In a patient treated with denosumab for osteoporosis, a case of stage II MRONJ occurred after 3 months from implant placement and subsequent implant loss. The first surgical approach led to a worsening at Stage III. A second surgery with a conservative approach was performed more than 6 months after the last denosumab injection obtaining therefore the definitive healing. Pharmacokinetics and surgical approach should be considered in MRONJ treatment scheduling.