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Dr. Anushan Madhushanka..BDS, MD/OMFS, MFDRCSI
Senior Registrar in OMF Surgery
Colombo North Teaching Hospital Sri Lanka
Introduction
 Definition
Inflammation of the bone marrow & cortical bone
& periosteum with a tendency to progression.
 N...
 Pre antibiotic era – Very common
 Antibiotic era – Uncommon
 Now – emerging due to AB resistance
 Diagnostic & therap...
Predisposing Factors
1. Immunocompromisation
2. Hypovascularity
3. Microbial virulence
Hypovascularity
 Radiation therapy
 Age
 Bone pathology that decreased blood supply-
Cemento ossifying fibroma
Osteopet...
Microbial virulence
 Secretes lysosomal enzymes
 Causes tissue destruction
 Microvascular embolisation
 Impaired blood...
Immunocompromisation
 Diabetes
 Immunodeficiencies
 Malignancies
 Malnutrition
 HIV
 Anaemia
 Agranulocytosis
 Ste...
Pathogenesis
Odontogenic infection / Trauma
Inflammation in marrow space Self limiting
Suppuration
Increased intra medulla...
Pus in Volkman,s & Haversean System
Further blood supply cutoff & cortical perforation
Subperiosteal pus collection
Necros...
Microbiology
 Aerobs – Streptococcus viridans, Pyogenes
Staphylococcus
 Anaerobic bacteria - Bacteroides
Pseudomonas
Pep...
Classification
 Several classifications - Cierny and colleagues.
Lew and Waldvogel.
Topazian
 Hudson’s classification – ...
Hudson’s classification of
OM
1. Acute osteomyelitis
a. Contiguous focus
b. Progressive
c. Hematogenous
2. Chronic osteomy...
Clinical classification
 Suppurative OML
1. Acute
2. Chronic
3. Infantale
 Non suppuratve
1. Sclerosing OML – Focal
Diff...
Clinical Presentation
 Acute OM features
Local - Pain – severe pain
Swelling and erythema
Paresthesia of the ID nerve
Tri...
Clinical Presentation
 Chronic OM
Dull pain/ No pain
Mild swelling & minimal inflammation
Fistula + Pus
Exposed bone
NO f...
Investigations
1. Plain X- rays – OPG
Lateral oblique view of mandible
changes of OM sources disease predisposing
conditio...
2. Computerized tomography (CT)
 Become the standard
 3D imaging
 Early cortical erosion
 Extent of the lesion
 Bony ...
3. Magnetic resonance imaging (MRI)
Assist in the early diagnosis-
loss of marrow signal before cortical erosion
Better th...
4. Technetium 99
 Sensitive to - increased bone turnover areas
Inflammation – Infection
Trauma
 No differentiation of in...
5. Biopsy –
Explorative
Send for - Gram stain
Culture
ABST
Histopathology
6. FBC - WBC count – Acute OM
Normal WBC count – Chronic OM
7. ESR, CRP - Nonspecific
Raised in inflammation
Use - to foll...
Treatment
1. Conservative Rx
2. Surgical Rx
Conservative Rx
 Bed rest
 Hydration – IV fluids, Oral
 Supportive Rx – Nutrition – High protein, Fat
Vitamin enriched
...
Antimicrobial Rx
 First choice
IV Pnicillin G - 2mu/ 6 hr
O. oxycilline - 1g/ 6 hr
If symptoms improved within 3 days – c...
Surgical Rx
 Incision & Drainage
 Teeth extractions
 Sequestrectomy
 Saucerisation
 Decortication
 Fenestration
 Ja...
Surgical Treatment
1. Sequestrectomy + Saucerisation
 Sequestrectomy - Remove necrotic bone & sequestra
Improve blood flo...
Sequestrectomy +
Saucerisation
Surgical Treatment
Jaw resection & Reconstruction
 last-ditch effort
 After - smaller debridements
unsuccessful previous...
 Resection – Segmental resection
 Reconstruction – Reconstruction plate
Bone graft & plating
Free flaps – Microvascular ...
Jaw resection &
Reconstruction
Jaw resection &
Reconstruction
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Osteomyelitis of jaws

Management of osteomyelitis of jaw bones

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Osteomyelitis of jaws

  1. 1. Dr. Anushan Madhushanka..BDS, MD/OMFS, MFDRCSI Senior Registrar in OMF Surgery Colombo North Teaching Hospital Sri Lanka
  2. 2. Introduction  Definition Inflammation of the bone marrow & cortical bone & periosteum with a tendency to progression.  Nonprogressive inflammation of the bone 1. Dentoalveolar abscess 2. Dry socket 3. Osteitis in infected fractures.
  3. 3.  Pre antibiotic era – Very common  Antibiotic era – Uncommon  Now – emerging due to AB resistance  Diagnostic & therapeutic Challenge - if occurs  Need – Multiple surgeries Prolonged Rx  Carries Morbidity risk – loss of Jaw & teeth
  4. 4. Predisposing Factors 1. Immunocompromisation 2. Hypovascularity 3. Microbial virulence
  5. 5. Hypovascularity  Radiation therapy  Age  Bone pathology that decreased blood supply- Cemento ossifying fibroma Osteopetrosis  Dento alveolar infection  Trauma – Fractures
  6. 6. Microbial virulence  Secretes lysosomal enzymes  Causes tissue destruction  Microvascular embolisation  Impaired blood supply  Brodie,s abscess formation
  7. 7. Immunocompromisation  Diabetes  Immunodeficiencies  Malignancies  Malnutrition  HIV  Anaemia  Agranulocytosis  Steroids  Chemotherapeutic agents  Bisphosphonates
  8. 8. Pathogenesis Odontogenic infection / Trauma Inflammation in marrow space Self limiting Suppuration Increased intra medullary pressure
  9. 9. Pus in Volkman,s & Haversean System Further blood supply cutoff & cortical perforation Subperiosteal pus collection Necrosis of cortical bone & Sequestrum formation Fistula formation
  10. 10. Microbiology  Aerobs – Streptococcus viridans, Pyogenes Staphylococcus  Anaerobic bacteria - Bacteroides Pseudomonas Peptostreptococci  Others – Klebsiella , Proteus , E. Coli  Specific – M. tuberculosis, T. Pallidum  Therefore Mixed infection
  11. 11. Classification  Several classifications - Cierny and colleagues. Lew and Waldvogel. Topazian  Hudson’s classification – Clinically valuable
  12. 12. Hudson’s classification of OM 1. Acute osteomyelitis a. Contiguous focus b. Progressive c. Hematogenous 2. Chronic osteomyelitis a. Recurrent multifocal b. Garre’s c. Suppurative or nonsuppurative d. Sclerosing
  13. 13. Clinical classification  Suppurative OML 1. Acute 2. Chronic 3. Infantale  Non suppuratve 1. Sclerosing OML – Focal Diffuse 2. Garre’s OML 3. Actinomycotic OML 4. Specific infective OML - TB, Syphilis 5. ORN 6. BRONJ
  14. 14. Clinical Presentation  Acute OM features Local - Pain – severe pain Swelling and erythema Paresthesia of the ID nerve Trismus Adenopathy Systemic – Fever Malaise
  15. 15. Clinical Presentation  Chronic OM Dull pain/ No pain Mild swelling & minimal inflammation Fistula + Pus Exposed bone NO fever - typical
  16. 16. Investigations 1. Plain X- rays – OPG Lateral oblique view of mandible changes of OM sources disease predisposing conditions  Moth eaten appearance +/- Sequestrum  25%- 50% Deminaralisation – Radiological evidence  Therefore – Early acute OM not visible in X-rays
  17. 17. 2. Computerized tomography (CT)  Become the standard  3D imaging  Early cortical erosion  Extent of the lesion  Bony sequestra  Pathologic fractures.  Requires 30 to 50% demineralization for visibility
  18. 18. 3. Magnetic resonance imaging (MRI) Assist in the early diagnosis- loss of marrow signal before cortical erosion Better than CT evaluation of soft tissue - fistula
  19. 19. 4. Technetium 99  Sensitive to - increased bone turnover areas Inflammation – Infection Trauma  No differentiation of infection  addition of Gallium 67 / Indium 111 Contrast agent, Bind to WBC Differentiate infection from Trauma
  20. 20. 5. Biopsy – Explorative Send for - Gram stain Culture ABST Histopathology
  21. 21. 6. FBC - WBC count – Acute OM Normal WBC count – Chronic OM 7. ESR, CRP - Nonspecific Raised in inflammation Use - to follow the clinical progress
  22. 22. Treatment 1. Conservative Rx 2. Surgical Rx
  23. 23. Conservative Rx  Bed rest  Hydration – IV fluids, Oral  Supportive Rx – Nutrition – High protein, Fat Vitamin enriched  Antimicrobials  Analgesics  Blood transfusion – If low Hb, WBC
  24. 24. Antimicrobial Rx  First choice IV Pnicillin G - 2mu/ 6 hr O. oxycilline - 1g/ 6 hr If symptoms improved within 3 days – convert to oral drugs O. Penicilline 500mg/6hr Cloxacilline 250mg / 6hr – 2/3 weeks  Second choice O. Clindamycine 600mg/ 8 hr – 2/3 weeks  Third choice O. Cefazolin 500 mg/ 8 hr  Fourth choice O. Erythromycine 2g /6hr Others – Ticarcilline, Vancomycine, Ciprofloxacine if not respond
  25. 25. Surgical Rx  Incision & Drainage  Teeth extractions  Sequestrectomy  Saucerisation  Decortication  Fenestration  Jaw resection +/- Vascularised flap & bone  Follow up
  26. 26. Surgical Treatment 1. Sequestrectomy + Saucerisation  Sequestrectomy - Remove necrotic bone & sequestra Improve blood flow.  Saucerization - Removal of adjacent bony cortices Open packing & permit 2ry healing  Decortication - Removal of infected cortex Cover marrow with periosteum Remove adjacent teeth if needed Surgery weaken the bone pathological # Therefore – Do elective plating , IMF
  27. 27. Sequestrectomy + Saucerisation
  28. 28. Surgical Treatment Jaw resection & Reconstruction  last-ditch effort  After - smaller debridements unsuccessful previous therapy associated pathologic fracture.  Performed via an extra oral route  Reconstruction - immediate or delayed  If ID paraesthesia – Immediate resection & reconstruction
  29. 29.  Resection – Segmental resection  Reconstruction – Reconstruction plate Bone graft & plating Free flaps – Microvascular surg Free flap – Independent blood supply Good healing No need of HBO Implants can be placed Ideal mandibular reconstruction
  30. 30. Jaw resection & Reconstruction
  31. 31. Jaw resection & Reconstruction
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Management of osteomyelitis of jaw bones

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