OSTEOMYELITIS OF THE JAWS

DR.SOORAJ S.

ORAL & MAXILLOFACIAL SURGEON

DEFINITION

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Osteomyelitis may be defined as inflammatory condition of the bone ,that begins as an infection of medullary cavity and haversian system of the cortex and extends to involve the periosetum of the affected area

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Predisposing factors

1)Condition that alter the host defences

a) Diabetes

b) Agranulocytosis

c) Leukemia

d) Severe anaemia

e) Malnutrition

f) Steroid drug use

g) Cancer chemotheraphy

2)Condition that alters the vascularity of the bone

a) Radiation

b) Osteoporosis

c) Osteopetrosis

d) Paget’s disease of bone

e) Fibrous dysplasia

f) Bone malignancy and bone necrosis caused

by Mercury, Bismuth, Arsenic

3)Virulance of the microorganisms

Certein organisms participatets thrombi formation by virtue of their destructive lysosomal enzymes

Pathogen born bioactive peptides, chemico attacked leukocytic purulance form the protective barrier for the infectious foci

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ETIOLOGY AND PATHOGENESIS

• Initiated by contagenous focus of infection or hematogenous spread
• Trauma, especially compound fractures
• Infection spreading from the periosteitits after gingival ulceration
• Odotogenic infections

Reduced host resistance during surgery or repeated movements of unreduced fractures may contributes to the development of suppurative osteomyelitis

• Most commonly occurs in mandible than maxilla
• In mandible regions affected

Body

Symphasis, angle

Ramus and condyle

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• Osteomyelitis of maxilla is rare due to

1) Extensive blood supply and significant collateral blood

flow in mid face

2) Porous nature of membranous bone

3) Thin cortical plates

4) Abundent medullary spaces

INFLAMMATION LEADING TO AVASCULAR BONE

Acute inflammation

(edema pus formation )

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Increased

Intramedullary pressure

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Vascular collapse

(stasis, ischemia of bone )

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Avascular bone

EXTENSION OF PUS AND MICROORGANISMS

Pus, organism extension

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Haversian system/nutrient

canal involvement

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Elevation of periosteum

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Disrupted blood supply

Avascular infected bone

MICROBIOLOGY OF OSTEOMYELITIS

Most of the cases caused by aerobic streptococci(alpha hemolytic streptococci,strep viridans),anaerobic streptococci ;and other anaerobes,such as peptostreptococci,fusobacteria and bacteroides

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CLASSIFICATION

Suppurative

1)Acute suppurative osteomyelitis

2)Chronic suppurative osteomyelitis

primary – no acute phase preceding

secondary – follows acute phase

3)Infantile osteomyelitis

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Non suppurative

1)Diffuse sclerosing osteomyelitis

2)Focal sclerosing osteomyelitis

(condensing osteitis)

3)Proliferative periostitis

(periosteitis ossificans,garries sclerosing osteomyelitis)

4)Osteoradionecrosis

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Cierny – Mader classification

• Anatomical staging

stage-1 : Medullary osteomyelitis

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stage-2 :Superficial osteomyelitis

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stage-3 :Localized osteomyelitis

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stage-4 :Diffuse osteomyelitis

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• Physiological classification

A – Host :Normal host

B – Host :Systemic compromise

Local compromise

C – Host :Treatment is worse than disease

ACCUTE SUPPURATIVE OSTEOMYELITIS

Microbiology

The most commonly found organisms in odontogenic OML is staph aureus;step pyogenes

Etiology

1)Odontogenic infections

2)Local traumatic injuries

3)Peritonsillar abscess

4)Furunculosis of the skin

CLINICAL FINDINGS

Involves alveolar process ,angle of mandible ,posterior part of ramus and coronoid process

a) Early cases are characterized by

-Fever ,malaise ,nausea ,vomiting

-Deep seated continuous boring pain in affected area

-Intermittent paraesthesia or anaesthesia of the lower part of the lip

-Indurated swelling of moderated size , which is more confined to periosteal envelop and its content

-Trismus

b) Established cases

-Deep pain , malaise , fever ,dehydration

-Loose teeth , sensitive to percussion

-Purulent discharge through sinuses

-Foetid odour is often present

-Regional lymphadenopathy

If left untreated in such cases osteomyelitis can spread to involve the both side of the mandible .Further spread to TMJ causes septic arithritis

CHRONIC OSTEOMYELITIS

It can be a) Primary

b) Secondary

Clinical features

1)Non healing boney and overlying soft tissue wounds with induration of the soft tissues

2)Intraoral or extraoral draining fistule

3)Thickened and wooden character of the bone

4)Enlargement of the mandible

5) Pathological fracture may occur

6) Teeth in the area becomes loose and sensitive to percussion

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Garre’s Sclerosing Osteomyelitis

• Described in 1893 by Carl Garr’e as an irritation induced focal thickening of periosteum and cortical bone .

Etiology

• A response to a low grade infection or irritation that influences the potentially active periosteum of young individuals to lay down new bone
• Commonly associated with carious tooth,with a history of past toothache

Clinical features

• Localized hard tender bony swelling of lateral and inferior aspects of mandible
• Lymphadenopathy, Hyperpyrexia and Leukocytosis usually not found

Treatment

• Removal of infected tooth and curettage
• Surgical recontouring
• Endodontic therapy

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IMAGING

ACUTE PHASE

RADIOGRAPHIC EXAMINATION

In early disease, no radiographic change may identifiable

LOCATION – Posterior body of the mandible

PERIPHERY – Ill defined periphery

INTERNAL STRUCTURE – Decrease in density of the involved bone, with loss of sharpness of existing trabeculae

Sequstra can be identified by close inspecting a region of bone

• there is widening of marrow spaces, and enlargement of volkman’s canal which imparts ‘moth eaten’ appearance

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EFFECTS ON THE SARROUNDING STRUCTURES

• Acute osteomyelitis can stimulate either bone resorption or bone formation
• Portion of the cortical bone may be resorbed
• An inflammatory exudate can lift the periostium and stimulate the bone formation
• This process may continue and

may result in several lines

(An ONION-SKIN appearance )

This process is referred as

proliferative periostitis

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Onion skin appearance

CHRONIC PHASE

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RADIOGRAPHIC FEATURES

PERIPHERY –

Gradual transition between

normal trabeculae and sarrounding

bone, when disease is active the

periphery may be radiolucent and

have poorly defined borders

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Subperiosteal new bone formation

fingerprint or orange peel

appearance

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INTERNAL STRUCTURE

Lesion usually composed of the

more radiopaque or sclerotic

bone pattern

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A close inspection of the radiolucent region may reveal an island of bone or sequstrum within the center

EFFECTS ON SARROUNDING STRUCTURE

Periosteal new bone formation ,which is radiographically single or series of radiopaque lines

Over a time the radiolucent strip that seperates this new bone from the outer cortical bone surface may be filled with granular sclerotic bone

Chronic lesions may develop

a draining fistula

Radionuclide imaging

Radionucleotide scanning or skeletal scintigraphy is usefull in determining the presence of the reactive bone

Tc – labelled methylene diphosphonate administrated intravenously . The radioisotope is distrubuted to the entire skeleton and concentrated in the areas of increased blood flow and osteoblastic activety

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OML OF MANDIBULAR POSTERIOR REGION

Advantages

• Usefull information based on reactive bone formation rather than demineralization
• Chnanges are seen as 3 days after the onset of the symptoms of the osteomyelitis
• Addtion of Ga -67 study to the Tc-scan aids in distunguishing osteomeylitis from malignancy and trauma
• Bone scanning also may be usefull in monitoring chronic osteomyelitis

Magnetic resonance imaging

When bone scan findings are negative or equivocal and osteomyelitis is still highly suspected MRI provides usefull information in selected cases

ADVANTAGES

• Able to depicit the bone marrow inflammation, define the extent of inflammatory process
• Helps in distingushing osteomyelitis from cellulitis

DISADVANTAGES

Distinction between soft tissue changes as a secondary reactive inflammation and primary soft tissue changes involvement in cases of OML is not possible

CONE BEAM CT-SCAN

Predominant radiographic pattern of osteomyelitis from computed tomograms (Yoshero et al)

1)Most common presentation of OML is mixed pattern in which osteosclerosis is combined with equal or less amounts of osteolysis, not associated with teeth

2)Sclerotic pattern, in which osteosclerosis is dominant

3)Lytic pattern, in which osteolysis is predominant

4)Sequestration seen with or without bony changes

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• CBCT is capable of providing images of less than 0.5 mm resolution that are of high diagnostic quality with shorter scanning time and considerably lower dose of radiation than conventional CT
• CBCT data are amenable to

information in volume, rather

than a slice providing three

dimensional images

• High contrast structres can be visualised almost equal to bone windo CT , with sufficient soft tissue visualisation

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MANAGEMENT

A) Conservative management

1)Complete bed rest

2)Supporative therapy

3)Dehydration

4)Blood transfusion

5)Control of pain

6.Antimicrobial theraphy

ANTIBIOTIC IMPREGNATED BEADS

• Delivers the high concentration of antibiotics into the wound bed and immidiate proximity to the infected bone
• Tobramycin or gentamycin is contained in acrylic resin bone cement beads

7) Special treatment for specific needs

-Anaemia

-Diabetes mellitus

- Malnutrition

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Hyperbaric O2 in treatment of OML

Hyperbaric oxygen therapy consists of breathing 100% oxygen through a face mask or hood in a monoplace or a large chamber at 2.4 absolute atmospheres pressure for 90 min session or dives for as many as 5 days a week totaling 30 or more sessions often followed by another 10 or more sessions

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Action of HBO

1)Enhancement of lysosomal degradation potential of polymorphonuclear leukocytes and O2 radicals

2)Exotoxin liberated by microorganisms are rendered inert by exposure to elevated partial pressure of O2

3)Tissue hypoxia is reversed by HBO

4)Postive enhancement of neoangiogenesis

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Clinical effects

• It aids in healing of draining sinus
• Improves osteogenesis in lytic areas
• Reduces destruction of bone and soft tissues
• Sequestra undergo rapid dissolution without suppuration

Marx protocol

Stage – 1

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Response

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Stage-2

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Response

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Stage-3

CONTRAINDICATIONS

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Pneumothorax

COPD

Optic neuritis

Acute viral infection

Congenital spherocytosis

Malignancy

Pregnancy

SURGICAL MANAGEMENT

A.Incision and drainage

• Opening up of pulp chamber
• By making fenstration through cortical plate over the apical area with a drill
• In an a edentulous area, especially in posterior maxilla or maxillary tubrosity region, by making incision over a alveolar crest
• OML at the angle of mandible or ascending ramus drainage can be achived by a small incision made over the point of greater tenderness, or just below mandible

B. Extraction of loose offending tooth

C.Decortication

• Removal of chronically infected lateral and inferrior cortical plates of bone 1-2 cm beyond the area of involvement .Thus an access is provided to the medullary cavity(Obswegeser -1960)
• Should be performed in subacute or chronic stage
• It is based on the principle that involved cortical bone is avascular and harbours microorganisms, while an abscess exist within the medullary cavity, where antibiotic cannot penetrate

Steps in decortication

1)Creation of buccal flap by crestal incision extending along the neck of the teeth

2)Reflection of mucoperiosteal flap

3)Removal of lateral and inferior border of cortical plate

4)Debride, flap should be primerly closed

5)Irrigation tubes are placed

E .Continuous or intermittent indwelling closed catheter irrigation

• Two small pediatric naso

gastric tube catheter or

Polyethylene drain tubes

3-4mm in diameter and

6-10 inch long

• One tube to low suction

drainage and other for

local antibiotic delivery

F. Sequestrectomy

• It helps in establishment of local microvascular proliferation
• The sequestrum can be classified as

a) Small and accessible – Intraoral approach

b) Large and inaccessible – Extraoral approach

• Preoperative radiograph is taken to locate sequestra and for deciding site of incision
• Involved teeth should be removed
• Extraoral submandibular incision is needed to expose the inferior border and posterior parts of the mandibular ramus
• Intraoral wound should be packed with Iodoform gauze socked in Betadine

• Condyle if involved reached via preauricular incision
• If suppuration is present, the wound is partly closed with suture and rubber drain is inserted through the skin

G . Saucerization

Saucerization is unroofing of the bone to expose the medullary cavity for through debridement

• The margins of necrotic bone overlying the focus of osteomyelitis are excised
• Saucerization is usefull in chronic osteomyelitis because it permits the removal of formed and forming sequestra
• Saucerization should be performed intraorally whenever posiible to avoid the facial scarring

• A buccal mucoperiosteal flap is elevated

to expose infected bone, loose teeth are

removed and superior aspect of buccal

cortical plate is excised.The bone is

trimmed until bleeding is noted from all

margin

• A medicated pack is placed within the

saucer, mucosa is trimmed,suture tied

over the pack

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• After healing the bone remodels and

covered by normal mucosa