Management of osteomyelitis of jaw bones

1. Dr. Anushan Madhushanka..BDS, MD/OMFS, MFDRCSI
Senior Registrar in OMF Surgery
Colombo North Teaching Hospital Sri Lanka

2. Introduction
 Definition
Inflammation of the bone marrow & cortical bone
& periosteum with a tendency to progression.
 Nonprogressive inflammation of the bone
1. Dentoalveolar abscess
2. Dry socket
3. Osteitis in infected fractures.

3.  Pre antibiotic era – Very common
 Antibiotic era – Uncommon
 Now – emerging due to AB resistance
 Diagnostic & therapeutic Challenge - if occurs
 Need – Multiple surgeries
Prolonged Rx
 Carries Morbidity risk – loss of Jaw & teeth

4. Predisposing Factors
1. Immunocompromisation
2. Hypovascularity
3. Microbial virulence

5. Hypovascularity
 Radiation therapy
 Age
 Bone pathology that decreased blood supply-
Cemento ossifying fibroma
Osteopetrosis
 Dento alveolar infection
 Trauma – Fractures

6. Microbial virulence
 Secretes lysosomal enzymes
 Causes tissue destruction
 Microvascular embolisation
 Impaired blood supply
 Brodie,s abscess formation

7. Immunocompromisation
 Diabetes
 Immunodeficiencies
 Malignancies
 Malnutrition
 HIV
 Anaemia
 Agranulocytosis
 Steroids
 Chemotherapeutic agents
 Bisphosphonates

8. Pathogenesis
Odontogenic infection / Trauma
Inflammation in marrow space Self limiting
Suppuration
Increased intra medullary pressure

9. Pus in Volkman,s & Haversean System
Further blood supply cutoff & cortical perforation
Subperiosteal pus collection
Necrosis of cortical bone & Sequestrum formation
Fistula formation

10. Microbiology
 Aerobs – Streptococcus viridans, Pyogenes
Staphylococcus
 Anaerobic bacteria - Bacteroides
Pseudomonas
Peptostreptococci
 Others – Klebsiella , Proteus , E. Coli
 Specific – M. tuberculosis, T. Pallidum
 Therefore Mixed infection

11. Classification
 Several classifications - Cierny and colleagues.
Lew and Waldvogel.
Topazian
 Hudson’s classification – Clinically valuable

12. Hudson’s classification of
OM
1. Acute osteomyelitis
a. Contiguous focus
b. Progressive
c. Hematogenous
2. Chronic osteomyelitis
a. Recurrent multifocal
b. Garre’s
c. Suppurative or nonsuppurative
d. Sclerosing

13. Clinical classification
 Suppurative OML
1. Acute
2. Chronic
3. Infantale
 Non suppuratve
1. Sclerosing OML – Focal
Diffuse
2. Garre’s OML
3. Actinomycotic OML
4. Specific infective OML - TB, Syphilis
5. ORN
6. BRONJ

14. Clinical Presentation
 Acute OM features
Local - Pain – severe pain
Swelling and erythema
Paresthesia of the ID nerve
Trismus
Adenopathy
Systemic –
Fever
Malaise

15. Clinical Presentation
 Chronic OM
Dull pain/ No pain
Mild swelling & minimal inflammation
Fistula + Pus
Exposed bone
NO fever - typical

16. Investigations
1. Plain X- rays – OPG
Lateral oblique view of mandible
changes of OM sources disease predisposing
conditions
 Moth eaten appearance +/- Sequestrum
 25%- 50% Deminaralisation – Radiological evidence
 Therefore – Early acute OM not visible in X-rays

17. 2. Computerized tomography (CT)
 Become the standard
 3D imaging
 Early cortical erosion
 Extent of the lesion
 Bony sequestra
 Pathologic fractures.
 Requires 30 to 50%
demineralization for visibility

18. 3. Magnetic resonance imaging (MRI)
Assist in the early diagnosis-
loss of marrow signal before cortical erosion
Better than CT
evaluation of soft tissue - fistula

19. 4. Technetium 99
 Sensitive to - increased bone turnover areas
Inflammation – Infection
Trauma
 No differentiation of infection
 addition of Gallium 67 / Indium 111
Contrast agent, Bind to WBC
Differentiate infection from Trauma

20. 5. Biopsy –
Explorative
Send for - Gram stain
Culture
ABST
Histopathology

21. 6. FBC - WBC count – Acute OM
Normal WBC count – Chronic OM
7. ESR, CRP - Nonspecific
Raised in inflammation
Use - to follow the clinical progress

22. Treatment
1. Conservative Rx
2. Surgical Rx

23. Conservative Rx
 Bed rest
 Hydration – IV fluids, Oral
 Supportive Rx – Nutrition – High protein, Fat
Vitamin enriched
 Antimicrobials
 Analgesics
 Blood transfusion – If low Hb, WBC

24. Antimicrobial Rx
 First choice
IV Pnicillin G - 2mu/ 6 hr
O. oxycilline - 1g/ 6 hr
If symptoms improved within 3 days – convert to oral drugs
O. Penicilline 500mg/6hr
Cloxacilline 250mg / 6hr – 2/3 weeks
 Second choice
O. Clindamycine 600mg/ 8 hr – 2/3 weeks
 Third choice
O. Cefazolin 500 mg/ 8 hr
 Fourth choice
O. Erythromycine 2g /6hr
Others – Ticarcilline, Vancomycine, Ciprofloxacine if not respond

25. Surgical Rx
 Incision & Drainage
 Teeth extractions
 Sequestrectomy
 Saucerisation
 Decortication
 Fenestration
 Jaw resection +/- Vascularised flap & bone
 Follow up

26. Surgical Treatment
1. Sequestrectomy + Saucerisation
 Sequestrectomy - Remove necrotic bone & sequestra
Improve blood flow.
 Saucerization - Removal of adjacent bony cortices
Open packing & permit 2ry healing
 Decortication - Removal of infected cortex
Cover marrow with periosteum
Remove adjacent teeth if needed
Surgery weaken the bone pathological #
Therefore – Do elective plating , IMF

27. Sequestrectomy +
Saucerisation

28. Surgical Treatment
Jaw resection & Reconstruction
 last-ditch effort
 After - smaller debridements
unsuccessful previous therapy
associated pathologic fracture.
 Performed via an extra oral route
 Reconstruction - immediate or delayed
 If ID paraesthesia – Immediate resection &
reconstruction

29.  Resection – Segmental resection
 Reconstruction – Reconstruction plate
Bone graft & plating
Free flaps – Microvascular surg
Free flap – Independent blood supply
Good healing
No need of HBO
Implants can be placed
Ideal mandibular reconstruction

30. Jaw resection &
Reconstruction

31. Jaw resection &
Reconstruction