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Osteomyelitis of jaws

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osteomyelitis of jaws

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Osteomyelitis of jaws

  1. 1. Osteomyelitis of the Jaws Dr. Ramank Mathur PG OMFS
  2. 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. 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. 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. 5.  Suppurative osteomyelitis(acute & chronic)  Chronic sclerosing non-suppurative osteomyelitis or Garre’s osteomyelitis  Osteomyelitis accompanying systemic disease such as tuberculosis,actinomycosis & syphillis
  6. 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. 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. 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)
  9. 9. 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
  10. 10.  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
  11. 11.  Sudden onset ,acute course  High fever, rapid pulse, vomiting, delirium.  Signs-  Swelling of face,  Edema of eyelids  Subperioteal abscess  Sinus tracts draining pus
  12. 12.  Minimal bone involment  Long standing case -Sequestra
  13. 13.  I.V. antibiotics-Schenk1948-5 cases Penicillin  Culture  Irrigations-sinus tracts  Sequestrectomy
  14. 14.  Localised or widespread  Debilitating systemic disease (a) Close-up view of the socket in the left mandibular first molar region.
  15. 15.  Odontogenic infections  Periapical disease  Periodontal disease  Pericororonal infection  Infection from odontogenic cyst or tumor  Infection from extraction wound o Staphylococcus aureus, rarely albus
  16. 16. 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.
  17. 17.  Mandible or maxilla  Presence of unerupted tooth  Conservative treatment (antibiotics)  Condyle or TMJ –Severe deformities (Rowe & Heslop 1957)
  18. 18.  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.
  19. 19.  Mandible> Maxilla  Sequestation of condyle rare –Linsey 1953  Rbc and hb decreased  Leukocytosis
  20. 20.  Enlargement of marrow spaces(early)  Cortex involved-sequestra  Larger radiolucent areas –active bone destruction.
  21. 21.  Complete bed rest  High protein ,high caloric diet  I.V. solutions  Blood transfusions  Analgesics  Antibiotics –penicillin
  22. 22.  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
  23. 23.  Angle of jaws-  Incision-greatest tenderness  Avoid facial nerve injury o Condylar pocess  Preauricular incision  Rubber drain
  24. 24.  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
  25. 25.  Primary or secondary  Radiopaque bone –dead sequestra attracts calcium  Subperiosteal bone deposition
  26. 26.  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
  27. 27.  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
  28. 28.  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
  29. 29. 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
  30. 30.  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
  31. 31.  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
  32. 32.  Paresthesia of lip  Frature of weakened bone –air drill with sharp cutting instruments  Splints and fracture appliance
  33. 33.  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
  34. 34.  Septicaemia  Metastatic foci  Suppuration  Pathologic fracture
  35. 35.  Rapid bone destruction-Azumi et al (1980)  Rolling in bed  During sequestrectomy or saucerization
  36. 36.  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
  37. 37.  Transosseous wiring,Plating ,Intraosseous fixation with kirschner wires contraindicated –spread infection to unaffected parts of bone.
  38. 38.  Constant recurrences  Disability & pain  Resection (kerley et al 1981)
  39. 39. 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
  40. 40. Use of gigli saw to make anterior osteotomy Osteotomies made with a combination of bur cuts
  41. 41. 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
  42. 42. 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 .
  43. 43.  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)
  44. 44.  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
  45. 45.  Dry osteomyelitis  Localized or diffuse (Bell 1959 ,Shafer 1957)  Older people ,black women  Sclerotic opacities & lytic areas  Bone –granite hard ,mandible
  46. 46.  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
  47. 47.  “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)
  48. 48.  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 .
  49. 49.  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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