Imaging Findings of Bisphosphonate-Associated Osteonecrosis of the Jaws
P.M. Phala,
R.W.T. Myallb,
L.A. Assaelb and
J.L. Weissmana,c,d
a Division of Neuroradiology
b Department of Oral and Maxillofacial Surgery, School of Dentistry
c Department of Otolaryngology, Oregon Health and Science University, Portland, Ore
d Department of Ophthalmology, Oregon Health and Science University, Portland, Ore
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Fig 1. Radiographic findings in bisphosphonate-associated osteonecrosis of the jaws.
A, Normal: the alveolar crest of the jaws is the cortical bone of the alveolar margin in between teeth and is continuous with the lamina dura around the root of the tooth. The 1- to 2-mm lucency between the root of the tooth and the lamina dura corresponds with the space for the periodontal ligament.
B, In our series, osseous sclerosis was most commonly involved in the alveolar margin and lamina dura. The sclerotic changes were often diffuse rather than localized to the area of clinical involvement.
C, In the patients with sequential imaging, the sclerotic changes were often progressive and may encroach on the mandibular canal. The sclerosis of the medullary cavity may be attenuated and reminiscent of osteopetrosis.
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Fig 2. A 65-year-old woman (patient 1 in Table 1) with multiple myeloma treated with zoledronate presented with a nonhealing extraction socket in the left posterior maxilla (second and third molars, black arrow). The orthopantomogram demonstrates generalized sclerosis of the alveolar margin of the mandible (white arrows) and the maxilla to a lesser extent. There is also thickening of the lamina dura.
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Fig 3. A 67-year-old woman (patient 2) with metastatic breast cancer treated with pamidronate and later zoledronate presented with a nonhealing extraction socket.
A, The orthopantomogram demonstrates the nonhealing extraction socket in the right posterior mandible (*) with sclerosis in the adjacent body and ramus of the mandible (arrow) and generalized thickening of the lamina dura in the mandible (arrowhead) and maxilla.
B, Axial CT demonstrates the osseous sclerosis, as well as narrowing the mandibular canal (*), thin periosteal new bone anteriorly (arrow) and generalized thickening of the lamina dura in the mandible (arrowhead).
C, Tc99m-HDP bone scan demonstrates increased radiotracer uptake in the right hemimandible corresponding with the area of sclerosis, which had increased over the last 3 years.
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Fig 4. A 60-year-old woman (patient 3) with widely metastatic breast cancer treated with pamidronate presented with a nonhealing extraction site in the left posterior mandible.
A, Orthopantomogram demonstrates the nonhealing extraction site in the left posterior mandible (*) and sclerosis of the left ramus and angle of the mandible (arrowhead).
B, Orthopantomogram, 23 months later with intervening curettage, demonstrates disorganized bone formation in the extraction socket of the lower left third molar, progressive sclerosis of the left ramus, and angle of the mandible (arrow) with further encroachment on the left mandibular canal (arrowhead).
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Fig 5. A 77-year-old woman (patient 4) with multiple myeloma initially treated with pamidronate and subsequently zoledronate.
A, The initial orthopantogram demonstrates osseous sclerosis (arrow).
B, Orthopantomogram 9 months later demonstrates lytic destruction of the mandible, most prominent in the left body of the mandible (arrow). Surgical debridement was performed.
C, Photomicrograph at low power (x40) of the curettage specimen stained with hematoxylin-eosin demonstrates fragments of necrotic bone with empty lacunae (arrow). There is extensive infiltration with inflammatory cells with surface resorption of bone (arrowhead) and bacteria (*).
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Fig 6. A 64-year-old man (patient 5) with multiple myeloma treated with pamidronate and subsequently clodronate presented with sinusitis and chronic nasal infection. Axial CT demonstrates maxillary sclerosis, sequestrum (arrow), and mucosal thickening in the right maxillary sinus.
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Fig 7. A 61-year-old man (patient 6) with metastatic prostate cancer treated with zoledronate presents with painful bone exposure of the right mandible (arrow).
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Fig 8. Coronal CT in a 7-year-old girl with sclerosing osteomyelitis demonstrates osseous sclerosis, remodelling, periosteal new bone (arrowhead), and soft tissue swelling (arrow).
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Fig 9. Orthopantomogram demonstrates mixed sclerotic and lytic destruction and pathologic fracture of the left body of the mandible (arrow) secondary to radiation osteonecrosis.
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Fig 10. Axial CT demonstrates mixed lytic and sclerotic (arrow) metastases in the mandible and cervical spine secondary to breast carcinoma. Note the cortical thinning related to the lytic lesions.
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