Antiresorptives are the commonly prescribed medications to treat osteoporosis in older patients, a condition that weakens the bones and makes them prone to fractures. Antiresorptives work by reducing the rate at which the bone breaks down, which can help prevent further bone loss and reduce the risk of fracture [7].

In older patients with implants, such as dental implants or joint replacements, there is some concern that bisphosphonate use may increase the risk of implant failure [8]. Antiresorptives can affect the bone remodeling process, which is necessary for the implant to integrate properly with the surrounding bone [9, 10].

However, the evidence on this topic is controversial. Some studies found an increased risk of implant failure in patients taking bisphosphonates, whereas others did not. Overall, the risk appears to be relatively low, and many experts agree that the benefits of bisphosphonate treatment for osteoporosis outweigh its potential risks [11,12,13].

The multifactorial background of implant complications and failures has been extensively reviewed [14,15,16,17]. Recognizing jaw conditions that increase the risk of failure will allow the surgeon to make informed decisions and refine the treatment plan to optimize the outcomes. The success or failure of implants is closely related to the patient’s general condition, especially in cases of diabetes and antiresorptive therapy [18]. The effect of antiresorptive medicines on the osseointegration and survival of dental implants remains controversial. Previous studies have recommended that treatment with oral bisphosphonates is not a definite contraindication for dentoalveolar surgery. Recently, many cases of MRONJ associated with implant or invasive dental procedures have been reported [2]. This study aimed to investigate implants as the risk factor for MRONJ and to depict the clinical and radiological features of implant-associated MRONJ. We hypothesized that implant placement or loading is associated with MRONJ and analyzed various clinical factors. However, the results of these investigations were inconclusive.

The results of this study show that the time between functional loading and placement of implants and the onset of osteonecrosis can be long. In the literature review, the duration ranged from 44.4 to 89.6 months. Previous studies are of the view that treatment with oral bisphosphonates is not considered an absolute contraindication for dentoalveolar surgery, and implant placement does not need a “drug holiday” [19]. However, some studies have reported about patients with “delayed osteonecrosis” who had implants and were prescribed antiresorptive agents [4, 5]. A study analyzing 12 clinical cases reported that one patient developed osteonecrosis immediately after implant placement (2 months). For the remaining 11 patients, the specific time from implant placement to symptom onset was not analyzed [20]. In a similar study, Kwon et al. referred to the term “implant surgery triggered osteonecrosis” to define cases in which osteonecrosis occurred within 6 months after implant placement surgery. In their report, 58% of the cases with osteonecrosis were not related to implant insertion [5]. Most previous studies on peri-implant MRONJ showed no association with implant surgery; however, these cases were triggered by previously osseointegrated implants [21].

The results of our clinical study confirm that MRONJ with implants occurs more frequently after loading. Among the 33 patients, 11 patients had implant-surgery-triggered MRONJ, while 22 patients had implant loading-triggered MRONJ. Because MRONJ patients usually have low bone mineral density, loading of the occlusal force after osseointegration may lead to microfractures in the bone. With the onset of such microfractures, the sequestration grows in the form of a block in the presence of an implant (complete necrosis of the bone around the implant). In the other cases, extensive osteolysis around the implant with or without sequestration occurred similar to the pattern of implant failure. These types of MRONJ with implants can occur simultaneously, depending on the quality of the local bone.

It is important for patients taking antiresorptives or denosumab to inform their dentist or oral surgeon regarding their medication before undergoing any dental procedures, including implant placement. This allows the dentist or oral surgeon to take appropriate precautions and minimize the risk of complications, including MRONJ. In some cases, it may be advisable to delay or avoid implant placement altogether, especially in patients at a high risk of MRONJ.