Osteomyelitis of jaw

Dr, Kathirvel Gopalakrishnan
M.D.S (OMFS)
Presentation on osteomyelitis of jaw which helps for a quick refresh.
Classification, management described in detail for easy understanding of the subject.

1. OSTEOMYELITIS G.KATHIRVEL PG - OMFS

2. CONTENTS: Introduction Definition Etiology Classification Pathophysio logy Types Radio logical features Management Comp lications

3. Introduction: Bones belong s to the connective tissue There are two major bone parts: The outer compact part The interior cancellous part. In the compact bone, the collagen fibrils form concentric lamellae around a central canal that is called the Haversian canal . These canals harbor vessels which are interconnected by further vessels lying in the Volkmann’s canal . On the outside of the compact bone is the periosteum and on the inside the endosteum. Christian Walter; Osteomyelitis, Osteoradionecrosis, and Medication-Related Osteonecrosis of Jaws; The Association of Oral and Maxillofacial Surgeons of India; Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician; 2021

4. Osteomyelitis: “Osseus” in Latin means “bony” “Osteon” in Greek means ’’bone’’ “Myelos” means “marrow” “Itis” in Greek means “inflammation” Osteomyelitis - Inflammation in bone marrow In 1834, Nelaton first coined the word “Osteomyelitis” Christian Walter; Osteomyelitis, Osteoradionecrosis, and Medication-Related Osteonecrosis of Jaws; The Association of Oral and Maxillofacial Surgeons of India; Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician; 2021

5. Definition: Inflammation of medullary portion of bone or bone marrow or cancellous bone. Inflammatory condition of bone, that begins as an infection of medullary cavity and h aversian systems of the cortex and extends to involve the periosteum of the affected area. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

6. Etiology: Odontogenic infections: Pulpal or periodontal tissues, pericoronitis, infected socket, infected cyst, tumor etc. Trauma: Compound fracture and Surgery - iatrogenic cause. Infections of orofacial regions derived from: Periostitis following gingival ulceration, Lymph nodes infected from furuncles, Lacerations, Peritonsillar abscess. Infections derived by hematogenous route: Furuncle on face, wound on the skin, upper respiratory tract infection, middle ear infection, mastoiditis, systemic tuberculosis. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

7. Termino logies: Acute: Sharp, severe , having a short and relatively course. Chronic: Persisting over a long period of time. Focal: limited to one specific area. Diffuse: Not clearly limited or localized, widely distributed.

8. Termino logies: Primary : First in order or in time of development. Secondary: C onsequent to a primary event or thing. Suppurative : T ending to suppurate; promoting suppuration. Sc l erosing: E ndosteal or periosteal reactions causing sc l erosing of bone.

9. C lassification

10. C lassification of o steomyelitis Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition Marx 1991

11. 1993 C lassification of o steomyelitis

12. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition C lassification of o steomyelitis

13. C lassification of o steomyelitis

14. Topazion ; Textbook or Ora l and Maxillofacial infection; 4 th edition; SAUNDERS; 2002 C lassification of o steomyelitis

15. Christian Walter; Osteomyelitis, Osteoradionecrosis, and Medication-Related Osteonecrosis of Jaws; The Association of Oral and Maxillofacial Surgeons of India; Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician; 2021 Zurich - 2004

16. PATHOGENESIS

17. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

18. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

19. Sequestrum and Invo lucrum T he dead necrotic bone results in the formation of the sequestrum . When both endosteal and periosteal blood supply are compromised extensive sequestrum formation results. The bone is often high l y radiopaque since dead bone including sequestra attracts calcium. Periosteal bone is usually deposited known as involucrum (new bone) may form to strengthen the jaw. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

20. Microbiology Most of the cases are caused by aerobic streptococci ( hemolytic streptococci, Streptococcus viridans), anaerobic streptococci; and other anaerobes, such as Peptostreptococci, Fusobacteria, and Bacteroides . Sometimes, Gram-negative organisms such as Klebsiella, Pseudomonas and Proteus are also found. Other organisms such as M. tuberculosis, T. pallidum, and Actinomyces species produce their respective specific forms of OML. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

21. TYPES

22. Acute suppurative osteomyelitis S equelae of a periapical infection results in a diffuse spread of the infection throughout the medullary spaces with subsequent necrosis of a variable amount of bone. History may reveal any one of the following: recent extraction, infection, debilitating disease. Clinical features Deep intense jaw pain Abscess High intermittent fever Paraesthesia of the lip (classic symptom) No fistulae Diffuse swelling Loosening of teeth Pus discharge Trismus SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

23. Radiographic features On initial examination, often no radiographic findings or localised periapical radiolucency are seen. A well-defined trabeculation of medullary bone is lost giving an irregular patchy moth-eaten appearance. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

24. Chronic suppurative osteomyelitis D evelop after acute phase of the disease has subsided (secondary) or it may arise from a dental infection without a preceding acute stage (primary). History of previous episode of acute suppurative osteomyelitis or odontogenic infection may be seen Clinical features : S imilar to that of acute osteomyelitis in a milder form. Acute exacerbations of the chronic stage may occur periodically. Paraesthesia of the lip may be seen, though not classically seen in chronic suppurative osteomyelitis. Radiographic features : Irregular radiolucent areas superimposed on more sclerotic and nontrabeculated zones SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

25. Focal sclerosing osteomyelitis C hronic condition which occurs in cases of extremely high tissue resistance or in cases of low-grade medullary infection which causes endosteal or periosteal reactions. Clinical features Most common in younger individuals in the mandibular first molar region M ild pain and decreased sensitivity in the tooth Radiographic findings The IOPA radiograph demonstrates pathognomonic well circumscribed radiopaque mass of sclerotic bone surrounding and extending below the apex of one or both roots. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

26. Diffuse sclerosing osteomyelitis C hronic condition and represents a proliferative reaction of the bone to a low-grade infection. The portal of entry for the infection is diffuse periodontal disease . Clinical features Often the disease shows no clinical sign of its presence. T he first symptom may be a fistula on the mucosal surface. The patient may complain of vague pain and a bad taste. Radiographic findings Extensive radiopaque lesion Mimicks Paget’s disease of the bone in having a cotton wool appearance. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

27. Infantile osteomyelitis U ncommon disease for the jaws I nvolves risks with ocular, intracranial spread and subsequent facial deformities. B elieved to occur by haematogenous route or from perinatal trauma that occurs few weeks after birth and usually involves the maxilla. Clinical features Facial cellulitis centred about the orbit I nner and outer canthal swelling Palpebral oedema Closure of the eye and proptosis Purulent discharge from the nose and medial canthus SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

28. Garre’s chronic nonsuppurative sclerosing osteitis In 1983, Garre described a distinctive type of chronic osteomyelitis as a ‘ focal gross thickening of the periosteum ’ of the long bones with peripheral reactive bone formation resulting from mild irritation or infection. It is essentially a periosteal osteosclerosis . Clinical features It occurs commonly in children and young adults. Mandible is affected more commonly than maxilla. The patient usually presents with a complaint of toothache or pain in the jaw and bony hard swelling in the outer surface of the jaw. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

29. Radiographic features An IOPA radiograph often reveals a carious tooth opposite the hard bony mass. S how a thin but definite cortical layer. Plain radiography of the mandible depicts area of local decalcification or sclerosis. Onion skin appearence SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

30. INVESTIGATIONS

31. Radiographic Findings Conventional radiography: Radiographic changes occur only 3 weeks after initiation of OML process. After 30 - 60% of bone destruction, radiographic changes appreciated In early stage, there is widening of marrow spaces, and enlargement of Volkmann’s canals, which imparts a “ mottled appearance ”. The granulation tissue between living and dead bone produces irregular lines and zones of radiolucency. This results in characteristic “ moth-eaten appearance ” of established OML. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

32. S equestrum appear highly calcified and therefore appear prominent. Subperiosteal new bone, the involucrum, can be seen as a fine linear opacity, or as a series of laminated opacities, like an onion skin , parallel to surface of cortex. Where new bone is superimposed upon that of jaw, a delicate “ fingerprint ” or “ orange peel ” appearance is seen Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

33. Specialized radiographic techniques Computerized tomography: It gives a more definitive picture of calcified tissue involvement, especially with regard to disruptions of cortical plates Radioisotope scanning: Radioisotope Tc-99m methylene diphosphonate bone scanning can identify occult areas of involvement and has previously been used to identify margins or extent of calcified tissue involvement. However, due to poor resolutions, this has not been proved to be effective Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

34. Positron emission tomography: Changes in the bone are seen as early as 3 days, after the onset of symptoms of OML. (a) Confirms the diagnosis of very early OML. (b) Early interceptive antibiotic and supportive therapy can be instituted. (c) Useful in chronic OML, when a decision is to be taken regarding the prolonged duration of antibiotic therapy. (d) In those patients, who show early symptoms suggestive of relapse, a positive scan allows early diagnosis and immediate resumption of therapy, before symptoms worsen. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

35. B one biopsy : T aking a piece of suspected afffected bone or taking tissue that resides inside a bone. T wo approaches : A closed/needle bone biopsy involves inserting a needle through the skin/mucosa directly into the bone, A n open bone biopsy requires making an incision to expose an area of the bone. In the jaws, the use of a large core bone biopsy needle to get a bone sample is not required because the jaw bone is covered with only mucosa in most areas and you can easily access the bone via a mucogingival flap procedure.

36. MANAGEMENT

37. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

38. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

39. SM Ba l aji ; Textbook or Ora l and Maxillofacial surgery ; 4 th edition; E l sevier

40. Topazion ; Textbook or Ora l and Maxillofacial infection; 4 th edition; SAUNDERS; 2002

41. S urgical modalities: (1) Incision and drainage (2) Extraction of loose or offending teeth (3) Debridement (4) Decortication (5) Continuous or Intermittent indwelling closed catheter irrigation (6) Sequestrectomy (7) Saucerization (8) Trephination (9) Resection of jaw (10) Immediate or delayed reconstruction with bone graft. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

42. Incision and drainage Opening up the pulp chamber, By making fenestration through cortical plate over t he apical area with a drill In an edentulous area, especially, posterior maxilla or maxillary tuberosity region, by making an incision over the alveolar crest, and by making a window, pus is evacuated A t the angle of mandible or ascending ramus, drainage can be achieved by a small incision made over the point of the greatest tenderness or just below the mandible. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

43. Extraction of loose or offending teeth: Sometimes, drainage is achieved by extraction of offending teeth. Debridement: Followed by incision and drainage (I/D), thorough debridement of affected area should be carried out. The area may be irrigated with hydrogen peroxide and saline. Any foreign body, necrotic tissue or small sequestrum should be removed. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

44. Decortication: First introduced in 1917 by Mowlem Decortication involves removal of the chronically infected cortex; usually the buccal and the inferior border are removed 1–2 cm beyond the affected area . Decortication should be performed in subacute or chronic stage. It is based on the principle that the involved cortical bone is avascular and harbors microorganisms, while an abscess exists within the medullary cavity, where a ntibiotics cannot penetrate. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

45. Procedure: Creation of buccal flap by crestal incision extending along the necks of the teeth. Reflection of mucoperiosteal flap to the inferior border. Removal of teeth in the involved area. Removal of cortical plates—lateral and inferior border, with chisel in one piece. Bone must be cut back to uninvolved areas. Bony bed should be thoroughly debrided and flap should be closed primarily and dead space is eliminated by applying pressure bandage placed to keep vascularized soft tissue in contact with bony bed. Irrigation tubes should be placed through separate stab incision and closed suction should be employed Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

46. Continuous or intermittent indwelling closed catheter irrigation: Two small pediatric nasogastric feeding tubes, catheters or polyethylene drain tubes, 3–4 mm in diameter and 6–10 inches long in length, are placed against the bony bed through separate skin incisions at some distance and secured with sutures. One tube is connected to the low pressure suction to allow drainage of pus and serum and another is kept patent to provide a route through which locally antibiotics may be instilled in very high concentrations. Daily, first saline irrigation followed by antibiotic instillation should be repeated, until negative cultures are obtained.

47. Sequestrectomy The process by which necrotic bone ( sequestrum ) is separated from the living bone is called Sequestration Procedure Using the preoperative radiograph, which shows the exact location of the sequestrum , the site of incision is decided. The approach may be either intraoral or extraoral . To expose entire sequestrum , intraoral incision is made over the alveolar ridge, but in many instances, entry can be gained by excising the fistulous tract. Following this, soft tissue is detached from the bone by blunt dissection and the sequestrum is lifted and removed. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

48. If the sequestrum is encased by involucrum, a window must be cut to allow it to be taken out. The border of the necrotic bone is identified by the initiation of bleeding during drilling. The excision of bone should be made at least 1.5 cm in front of or behind the area of the radiographic bone necrosis. The cavity is thus exposed and almost contains granulation tissues. The defect should be packed with iodoform gauze, moistened with compound tincture of benzoin and the wound should be irrigated daily until complete healing by granulation occurs. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

49. Saucerization: The buccal cortex is reduced to the level of unattached mucosa, producing a saucer like defect. This procedure is done mainly in the mandible It is useful in chronic form, since it permits removal of formed and forming sequestra with better visualization. Sequestrectomy and saucerization are to be carried out after the acute phase has subsided and the defense mechanism of host and antimicrobial therapy have overcome the virulence of organisms. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

50. Procedure: T he incision is made longer than usual to expose the entire infected portion of the bone and extended through the periosteum. The walls of the bone overhanging the cavity resulting from the removal of the sequestrum are chipped off with the use of rongeurs or sharp osteotomes. M ore of the cortex should be removed if necessary to saucerise the cavity completely The bone is made smooth with the help of bone files or round burs. The wound is packed tightly with gauze covered with antibiotic ointment and the flap is loosely sutured over it. The packing is removed after 3–7 days and replaced several times until the exposed raw surface of the bone is epithelialised. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

51. Trephination: Trephination or fenestration is the creation of bony holes or windows in the overlying cortical bone adjacent to the infectious process for tissue ammoniation and decompression of the medullary compartment. Drilling of holes into the cortex and reaching medulla provides multiple surgical transcortical ports, that allow vascular communication between the periosteum and the medullary cavity. Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

52. Resection: When full thickness of segment of jaw is involved and a conservative approach has failed to cure, resection of the involved part should be considered. However, while exposing the affected area, the only soft tissue related to the necrotic bone should be elevated, to avoid devitalization of the adjoining cortex Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

53. Complications: Neoplastic transformation: With chronic OML, neoplastic conversion of inflammatory metaplasia to squamous cell carcinoma is noted. The incidence reported is 0.2–1.5%. Discontinuity defects: (a) spontaneous (b) surgically induced Necessitating jaw reconstruction; once infection is resolved Progressive diffuse sclerosis: It involves the medullary and cortical portions of maxillofacial skeleton; especially mandible, over a period of time Reference: Nee lima Anil Malik; Textbook of Oral and Maxillofacial surgery; Jaypee brothers; 4 th edition

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