CT-based qualitative classification of medication-related osteonecrosis of the jaw: association with surgical strategy and outcomes

Abstract Medication-related osteonecrosis of the jaw (MRONJ) exhibits marked heterogeneity in imaging appearance and clinical behavior, which is not fully captured by conventional staging systems. This retrospective observational study aimed to propose a novel computed tomography (CT)-based qualitative classification of MRONJ and to evaluate its clinical relevance in treatment selection and outcome prediction. A total of 253 patients diagnosed with MRONJ between 2014 and 2024 were analyzed. Based on CT findings, including osteolytic patterns, sequestrum separation, and periosteal reaction, lesions were classified into three types: type A (well-demarcated), type B (diffusely progressive), and type C (atypical). Associations between imaging classification, surgical procedures, and treatment outcomes were evaluated. Type A lesions were associated with favorable outcomes following limited surgery, whereas type B and type C lesions showed significantly poorer outcomes after conservative surgical approaches. Extended surgery resulted in comparable outcomes for type A and type B lesions, while type C lesions remained associated with unfavorable prognosis. These findings indicate that CT-based qualitative assessment reflects biologically relevant differences in MRONJ and may complement existing staging systems to optimize surgical decision-making and prognostic stratification.