Bisphosphonate-related osteonecrosis of the jaw

Case contributed by Dr Tamer O. Abdo


Known case of multiple myeloma on bisphosphonate. Complains of pain in the right side of the jaw.

Patient Data

Age: 40 years
Gender: Female

Panoramic Dental X Ray

An area of sclerosis and osteolysis at the junction of the right body and ramus of the right hemi-mandible.

Sclerosis of the right hemi-mandible is seen.


There is an ill-defined area of osteolysis interrupting the superficial and deep cortices, in the right mandibular angle deep to the right 2nd molar tooth, extending to the mandibular canal with bone marrow sclerosis and thick periosteal reaction of the right hemimandible. Lysis of the roots of both right lower molar teeth is.

Overlying soft tissue edema is noted as well as edema and enlargement of the right masseter muscle.
In keeping with the patient's medical history, appearances are suggestive of bisphosphonate induced osteonecrosis of the jaw. 

Multiple enlarged right submandibular lymph nodes, the largest measures 11 mm in short axis. Multiple sub centimeter lymph nodes in both cervical regions.

There is an elongated ovoid dense fluid collection in the right side of the retropharyngeal space measuring 6.7 x 2.8 x 1.3 cm. A small fluid attenuation focus in the right tonsil.

Case Discussion

Bisphosphonate is used to treat osteoporosis, bone metastases, hypercalcemia of malignancies and multiple myeloma.

Bisphosphonate related osteonecrosis of the jaw (BRONJ) is defined as exposed necrotic bone in the maxillofacial area that persists for more than 8 weeks in patients with a history of nitrogen-containing bisphosphonate use without a history of radiation exposure. Patients present with pain, swelling, purulent secretions, paresthesia, and difficulty in eating.

Image features of BRONJ are osteolysis, osteosclerosis, sequestration, periosteal reaction and spreading of soft tissue inflammation.

The top differential diagnosis is osteoradionecrosis, which has almost indistinguishable imaging features. Patients report a history of radiotherapy.

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Case information

rID: 71324
Published: 29th Sep 2019
Last edited: 30th Sep 2019
Inclusion in quiz mode: Excluded
Institution: Ibn Al Haitham hospital

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