Severe Case of Osteonecrosis Following Implant Placement in a Patient in Therapy With Bisphosphonates: A Case Report
Osteonecrosis of the jaw is a rare complication that has been associated with the use of bisphosphonates. A 77-year-old patient presented in April 2013 asking for a consultation. She reported that in May 2009, she underwent an implant rehabilitation with 8 implants and an immediately loaded fixed prosthesis in the maxilla. After a few months the patient started to report pain and purulent secretions that were neglected by the clinician for several years. She decided to refer to the Dental Clinic after another acute pain episode. Once the fixed prosthesis was removed, exposed necrotic bone was found in relation to the implants. The patient reported having taken oral alendronic acid to treat osteoporosis since before 2006. The patient underwent a functional endoscopic sinus surgery and a removal of necrotic bone blocks. Three years of follow-up showed healed tissues with no recurrence, although the alveolar crest appeared irregular on radiographs.
Figure 1. Orthopantomogram of the patient immediately after the implant placement and the immediate loading in 2009. Figure 2. Intraoral frontal photograph of the patient at the time of the first consultation at S. Paolo Hospital, Milan in 2013. Figure 3. Intraoral radiographic status of the patient during the consultations in 2013.
(a–c) CT scan images showing no bone alterations and the position of the apex of the posterior implants directly inside the maxillary sinus with bilateral sinusitis.
Figure 5. Intraoral photo of the maxilla of the patient after removing the prosthesis. Around the implants there is erythematous tissue, purulent secretion, and exposed necrotic bone between implants 24 and 25. Figure 6. In area 24-25 implants appeared to be surrounded by necrotic bone. Full-thickness flaps were raised to expose the sequestered maxillary bone. Figure 7. The necrotic bone was isolated and separated by the maxillary bone using a burr. Figure 8. A portion of 2 × 1 cm of necrotic bone war removed from the left maxillae bone in area 24-25. Figure 9. Implants in the pre-maxilla were unscrewed with a specific instrument. Implant in position 12 fractured during removal. Figure 10. The 2 flaps were sutured and an antibiotic and analgesia therapy was prescribed. Figure 11. All implants were extracted from the maxillae bone of the patient and two blocks of 2 × 1 cm and 1 × 1 cm of necrotic bone were removed, as well as many other particles. Figure 12. Intraoral image of the healed crests at 3 year after the surgery. It is possible to acknowledge the amount of bone loss. Figure 13. OPG at 3 years showing the amount of bone loss faced by the patient.
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