Severe atrophy of the maxilla

This code signifies a significant and advanced reduction in the size and density of the upper jawbone (maxilla). This atrophy can result from long-term tooth loss, periodontal disease, trauma, or systemic conditions, leading to compromised bone volume and architecture. It often impacts the ability to wear dentures or receive dental implants.

Apply this code when documentation clearly indicates severe, extensive bone loss in the maxilla, impacting its structural integrity or function. This is typically supported by radiographic evidence (e.g., panoramic X-rays, CBCT scans) showing marked alveolar ridge resorption, along with clinical findings of significant bone deficiency.

• Differentiate from moderate or mild atrophy; ensure documentation specifies "severe."
• Consider sequencing this code as a secondary diagnosis if the primary reason for the encounter is a related procedure (e.g., bone grafting, implant placement).
• Ensure the laterality (e.g., right, left, bilateral) is not specified, as this code represents a general severe atrophy of the maxilla.