Osteonecrosis of the Jaws: Which Imaging Strategy Best Supports Diagnosis and Differential Diagnosis?

Purpose or Learning Objective:
To review the main types of maxillary bone osteonecrosis—osteomyelitis, osteoradionecrosis, and medication-related osteonecrosis of the jaw (MRONJ)—and to evaluate the most appropriate imaging modalities and diagnostic criteria for their identification and differential diagnosis.
Methods or Background:
A retrospective analysis was performed using personal imaging archives collected over the past five years, including cone-beam computed tomography (CBCT), contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI).
The most recent peer-reviewed publications on maxillary osteonecrosis were reviewed to integrate current evidence regarding imaging strategies and diagnostic features.

Results or Findings:
The maxillary bone osteonecroses addressed in this review comprise osteomyelitis, osteoradionecrosis, and MRONJ.
Differentiating these entities is challenging because their imaging manifestations frequently overlap, including sequestration, cortical and trabecular bone destruction, jaw enlargement, and inflammatory osseous opacities.
Accurate diagnosis depends on a thorough clinical evaluation and a detailed medical history, notably prior radiotherapy, bisphosphonate therapy, or infectious episodes.

Panoramic radiography is usually the first-line investigation but provides limited diagnostic specificity.
Advanced imaging modalities—CBCT, CT, and MRI—are essential for precise assessment.
CBCT offers superior spatial resolution for delineating osseous architecture.
Contrast-enhanced CT is preferred when soft-tissue extension is suspected, while MRI supplies complementary information on bone marrow and adjacent soft-tissue involvement.
When imaging findings remain equivocal, histopathological confirmation through biopsy is required to exclude malignancy.
Conclusion:
Timely and accurate differentiation of maxillary osteonecroses is critical for appropriate management.
Integration of the patient’s clinical history with targeted imaging strategies optimizes diagnostic confidence, and biopsy remains indispensable when neoplastic processes cannot be definitively ruled out. Imaging technique used depends on the suspected pathology and whether adjacent soft tissue involvement is suspected. In some cases, a biopsy is necessary to formally rule out a tumour.