Medication-related osteonecrosis of the jaw and successful implant treatment in a patient on high-dose antiresorptive medication: A case report

Camilla Ottesen, Sanne W M Andersen, Simon S Jensen, Thomas Kofod, Klaus Gotfredsen, Camilla Ottesen, Sanne W M Andersen, Simon S Jensen, Thomas Kofod, Klaus Gotfredsen

Abstract

Objectives: Oral rehabilitation can be a challenge in patients on high-dose antiresorptive medication (HDAR), especially if the alveolar anatomy has changed due to previous medication-related osteonecrosis of the jaw (MRONJ) resection. In healthy patients, dental implant treatment has found wide acceptance in prosthetic rehabilitation as it increases the patient's oral health-related quality of life. However, it is considered contraindicated in patients on HDAR due to the risk of MRONJ, although a recent feasibility study indicates that implant treatment may indeed be an option in these patients. The aim of the present case report is to illustrate the risk of MRONJ in a patient with cancer on HDAR and to discuss the reasons behind the outcomes of the implant treatment.

Materials and methods: A patient with prostate cancer with bone metastases on high-dose denosumab therapy with previous MRONJ had four implants inserted bilaterally in the maxilla (14, 13, 23, 24). Two identical implant-supported screw-retained cantilever bridges were fabricated. The patient was followed for more than 1 year.

Results and conclusion: Peri-implantitis, and/or MRONJ, was diagnosed around two of the implants (23, 24), probably induced by crestal bone trauma from a healing abutment and/or a misfitting prosthetic reconstruction. A peri-implantitis operation was performed, but without the desired response, and the two implants (23, 24) were later removed in an MRONJ resection. The implants on the other side of the maxilla (14, 13) remained without complications. Dental implant treatment is feasible in patients on HDAR, but comorbidities (e.g., diabetes mellitus) and polypharmacy (e.g., chemotherapy and steroids) may add to the risk of implant failure. Minimal trauma surgery and prosthodontics are crucial to increase the chance of successful healing in an HDAR patient.

Trial registration: ClinicalTrials.gov NCT04741906.

Keywords: denosumab; dental implants MRONJ; osteonecrosis of the jaw.

Conflict of interest statement

The authors declare no conflict of interest.

© 2022 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

Figures

Figure 1
Figure 1
Implant surgery. (a, b) Before implant surgery, clinical photo, and panoramic radiograph. (c‐f) Implant surgery. (g, h) Healing before abutment surgery, clinically and on panoramic radiograph. No signs of bone degeneration around dental implants. (I, k) Periapical radiographs immediately after abutment surgery. The healing abutment in region 23 which was not completely in place (arrow) probably due to interference with the alveolar crestal bone distal to the lateral incisor (arrow). (j, l) Two weeks after abutment surgery, no signs of infection on the left side. Minor mucosal reaction distally around abutment at implant in the region 14.
Figure 2
Figure 2
Prosthetic treatment. (a) Abutments at referral. (b) and (c) Implant‐supported restorations. (d) Installation using individual guide. (e‐g), and (h). Clinical and radiographic situation immediately after installation. Erythematous mucosa was observed in region 23. The minor bleeding in region 22 (f), is due to the newly performed composite restoration.
Figure 3
Figure 3
Treatment of minor peri‐implant abscess facially to implant 24. (a) Right side, no signs of any pathological conditions. (b) Minor abscess facially to dental implant 24. (c) Panoramic radiograph revealed no signs of bone degeneration around the dental implants.
Figure 4
Figure 4
Peri‐implantitis treatment. (a) Right side, no signs of pathologic conditions. (b) Left side, edematous mucosa facially to dental implant 24. (c) Panoramic radiograph shows sign of bone degeneration approximal to implants 23 and 24 (arrows). (d, e) Periimplantitis operation, no signs of bone necrosis, picture taken after removal of granulation tissue. (g, h) Fourteen days postoperatively at suture‐removal. No signs of infection. (i) One month postoperative follow‐up. No sign of any pathologic conditions.
Figure 5
Figure 5
Removal of dental implants and resection of necrotic bone. (a, b) Six months follow‐up revealed necrotic bone (arrows) facially to implants 23 and 24. Patient had initially no pain or discomfort. (c) Panoramic radiograph indicating a sequestrum around dental implants 23 and 24 (dotted line). No pathologic conditions on right side of the maxilla. (d) Intraoperative, sequestrum facially to dental implant 23 (arrow). (e) Removal of dental implant restoration, with minor sequestrum attached to dental implant 23. (f) Before wound closure, clinically vital bone. (g) Tension‐free wound closure with interrupted single sutures, Vicryl 4‐0. (h,i) One‐month follow‐up clinical and radiographical. Uneventful mucosal healing.

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