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Osteomyelitis of the Jaws
Dr. Ramank Mathur
PG OMFS
The word “osteomyelitis” originates from the
ancient Greek words osteon (bone) and
muelinos (marrow) and means infection of
medullary portion of the bone.
The infection- pus and edema in the
medullary cavity and beneath the periosteum
compromises or obstructs the local blood
supply.
Following ischemia, the infected bone
becomes necrotic and leads to sequester
formation, which is considered a classical
sign of osteomyelitis (Topazian 1994, 2002).
True infection of the bone induced by
pyogenic microorganisms (Marx1991).
In the preantibiotic era:
an acute onset secondary chronic
process (Wassmund 1935; Axhausen 1934).
After the introduction of antibiotics:
Subacute or chronic forms of osteomyelitis
(Becker 1973; Bünger 1984).
Suppurative osteomyelitis(acute & chronic)
Chronic sclerosing non-suppurative
osteomyelitis or Garre’s osteomyelitis
Osteomyelitis accompanying systemic disease
such as tuberculosis,actinomycosis & syphillis
Reference Classification Classification
criteria
Hudson JW
Osteomyelitis of the jaws: a 50-
year
perspective.
J Oral Maxillofac Surg 1993 Dec;
51(12):1294-301
I. Acute forms of osteomyelitis
(suppurative
or nonsuppurative)
A. Contagious focus
1. Trauma
2. Surgery
3. Odontogenic Infection
B. Progressive
1. Burns
2. Sinusitis
3. Vascular insufficiency
C. Hematogenous(metastatic)
1. Developing skeleton (children)
II. Chronic forms of osteomyelitis
A. Recurrent multifocal
1. Developing skeleton (children)
2. Escalated osteogenic (activity
< age 25 years)
B. Garre's
1. Unique proliferative
subperiosteal reaction
2. Developing skeleton (children
and young adults)
Classification based on clinical
picture and
radiology.
The two major groups (acute and
chronic osteomyelitis) are
differentiated
by the clinical course of the
disease after onset, relative to
surgical
and antimicrobial therapy. The
arbitrary time limit of 1 month is
used
to differentiate acute from chronic
osteomyelitis (Marx 1991;
Mercuri1991;
Koorbusch1992).
C. Suppurative or nonsuppurative
1. Inadequately treated forms
2. Systemically compromised
forms
3. Refractory forms (chronic
recurrent
multifocal osteomyelitis
CROM)
D. Diffuse sclerosing
1. Fastidious microorganisms
2. Compromised host/pathogen
interface
Reference Classification Classification
criteria
Topazian RG
Osteomyelitis of the Jaws. In
Topizan RG,
Goldberg MH (eds): Oral and
Maxillofacial
Infections.
Philadelphia, WB Saunders 1994,
Chapter 7, pp 251-88
I. Suppurative osteomyelitis
1. Acute suppurative osteomyelitis
2. Chronic suppurative
osteomyelitis
– Primary chronic suppurative
osteomyelitis
– Secondary chronic suppurative
osteomyelitis
3. Infantile osteomyelitis
II. Nonsuppurative osteomyelitis
1. Chronic sclerosing osteomyelitis
– Focal sclerosing osteomyelitis
– Diffuse sclerosing osteomyelitis
2. Garre's sclerosing osteomyelitis
3. Actinomycotic osteomyelitis
4. Radiation osteomyelitis and
necrosis
Classification based on clinical
picture,
radiology, and etiology
(specific forms such as syphilitic,
tuberculous, brucellar, viral,
chemical,
Escherichia coli and Salmonella
osteomyelitis not integrated in
classification)
Fractures due to trauma and RTA
Gunshot wounds
Radiation damage
Paeget’s disease
Osteoporosis
Systemic disease
:Malnutrition,acute
leukemia,uncontrolled D.M.,Sickle
cell anemia,Chronic alcoholism
Wilensky 1932
Hitchin & Naylor(1957)- 4 cases maxillitis of
infancy
Staphylococcus aureus
Injuries through foreign objects
Ramon et al 1977 –infections from infant’s
nose
Haematogenous invasion – streptococci
Sudden onset ,acute course
High fever, rapid pulse, vomiting, delirium.
Signs-
Swelling of face,
Edema of eyelids
Subperioteal abscess
Sinus tracts draining pus
Minimal bone involment
Long standing case -Sequestra
I.V. antibiotics-Schenk1948-5 cases
Penicillin
Culture
Irrigations-sinus tracts
Sequestrectomy
Localised or widespread
Debilitating systemic disease
(a) Close-up view of the socket in the
left mandibular first molar region.
Odontogenic infections
Periapical disease
Periodontal disease
Pericororonal infection
Infection from odontogenic cyst or tumor
Infection from extraction wound
o Staphylococcus aureus, rarely albus
Panoramic radiograph showing neither
abnormal consolidation nor ill-defined
trabecular bone structure around the
socket and clear running of the inferior
alveolar arteries.
CT scans at 14 days after the initial visit
showing remarkable absorption of the
cortical bone in the left mandibular molar
region. (a) Axial section. (b) Coronal
section.
Mandible or maxilla
Presence of unerupted tooth
Conservative treatment (antibiotics)
Condyle or TMJ –Severe deformities (Rowe &
Heslop 1957)
A proliferative rather than a lytic bony response is usually seen due to attenuation of the causative organisms and the improved immunological status of children in Britain.
The importance of penicillin-resistant organisms and anaerobes, early diagnosis by scintigraphy and the use of hyperbaric oxygen therapy are highlighted.
Br J Oral Maxillofac Surg. 1987 Jun;25(3):204-17.
Osteomyelitis of the mandible in children--clinical presentations and review of management.
Ord RA, el-Attar A.
Mandible> Maxilla
Sequestation of condyle rare –Linsey 1953
Rbc and hb decreased
Leukocytosis
Enlargement of marrow spaces(early)
Cortex involved-sequestra
Larger radiolucent areas –active bone
destruction.
Complete bed rest
High protein ,high caloric diet
I.V. solutions
Blood transfusions
Analgesics
Antibiotics –penicillin
Immobilization-bartons bandage
Hot moist compresses –localization of
infection
Surgical drainage
Extactions-offending tooth
Edentulous jaws
Incision –along alveolar crest
Window is cut
Rubber dam inserted
Angle of jaws-
Incision-greatest tenderness
Avoid facial nerve injury
o Condylar pocess
Preauricular incision
Rubber drain
Continued use of
Antibiotics
External hot moist packs
Analgesics
Hot saline mouth rinses
o Catheter –irrigate area with warm normal saline
o Further sequestrectomies-acute symptoms subside
Primary or secondary
Radiopaque bone –dead sequestra attracts
calcium
Subperiosteal bone deposition
Bone biopsies from the mandibles of 5 patients with PCO were sampled with an extraoral sterile approach. Cultivation and polymerase chain reaction (PCR) were performed.
RESULTS:
Two of the biopsies yielded growth of Propionebacterium acnes. One biopsy also demonstrated Staphylococcus capitis. The biopsies with bacterial growth were also positive for the same bacteria by PCR analysis.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2009 May;107(5):641-7. doi: 10.1016/j.tripleo.2009.01.020.
Primary chronic osteomyelitis of the jaw--a microbial investigation using cultivation and DNA analysis: a pilot study.
Frid P,Tornes K, Nielsen Ø, Skaug N
Surgical removal of sequestra
Not affected by systemic antibiotics –no
circulation(Khosla 1970)
Sequestrectomy & Sucerization –acute phase
subsided
Saucerization –eliminate dead space
Obwegeser (1960)-decortication of bone-
shortens healing time
Preoperative radiographs –site of incision
Maxilla – intraoral incisions
Mandible
1.Alveolar part –intraoral incisions
Involved teeth –removed
Intraoral wounds packed –iodoform gauge
soaked in compound tincture of benzoin or
balsam of peru
2.Inferior body of mandible
Skin incision –below angle of jaw
Masseter muscle detached
Sequestra removed
3. Condyle
Preauricular incision
4. Coronoid
Intraoral –along ramus (anterior border)
5. Mandibular notch
Retromandibular approach –incision at angle of jaw
Sequestrum –surface of bone
Window –sharp currette
Granulation –blunt curette
Closure
Completely with sutures
Sutures with Penrose rubber drain
Indwelling catheter
Smith –Peterson ,Larson (1945)-aqueous
penicillin
Large cavity –combined with sequestrectomy
Periosteum –retracted
Sequestrectomy –done
Abditional cortex-saucerize the cavity
Margins –smothened with bone file or round
bur
Suture & drain
Wound packed with iodoform gauge
Systemic antibiotics -10 days to 2 weeks
Paresthesia of lip
Frature of weakened bone –air drill with
sharp cutting instruments
Splints and fracture appliance
Systemic antibiotics -10 days to 2 weeks
Dehydration –I.V. fluids with added vitamins
Blood transfusion
High protein diet
Immobization of jaw –maxillomandibular
fixation or a Barton bandage –for several
weeks
Rubber catheter-normal saline irrigation
every 3-4 hrs
Septicaemia
Metastatic foci
Suppuration
Pathologic fracture
Rapid bone destruction-Azumi et al (1980)
Rolling in bed
During sequestrectomy or saucerization
Maxillomandibular wiring-safest
1.Arch bars
2. Ivy wire loops
o Skeletal fixation
1.Pins and external bars
2. 2-3 weeks
3.Pins – chronic cases
Transosseous wiring,Plating ,Intraosseous
fixation with kirschner wires contraindicated
–spread infection to unaffected parts of
bone.
Constant recurrences
Disability & pain
Resection (kerley et al 1981)
Incision from midline to high
on Ascending ramus
Reflection of buccal and
lingual mucoperiosteal flaps
and sectioning of the
neurovascular bundle at its
exit from mental foramen
Use of gigli saw to make
anterior osteotomy
Osteotomies made with a
combination of bur cuts
Space left should be closed in
layers to eliminate dead space
A drain is placed for 24 hrs
to 48 hrs to prevent
hematoma formation
Incision parallel to and
1cm below the angle of
mandible
Mandilmandible exposed
,neurovascular bundle
cut and tied
,osteotomies are made
with gigli saw ,air drill .
Mainous 1975,Marx 1983
Pure oxygen –greater alveolar
partial pressure
Elevation of oxygen tension
Improved vascular supply
& increased oxygen perfusion
Fibroblast proliferation ,
new capillary (Hunt et al 1975)
Osteogenesis (Maekley et al 1967)
Protocol –Hart 1976,Marx 1983
2 ATA -60 sessions (120 hrs)
Mansfield et al 1981-alternating 100% oxygen with intermittent oxygen followed by air
Marx 1983 – osteoradionecrosis
1.30 initial dives
2.Clinical improvement -60 dives
3.Resection –additional 20 dives 10 weeks after resection
Dry osteomyelitis
Localized or diffuse (Bell 1959 ,Shafer 1957)
Older people ,black women
Sclerotic opacities & lytic areas
Bone –granite hard ,mandible
Six patients- particulate cancellous bone and marrow grafting after saucerization
The partial resection of the mandible is associated with disadvantages- including loss of mandibular support, dysfunction, and problems related to mandibular reconstruction.
Therefore, it would be reasonable to choose saucerization combined with particulate cancellousbone and marrow grafting, which is a relatively conservative surgical treatment for chronic diffuse sclerosing osteomyelitis of the mandible.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2001 Apr;91(4):390-4.
Treating chronic diffuse sclerosing osteomyelitis of the mandible with saucerization and autogenous bone grafting.
Ogawa A Miyate H Nakamura YShimada M Seki S Kudo K
“Nonsuppurative process in which there is
peripheral sub-periosteal bone deposition
caused by infection and irritation.”
Carles garre 1893
In mandible –Pell et al (1955)
Children and young adults
Etiology –carious tooth ,soft tissue infection
(Ellis ,Winslow 1977)
Radiograph
1.Condensation of cortical bone
2.Overgrowth of osseous tissue beneath periosteum
Differential Diagnosis –
-Infantile cortical hyperstosis /Caffey’s Disease
young infants ,no of bones,clavicle .
Removal of infected tooth
Curettage of socket
Surgical recontouring
Surgery – obvious facial asymmetry -6 month waiting period
Garre's osteomyelitis in a 10-year-old boy -pulpoperiapicalinfection in relation to permanent mandibular right first molar.
The elimination of periapical infection was achieved by endodontic therapy and the complete bone remodelingwas seen radiographically after three months follow-up.
J Indian Soc Pedod Prev Dent.2007;25 Suppl:S30-3.
Garre's sclerosing osteomyelitis.
Suma R Vinay C, Shashikanth MC, Subba Reddy VV
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