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).

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

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

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

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