6. INTRODUCTION
Osteomyelitis of maxillofacial region is a challenging d
isease for clinicians and patients despite many advanc
es in diagnosis and treatment.
*In the past osteomyelitis was encountered frequently
and dreaded because of its prolonged course, uncerta
inty of outcome and occasional disfigurement resultin
g from loss of teeth and bone and the accompanying f
acial scarring.
7:42:00 AM 6
7. The development of organisms resistant to co
mmonly used antibiotics, existence of more in
dividuals who are medically compromised, lack
of experience with managing the disease by m
any practitioners and its unique manifestation
s when jaws are affected have made the effe
ctive management of osteomyelitis increasingl
y difficult.
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8. DEFINATION…
Literal meaning- Inflammation of bone & marrow elements
Derived from the words
osteon- bone
myelo- marrow
This term denotes bacterial & occasionally fungal infections
Defination : Osteomyelities is defined a
s an inflammation of the medullary porti
on of bone and extends to involve corte
x and periosteum.
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10. HISTORICAL PERSPECTIVE
Osteomyelitis has been a feature of ver
tebrate of biology since the time of din
osaurs.
The fossil evidence of healed bone infec
tion from pleistocene era to early human
remains reflects equally long dynamic re
lationship between vertebrate host and
pathogenic bacteria.
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11. • First written documentation – charaka & sushruta
• Hippocrates described the- extrusion of the sequestru
m
-surgical procedure for its removal
-connection between non healing sinus & presence
of dead bone
• In 14 th & 15 th centuries the usage of missiles from fir
earms in wars resulted in higher incidence of infected bo
ne injuries.
This lead to a class of unqualified practitioners called W
ANDARZTE – Germany & BONESETTERS – England
PERCIVAL POTT -1771 described an osteomyelitic lesi
on & speculated that the source of sequestrum lays in th
e seperation of periosteum from bone due to avascularity
of bone7:42:00 AM 11
13. II. Topazian classification : Based on a
bsence or presence of suppuration
Suppurative
Acute suppurative osteomyelitis
Chronic suppurative osteomyelitis
Primary
Secondary
Infantile osteolmyelitis
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15. III. Based on clinical course: According to JOMS
1993: 51; 1994 by Hudson et al
Acute forms of osteomyelitis (suppurative and non-suppurati
ve)
Contigous focus
Trauma
Surgery
Odontogenic infection
Progressive
Burns
Sinusitis
Vascular insufficiency
Hematogenous (metastatic)
Developing skeleton (children)
Developing dentition (children)7:42:00 AM 15
16. Chronic forms of osteomyelitis
Recurrent multifocal
Developing skeleton (child)
Escalated osteogenic activity (< age 25yrs)
Garre’s osteomyelitis
Unique proliferative subperiosteal reaction
Developing skeleton
Suppurative or non-suppurative
Inadequately treated forms
Systemically compromised forms
Refractory forms
Sclerosing
Diffuse
Fastidious microorganisms
Compromised host and pathogen interface
Focal
Predominantly odontogenic7:42:00 AM 16
17. IV. Based on pathogenesis of altered, vasc
ular perfusion (Vibhagool et al, 1993)
3 Types:
Haematogenous osteomyelitis
Osteomyelitis secondary to a contiguous focus infection
Osteomyelitis with or without peripheral vascular disease.
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18. V. Classification and staging system for o
steomyelitis (Mader et al 1985, & Vibhago
ol)
Anatomic type:
Stage I: Medullary osteomyelitis – involved
medullary without cortical, Haematogenous
Stage II: Superficial osteomyelitis – less tha
n 2 cm bony defect without cancellous bone.
Stage III: Localized osteomyelitis – < 2 cm bo
ny defect on radiograph, does not appear to involve bo
th cortices.
Stage IV: Diffuse osteomyelitis – > 2 cm patho
logic feature, infection, non-union.
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19. PREDISPOSING FACTORS
Resistance of the host.
Virulence of the microorganism.
Systemic or local conditions affecting
host resistance.
Alteration of vascularity of jaw.
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20. Predisposing factors
Virulence of microbes : Lysosomal and enzymatic degradation o
f host tissue along with microvascular thrombosis brought about
by pathogen borne bioactive peptides and chemoattracted leuco
cytic purulence forms a protective barrier for the infections foc
i allowing organisms to proliferate in enriched host medium.
Conditions affecting host resistance
-Diabetes mellitus
-Autoimmune disease
-Agranulocytosis
-Leukemia
-Severe anemia
-Steroid therapy
-Syphilis
-Cancer chemotherapy
-Malnutrition
-Sickel cell anaemia
-Aids
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21. Predisposing factors
Alteration in jaw vascularity
-radiation therapy
-osteoporosis
-osteopetrosis
-pagets disease of bone
-fibrous dysplasia
-bone malignancy
-bone necrosis by mercury, bismuth, arsenic
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23. Microbiology
Osteomyelities of the jaws now is recognized a
s a disease caused primarily by:
-Alfa hemolytic streptococci
-oral anaerobes: peptostreptococcus , fuso
bacterium & prevotella
M tuberculosis , T pallidum & actinomyces pr
oduce specific forms of osteomylities
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26. Periostitis following
gingival ulceration
Lymph nodes infected
from faruncles
Laceration
Peritonsillar abscess
Furuncle on face
Wound on skin
Upper respiratory tract
infection
Middle ear infection
Mastoiditis
Systemic TB
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27. ETIOLOGY & PATHOGENESIS
Long bones primarily haematogenous osteomyelitis
occurs mainly in infants and children because of the
anatomy of metaphyseal region.
Staphylococcus is the most commonly involved
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32. Pathogenesis
SEQUESTRUM:
Is a microscopic / macrosc
opic fragment of necroti
c , usually cortical bone
,found at the nidus of in
fection within bone
Usually begin as part of co
rtex are surrounded by
pus & infested granulati
on tissue
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33. Pathogenesis
INVOLUCRUM:
Volvere- to wrap
This takes place when ne
wly formed reactive bo
ne occurs at the interfa
ce between diseased bo
ne & healthy bone
Radiographically: radioden
se
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34. In contrast haematogenous osteomyelitis of
jaw is infrequent.
1. The disease is caused primarily by contiguous spread of odon
togenic infection.
2. Trauma- specially by compound fractures which is the secon
d leading cause of jaw osteomyelitis.
3. Infection derived from periostitis after gingival ulceration,
lymph nodes infected by furuncles, lacerations or haematog
enous origin accounts for additional small number of jaw inf
ections.
7:42:00 AM 34
35. Maxilla is rarely involved compared to
mandible because of –
1. Maxillary blood supply is more extensive.
2. Thin cortical plates
3. Relative pausity of medullary tissues in the maxill
a prelude confinement of infection within bone and
permits dissipation of edema and pus into soft tissu
e and paranasal sinuses.
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36. Mandible resembles a long bone. It has a medullary
cavity, dense cortical plates and well defined perios
teum.
Compromise of blood supply is a critical factor in es
tablishment of osteomyelitis.
Except for coronoid process which is supplied by te
mporalis vasculature
The mandible recieves major blood supply from infe
rior alveolar artery and a secondary source is the p
eriosteal supply.
7:42:00 AM 36
38. 38
In mandible the sites involved are
-body
-symphysis
-angle
-ramus
-condyle
Reduced host resistance during surgery / rep
eated movement of unreduced # may contribu
te to suppurative osteomylities
7:42:00 AM
39. Compression of neurovascular bundle acceler
ate ischemia and necrosis and results in oste
omyelitis mediated inferior alveolar nerve dy
sfunction.
As effectiveness of host defense and therap
y the osteomyelitis process may become chro
nic, inflammation regresses, granulation tissu
e forms and new blood vessels lyse bone thus
separating fragments of necrotic bone (sequ
estra) from viable bone.
7:42:00 AM 39
