Periimplantitis in non-bisphosphonate cases usually initiates in the interface between mucosa and implant surface as a mucositis. Then it affects the integrity of the bone-implant junction in a bone resorption process in direction from crestal to apical. If untreated, a gap between implant and bone is generated and osseointegration is lost. Contrarily, it was shown that the jaw bone develops sequestrum which includes the implant itself, but histologically, osseointegration of the implant can persist [3, 42]. One could explain this with regard to the fact that bone resorption is inhibited by the bisphosphonates, especially near to the surface of the bone, while deep in the bone marrow, there is still potential for a process like sequestration (Figs. 17.1 and 17.2).

MRONJ has a significant impact on quality of life and a big part of this is caused by bad oral conditions like eating discomfort, lack of self-consciousness, and mucosal irritability [43]. MRONJ itself often leads to relevant destruction of the jaw bone (Fig. 17.3), and surgical treatment of the disease regularly sacrifices parts of the jaw bone, additionally (Fig. 17.4). While surgical protocols to treat MRONJ seem to assimilate as they lead to curing in the majority of cases (see treatment chapter), bony reconstruction is problematic, as MRONJ can affect transferred bone [44] like it does in the jaw bone. As well as, there is lack of protocols for rehabilitation after MRONJ: Dentures should be very stable, because denture sores can trigger MRONJ [45]. But often in these patients, teeth and jaw bone loss leads to conditions where dentures cannot be fit in a sufficient manner (Fig. 17.5). Implants can immobilize dentures perfectly, but a history of MRONJ is a risk factor of relevant and highly debated impact, which excludes these patients from implantology, when regarding the AAOMS recommendations [8]. Consequently, leaving patients without dental prosthodontic rehabilitation is a recommendation given [46]. In the last years, the point of view changed from oral surgery as a true risk factor for MRONJ to the idea of oral surgery as a possible trigger of infection and acidic milieu, which then starts the cascade for MRONJ [47]. While still under debate [15, 48], some evidence for successful implant therapy in patients on oral bisphosphonate medication also came up in the recent literature.

In the author’s opinion, surgeons should use implants as a means of oral rehabilitation in selected cases and under control for other risk factors: In a 73-year-old female, which was on oral bisphosphonates for 5 years, MRONJ and MRONJ-induced pathological fractures were treated (Figs. 17.3, 17.4, and 17.5). After MRONJ was cured, implants were inserted (Fig. 17.6) and a bar-retained removable prosthesis was inserted (Fig. 17.7). The patient is on high-frequency recall and without any clinical or radiographical signs of infection (Figs. 17.8 and 17.9). The experience of other authors is consistent with this opinion [41], but of course, there is still lack of data on the topic.