MRONJ is a side effect of drugs with a predilection for the mandible [24], which can be attributed to the relatively low vascularization of the mandible as compared to the maxilla [13]. Dental infections, surgical interventions, corticosteroid treatment, and chemotherapy have been described as risk factors for osteonecrosis [25]. In this case, the patient presented with stage 2 osteonecrosis with dental infections in an area of the mandible, even after receiving antibiotic therapy, prior to implant placement.

The treatment of MRONJ with ozone therapy in conjunction with debridement and antibiotics presented a success rate of 90% in 131 patients with a history of bisphosphonate use [26]. Ozone therapy is occasionally beneficial, including antimicrobial, fungicidal, and virucidal activities [27, 28]; stimulation of the vascular system which increases tissue oxygenation; modulation of the immune response; stimulation of angiogenesis; and replication of fibroblasts [29]. Ozone induces bone sequestration, which is a favorable prognostic sign; because the necrotic bone tissue is removed during debridement, a bleeding bone with well-vascularized mucosa can be observed underneath [23]. Similar findings were noted in our case. After 10 sessions of ozone therapy, bone sequestration and loss of dental implants occurred, revealing the remaining vascularized alveolar bone.