This systematic review aims to evaluate the maxillomandibular bone changes post-radiotherapy in head and neck cancer (HNC) patients using qualitative and quantitative imaging analyses. The review was conducted following PRISMA guidelines, using the PEOS framework: patients with HNC (population), radiotherapy in the head and neck region (exposure), bone changes in the jaws detectable by radiographs (outcomes), including observational studies and experimental clinical trials (study design). A comprehensive search was performed in PubMed, Embase, Cochrane, and Web of Science, along with gray literature. Demographic data, tumor characteristics, radiotherapy modalities, and imaging findings from computed tomography scans or panoramic radiographs were extracted, with the risk of bias assessed using JBI’s critical appraisal tools, and studies at high risk of bias were excluded from the meta-analysis. A total of 30 studies involving 2441 patients met the inclusion criteria. Bone integrity alterations were the most frequently reported outcomes, including osteoradionecrosis (ORN), bone sclerosis, cortical thinning, trabecular density reduction, and osteolytic and osteosclerotic lesions. ORN was observed in 7 % of cases (95 % CI: 4–10 %). Periodontal alterations, such as periodontal ligament widening, were reported in five studies. Impaired bone healing included delayed socket ossification and nonunion after surgery. Panoramic radiography was the most used imaging modality, while quantitative analyses, such as fractal dimension reductions and radiomics, revealed subtle changes indicative of bone deterioration. Radiotherapy significantly impacts bone integrity and healing in HNC patients. These findings highlight the importance of advanced imaging techniques for early detection and personalized intervention strategies to mitigate radiation-induced bone complications.