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Bone-Within-Bone Appearance: A Red Flag for Biphosphonate-Associated Osteonecrosis of the Jaw

Fatterpekar, Girish M. MD, MBBS*; Emmrich, Julius Valentin MD; Eloy, Jean Anderson MD; Aggarwal, Amit MD§

Journal of Computer Assisted Tomography: September-October 2011 - Volume 35 - Issue 5 - p 553-556
doi: 10.1097/RCT.0b013e318227a81d

Objective: Osteonecrosis of the jaws is recognized as a serious complication of biphosphonate therapy. The purpose of this study was to characterize the computed tomography (CT) imaging appearance of biphosphonate-associated osteonecrosis and to evaluate for distinguishing features of radiation-induced osteonecrosis (RION), osteomyelitis (OM), and metastases.

Methods: We retrospectively reviewed CT scans of 6 patients with biopsy-proven biphosphonate-associated osteonecrosis (BAON). Computed tomographic scans were evaluated for presence of periosteal reaction, cortical erosion, reactive sclerosis, fragmentation and collapse of the underlying bone, destruction of the underlying trabecular bone manifested as radiolucency, sequestrum, and presence of any underlying bone expansion. Examinations were also assessed for presence of associated soft tissue mass. For comparison, we also retrospectively analyzed the CT scans of 5 patients with biopsy-proven RION of the jaw, 6 patients with OM, and 4 patients with metastases.

Results: An expansile lytic lesion with dense central sequestrum likened to a "bone-within-bone" appearance is highly suggestive of BAON. No RION or OM cases demonstrated an expansile lytic process. Instead, all the RION cases showed fragmentation and collapse of the underlying bone. Presence of cortical erosion, reactive sclerosis, radiolucency, and associated soft tissue mass should raise the possibility of OM in the appropriate clinical setting.

Conclusions: In an appropriate clinical setting, a bone-within-bone appearance should alert the clinician to the possibility of BAON.

From the *Section Neuroradiology, NYU Langone Medical Center, New York, NY; †Radiologie, Universitätsklinikum Leipzig, Leipzig, Germany; ‡Division of Otolaryngology, New Jersey Medical School, Newark, NJ; and §Department of Radiology, Mount Sinai Medical Center, New York, NY.

Received for publication April 15, 2011; accepted June 3, 2011.

Reprints: Girish M. Fatterpekar, MD, MBBS, NYU Langone Medical Center, New York, NY 10128 (e-mail:

G.M.F. has received consultancy fees from Terarecon and currently receives royalties from Elsevier. The remaining authors declare that they have no conflict of interest in relation to this article. No grant support was received.

© 2011 Lippincott Williams & Wilkins, Inc.