Clinical Dentistry

C l i n i c a l D e n t i s t r y , Mu mb a i J u l y 2 0 1 2 50
Clinical Dentistry
Correspondence Address:
Dr. Rohit Goyal
Department of Oral &
Maxillofacial surgery
Govt. Dental College
Pt. B.D. Sharma
University of Health Sciences,
Rohtak, Haryana (India)
E-mail: drrohitgoyal@rediffmail.com
Oral Surgery
Dr. Mahesh Goel,
Associate Professor
Dr. Anjali Narwal,
Assistant Professor
Dr. Shashi Bala,
Professor
Dr. Rohit Goyal, M. D. S.
Demonstrator,
Chronic
Suppurative
Osteomyelitis -
A Case Report
Abstract
|| Brief Background
This paper presents a case of chronic suppurative Osteomyelitis
treated with marginal resection and reconstruction plate.
|| Materials and Methods
On radiographic examination, the patient was diagnosed as a
case of pathologic left body of mandible fracture secondary to
chronic suppurative Osteomyelitis.
|| Discussion
Osteomyelitis is more commonly observed in the mandible
because of its poor blood supply as compared to the maxilla,
and also because the dense mandibular cortical bone is more
prone to damage and, therefore, to infection at the time of
tooth extraction. Management entailed a course of antibiotic in
combination with surgical debridement (sequestrectomy).
|| Summary and Conclusions
The disease is completely curable and can lead to reversal of
all destructive bony changes, if treated early with judicious use
of antibiotics and surgical intervention. Thus, emphasizing the
fact that a well-executed timely treatment plan does have a
high healing rate.
|| Key Words
Osteomyelitis, reconstruction plate, mandible, fracture.
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Clinical Dentistry
|| Introduction
Jaw bones are relatively more frequently affected by
osteomyelitis than other skeletal bones. Odontogenic
infection is the most common cause of osteomyelitis
of the jaws even though other causes such as injury,
malignancy, malnutrition, diabetes, chronic systemic
disease or disease occurring in hypovascularized bone
and so on may be associated with Osteomyelitis. The
incidence of Osteomyelitis is more common in the
mandible than in the maxilla because the distribution
of blood vessels is poorer in the mandible than in the
maxilla and the cortical bone of the mandible is thicker
and more compact than that of the maxilla. Depending
on the circumstances, a suppurative focus is apt to be
packed within the jaw bone and severe Osteomyelitis
might be produced in the mandible more frequently.
In addition, the typical course of this disease is also
observed in the mandible rather than in the maxilla.
There might some different processes occurring in
chronic Osteomyelitis. Although most cases of chronic
Osteomyelitis may result from a partial regression of
acute Osteomyelitis, more than a few cases seem to
shift to the chronic phase without acute or subacute
symptoms. Infection with less virulent bacteria, long term
malnutrition, worsening of general condition or other
causes could be related to the lack of acute symptoms.
|| Case Report
A 50 year old female patient reported to our department
of Oral & Maxillofacial Surgery with chief complaint
of pain and swelling on left side of lower jaw since 7
months. Her past history revealed extraction of lower left
posterior tooth from a local practitioner with swelling
being noticed after 8-10 days of extraction. Swelling
gradually increased with time. Intraoral examination
revealed a step palpable at left body of mandible.
Patients oral hygiene was poor. A draining sinus was
noted in left mandibular posterior vestibular region. Her
medical history was essentially non-contributory. Her
haematological investigations were within the normal
range.
On radiographic examination, OPG revealed mixed
radiolucent- radiopaque lesion with irregular borders
with relation to left body mandible and showing fracture
of lower border of left body of mandible. Provisional
diagnosis of pathological fracture of left body of
mandible secondary to chronic suppurative Osteomyelitis
was made.
Fig.(1): Asymmetrical face showing swelling on left side of mandible.
Fig.(2): Intraoral photograph showing draining sinus.
Fig.(3): OPG showing pathological fracture on left side of mandible.
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Clinical Dentistry
Fig.(4): Intraoperative extraoral photograph showing removal of
pathological bony fragment.
Fig.(5): Adaptation and fixation of reconstruction plate.
Fig.(6): Postoperative PA view mandible with reconstruction plate in situ
Surgical Technique
The patient was operated under general anaesthesia. A
Submandibular/ Risdon incision was given to expose the
fracture site. Sequestrum/necrotic bone was removed
with help of curette and fresh bleeding was induced in
the affected area. Then, an eleven hole reconstruction
plate adapted across the fracture site and fixed with
3 screws on either side and the tissue was sutured
back. The necrotic bone was sent for histopathology,
which confirmed the diagnosis of chronic suppurative
osteomyelitis.
The patient was kept on antibiotics; analgesics and
betadine mouth wash were prescribed. A regular recall
after every three days was kept for a period of two
weeks and then weekly for a period of two months. The
affected area showed complete healing clinically and a
panoramic radiograph was taken.
|| Discussion
Osteomyelitis results from either from the direct
extension of pulpal infection without the formation of a
granuloma or from the acute exacerbation of a periapical
lesion. Marx (1991) and Mercuri (1991) were the first
and only authors to define the duration for an acute
osteomyelitis until it should be considered as chronic.
They set an arbitrary time limit of 4 weeks after onset of
disease. It is by far the most common osteomyelitis type.
The primary cause of chronic osteomyelitis of the jaws
is infection caused by odontogenic microorganisms. It
may also arise as a complication of dental extractions
and surgery, maxillofacial trauma and the subsequent
inadequate treatment of a fracture, and/or irradiation
to the mandible.
The four primary factors which are responsible for deep
bacterial invasion into the medullar cavity and cortical
bone and hence establishment of the infection are: (a)
Number of pathogens, (b) Virulence of pathogens,
(c) Local and systemic host immunity (d) Local tissue
perfusion.
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In a healthy individual with sufficient host immunity
mechanisms, these factors form a carefully balanced
equilibrium. If this equilibrium is disturbed by altering
one or more of these factors, deep bone infection
establishes.
Usually there is an underlying predisposing factor
like malnutrition, alcoholism, diabetes, leukaemia
or anaemia. Other predisposing factors are those
that are characterized by the formation of avascular
bone, for example, therapeutically irradiated bone,
osteopetrosis, Paget's disease, and florid osseous
dysplasia. Osteomyelitis is more commonly observed
in the mandible because of its poor blood supply as
compared to the maxilla, and also because the dense
mandibular cortical bone is more prone to damage and,
therefore, to infection at the time of tooth extraction.
The most common symptoms and signs include pain,
exposed bone, cheek swelling, and discharge/drainage.
Management entailed a course of antibiotic
in combination with surgical debridement
(sequestrectomy). Improvement of local vascularization
is further accomplished by surgical decortication,
exceeding conventional surgical debridement, which
not only removes the poorly vascularized (infected) bone
but also brings well-vascularized tissue to the affected
bone, thus facilitating the healing process and allowing
antibiotics to reach the target area; therefore, surgery
and antibiotics are to be considered the major columns
in treating osteomyelitis of the jaws.
Selecting antibiotics is based mostly on isolating bacteria
from the cultures. Empiric antibiotics are started pending
cultures providing adequate coverage for streptococci
and anaerobic bacteria such as Actinomyces and
Prevotella. Penicillin remains the drug of choice. Other
alternatives which may be used as a combination regimen
include clindamycin, fluoroquinolones, metronidazole,
a variety of cephalosporins, carbapens, Vancomycin in
combination with other antibiotics and tetracyclines.
Although of rare occurrence, the differential diagnosis
of osteomyelitiss radiological picture includes
tumours, which can also mimic the scintigraphic
findings, other bone destructive pathologies, fibrous
dysplasia, metastases (especially originating from the
prostate) and Pagets disease. Especially in cases with
significant periosteal reaction, the differentiation from
osteosarcoma has to be kept in mind.
However, the disease is completely curable and can lead
to reversal of all destructive bony changes, if treated early
with judicious use of antibiotics and surgical intervention.
Thus, emphasizing the fact that a well-executed timely
treatment plan does have a high healing rate.
|| References
1. Marc Baltensperger and Gerold Eyrich. Osteomyelitis of the
Jaws: Springer Berlin, Heidelberg. November 07, 2008.
2. Marx RE. Chronic osteomyelitis of the jaws. In: Laskin D, Strass
R, eds. Oral and maxillofacial surgery clinics of North America.
Philadelphia: Saunders. 367-438, 1992.
3. Yeoh SC, MacMahon S, Schifter M. Chronic suppurative
osteomyelitis of the mandible: Case report. Australian Dental
Journal 2005; 50(3): 200-03.
4. Koorbusch GF, Fotos P, Goll KT. Retrospective assessment
of osteomyelitis: Etiology, demographics, risk factors, and
management in 35 cases. Oral Surg Oral Med Oral Pathol
1992; 74:149-54.
5. Kim S, Jang H. Treatment of chronic osteomyelitis in Korea.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;
92:394-98.
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