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

THANK YOU