osteomyelitis of jaws

1. Osteomyelitis of the Jaws
Dr. Ramank Mathur
PG OMFS

2.  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.

3.  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).

4.  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).

5.  Suppurative osteomyelitis(acute & chronic)
 Chronic sclerosing non-suppurative
osteomyelitis or Garre’s osteomyelitis
 Osteomyelitis accompanying systemic disease
such as tuberculosis,actinomycosis & syphillis

6. 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).

7. 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

8. 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)

10. 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

11.  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

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

13.  Minimal bone involment
 Long standing case -Sequestra

14.  I.V. antibiotics-Schenk1948-5 cases
Penicillin
 Culture
 Irrigations-sinus tracts
 Sequestrectomy

15.  Localised or widespread
 Debilitating systemic disease
(a) Close-up view of the socket in the
left mandibular first molar region.

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

18. 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.

19.  Mandible or maxilla
 Presence of unerupted tooth
 Conservative treatment (antibiotics)
 Condyle or TMJ –Severe deformities (Rowe &
Heslop 1957)

20.  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.

21.  Mandible> Maxilla
 Sequestation of condyle rare –Linsey 1953
 Rbc and hb decreased
 Leukocytosis

22.  Enlargement of marrow spaces(early)
 Cortex involved-sequestra
 Larger radiolucent areas –active bone
destruction.

23.  Complete bed rest
 High protein ,high caloric diet
 I.V. solutions
 Blood transfusions
 Analgesics
 Antibiotics –penicillin

24.  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

25.  Angle of jaws-
 Incision-greatest tenderness
 Avoid facial nerve injury
o Condylar pocess
 Preauricular incision
 Rubber drain

26.  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

27.  Primary or secondary
 Radiopaque bone –dead sequestra attracts
calcium
 Subperiosteal bone deposition

28.  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

29.  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

30.  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

31. 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

32.  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

33.  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

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

35.  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

36.  Septicaemia
 Metastatic foci
 Suppuration
 Pathologic fracture

37.  Rapid bone destruction-Azumi et al (1980)
 Rolling in bed
 During sequestrectomy or saucerization

38.  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

39.  Transosseous wiring,Plating ,Intraosseous
fixation with kirschner wires contraindicated
–spread infection to unaffected parts of
bone.

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

41. 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

42. Use of gigli saw to make
anterior osteotomy
Osteotomies made with a
combination of bur cuts

43. 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

44. 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 .

45.  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)

46.  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

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

48.  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 H Nakamura YShimada M Seki S Kudo K

49.  “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)

50.  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 .

51.  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

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