IntroductionBony sequestration, also known as sequestrum formation, is a well-documented pathological process characterized by the separation of necrotic bone from viable surrounding tissue, typically observed in the context of osteomyelitis or malignancy. In the maxillofacial region, this condition predominantly affects the mandible due to its relatively limited vascular supply; however, maxillary involvement, though less frequent, presents unique clinical challenges [1].The maxilla’s rich vascularity and porous membranous structure typically confer resistance to osteomyelitis, with a mandible-to-maxilla involvement ratio of approximately 3:1[2]. Predisposing factors for jawbone osteomyelitis include trauma, radiotherapy, and pharmacotherapies such as bisphosphonates and denosumab, which disrupt bone remodeling and increase susceptibility to necrosis [3, 4]. Radiation-induced osteonecrosis, a recognized complication of head and neck cancer treatment, further exacerbates this risk by impairing vascular integrity and promoting hypoxic tissue damage [5].The emergence of mucormycosis as a significant etiological factor in maxillary osteomyelitis has gained attention, particularly in the post-COVID-19 era. Mucormycosis, caused primarily by Mucorales species, is an angioinvasive fungal infection that thrives in immunocompromised states, infiltrating blood vessels and inducing thrombosis and necrosis [6]. Its predilection for the maxilla is attributed to anatomical proximity to the paranasal sinuses, a common entry point for fungal spores [7] .Pre-COVID-19 literature reported maxillary fungal osteomyelitis as a rare entity, with incidence rates favoring the maxilla (52%) over the mandible and a male-to-female ratio of 2.1:1 [8]. However, since 2020, a dramatic rise in mucormycosis cases has been documented among COVID-19 patients, particularly in India, linked to corticosteroid use, hyperglycemia, and immune dysregulation [9]. Pal et al. (2021) reported that Mucorales species accounted for 44% of fungal osteomyelitis cases, with Aspergillus spp. contributing a smaller fraction (2%) [10].Clinically, maxillary bony sequestration presents with pain, swelling, sinus tracts, and occasionally exposed necrotic bone, often mimicking other odontogenic or neoplastic conditions [11]. Radiographic evaluation remains a cornerstone of diagnosis. Plain radiographs and computed tomography (CT) reveal sequestra as calcified fragments within lucent lesions, with multiplanar CT reconstructions enhancing detection sensitivity [12]. However, these modalities struggle to differentiate necrotic bone from residual viable bone or calcified matrix [13]. Magnetic resonance imaging (MRI) offers superior soft-tissue contrast, distinguishing avascular sequestra within necrotic zones from vascularized bone in viable tissue when enhanced with gadolinium [14]. Nevertheless, MRI’s limitations in detecting small calcifications underscore the need for combined CT-MRI approaches [15].The post-COVID-19 surge in mucormycosis-associated osteomyelitis has introduced new diagnostic and therapeutic challenges. Studies indicate that COVID-19 exacerbates susceptibility to opportunistic infections through systemic inflammation and immune suppression, with fungal osteomyelitis emerging as a life-threatening complication (Mehta & Pandey, 2020). Treatment typically involves surgical debridement of necrotic tissue, antifungal therapy (e.g., amphotericin B), and management of underlying predispositions, though outcomes vary widely based on disease extent and patient comorbidities (Skiada et al., 2018).Despite advances in understanding maxillary bony sequestration and its association with mucormycosis in the post-COVID-19 context, several knowledge gaps persist. First, the precise mechanisms linking COVID-19-induced immune dysregulation to enhanced fungal pathogenicity remain poorly elucidated, limiting targeted preventive strategies. Second, the rarity of maxillary involvement prior to the pandemic complicates establishing baseline incidence rates and risk profiles specific to this site, particularly in immunocompetent populations. Third, while imaging modalities like CT and MRI have improved diagnostic precision, their ability to predict sequestrum viability and guide surgical planning remains suboptimal, necessitating novel imaging or biomarker-based approaches. Finally, the long-term outcomes of mucormycosis-associated osteomyelitis in COVID-19 survivors, including recurrence rates and quality of life, are inadequately documented, hindering the development of evidence-based management protocols. Addressing these gaps is critical to improving clinical outcomes in this emerging and complex disease entity.This case report explores the etiology, clinical presentation, and management of post-COVID-19 maxillary bony sequestration, highlighting its association with mucormycosis and the diagnostic challenges posed by this emerging complication.
