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Osteomyelitis of the

Jaws

Dr. Ramank Mathur


PG OMFS

DEFINITION

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).

HISTORY

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; Bnger 1984).

CLASSIFICATION

Suppurative osteomyelitis(acute & chronic)

Chronic sclerosing non-suppurative


osteomyelitis or Garres osteomyelitis

Osteomyelitis accompanying systemic disease


such as tuberculosis,actinomycosis & syphillis

Reference

Classification

Classification
criteria

Hudson JW
Osteomyelitis of the jaws: a 50year
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)

PREDISPOSING FACTORS
Fractures due to trauma and RTA
Gunshot wounds
Radiation damage
Paegets disease
Osteoporosis
Systemic disease
:Malnutrition,acute
leukemia,uncontrolled D.M.,Sickle
cell anemia,Chronic alcoholism

Osteomyelitis In Infants
(Osteomyelitis Maxillaris
Neonaturum)

Wilensky 1932
Hitchin & Naylor(1957)- 4 cases maxillitis of
infancy
Staphylococcus aureus
Injuries through foreign objects
Ramon et al 1977 infections from infants
nose
Haematogenous invasion streptococci

CLINICAL FINDINGS
Sudden onset ,acute course
High fever, rapid pulse, vomiting, delirium.
Signs Swelling of face,
Edema of eyelids
Subperioteal abscess
Sinus tracts draining pus

RADIOGRAPHIC FINDINGS

Minimal bone involment


Long standing case -Sequestra

TREATMENT

I.V. antibiotics-Schenk1948-5 cases


Penicillin
Culture
Irrigations-sinus tracts
Sequestrectomy

ACUTE PYOGENIC
OSTEOMYELITIS

Localised or widespread
Debilitating systemic disease

(a) Close-up view of the socket in the


left mandibular first molar region.

ETIOLOGY
Odontogenic infections
Periapical disease
Periodontal disease
Pericororonal infection
Infection from odontogenic cyst or tumor
Infection from extraction wound
o Staphylococcus aureus, rarely albus

PATHOLOGY

RADIOGRAPHIC CONSIDERATIONS
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.

Acute Osteomyelitis In
Children

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.

Acute Osteomyelitis In Adults

Mandible> Maxilla
Sequestation of condyle rare Linsey 1953
Rbc and hb decreased
Leukocytosis

RADIOGRAPHIC FINDINGS

Enlargement of marrow spaces(early)


Cortex involved-sequestra
Larger radiolucent areas active bone
destruction.

TREATMENT

Complete bed rest


High protein ,high caloric diet
I.V. solutions
Blood transfusions
Analgesics
Antibiotics penicillin

OPERATIVE PROCEDURES
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

Condylar pocess
Preauricular incision
Rubber drain
o

POST-OPERATIVE CARE
Continued use of
Antibiotics
External hot moist packs
Analgesics
Hot saline mouth rinses

Catheter irrigate area with warm normal


saline

Further sequestrectomies-acute symptoms


subside

CHRONIC SUPPURATIVE
OSTEOMYELITIS

Primary or secondary
Radiopaque bone dead sequestra attracts
calcium
Subperiosteal bone deposition

ETIOLOGY

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 ,Skaug N

TREATMENT

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 boneshortens healing time

SEQUESTRECTOMY
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

SAUCERIZATION

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

SURGICAL COMPLICATIONS

Paresthesia of lip
Frature of weakened bone air drill with
sharp cutting instruments
Splints and fracture appliance

POST OPERATIVE TREATMENT

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

POST OPERATIVE
COMPLICATIONS

Septicaemia
Metastatic foci
Suppuration
Pathologic fracture

PATHOLOGIC FRACTURE

Rapid bone destruction-Azumi et al (1980)


Rolling in bed
During sequestrectomy or saucerization

FIXATION METHODS
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.

INDICATIONS FOR RESECTION

Constant recurrences
Disability & pain
Resection (kerley et al 1981)

INTRAORAL RESECTION
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

EXTRAORAL RESECTION

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 .

HYPERBARIC OXYGEN
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

CHRONIC NON SUPPURATIVE


SCLEROSING OSTEOMYELITIS

Dry osteomyelitis
Localized or diffuse (Bell 1959 ,Shafer 1957)
Older people ,black women
Sclerotic opacities & lytic areas
Bone granite hard ,mandible

TREATMENT

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 cancellous bone
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 HNakamura YShimada MSeki SKudo K

GARRES OSTEOMYELITIS
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 /Caffeys Disease
young infants ,no of bones,clavicle .

TREATMENT

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 -pulpoperiapical
infection in relation to permanent mandibular right first
molar.
The elimination of periapical infection was achieved by
endodontic therapy and the complete bone remodeling was
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

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