroun Joseph August 6, 2014

    Osteonecrosis of the maxilla after IV biphosphonates. Absolute contre-indication of implants.
    We are in use to treat these patients (ONJ or Osteoradionecrosis) with schock-wave therapy and A-PRF. With high percentage of success.

  3. Cliff Leachman August 6, 2014

    Osteonecrosis of the maxilla after implantation, patient is under IV biphosphonates: absolute contra-indication of implants !
    Patient could be treated with A-PRF and shock waves. After necrosis removal with piezo

    1. Anonymous August 12, 2014

      What’s involved in A-PRF treatment. How is it applied?

      1. Cliff Leachman August 13, 2014

        Here is a link to Dr. Choukroun’s site all questions you have can be answered there:


        Below is a link to an EXCITING video, exciting to me anyways, from Blue Sky Bio showing the latest in A-PRF technology and its application:


        You can also go to my Facebook site. Dr. Leachman Inc for pics of mine

  4. Antonis Balaskas August 7, 2014

    biphosphonic osteonecrosis from intravenus za without CTx telopeptidase exam


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