Osteomyelitis of the maxillofacial skeleton is a rare condition in recent times. The combination of antibiotic therapy and surgical debridement is effective in the treatment of chronic suppurative osteomyelitis (CSO). This case report describes the successful surgical treatment of CSO of the mandible in an 18-year-old adult. Treatment included a pre-surgical course of antibiotics followed by sequestrectomy, resection of the coronoid process and removal of the pathologically fractured condylar process of the left side of the mandible. On post-operative clinical review at 1 week, the extra oral draining sinus healed with improved mouth opening.
Osteomyelitis is the inflammation of bone and bone marrow that develops in the jaws after a chronic odontogenic infection or a variety of other reasons. [1] Advances in the field of anesthesia, antibiotic therapy, preventive and restorative dentistry, as well as the availability of component medical and dental care have reduced the incidence of the disease. [2] Chronic osteomyelitis may show a suppurative course with abscess or fistula formation and sequestration at some stage. [3]
Several reports have concluded that chronic suppurative osteomyelitis (CSO) can be treated successfully by a combination of antimicrobial therapy with surgery, either sequestrectomy or decortication of the affected bone. The aim of surgery is to eliminate all of the infected and necrotic bony tissue and, if incomplete, surgical debridement may lead to persistence of the osteomyelitis.
An 18-year-old adult male was referred to the Department of Oral and Maxillofacial Surgery, M.R. Ambedkar Dental College and Hospital, with a 3-month history of discharging pus from a cutaneous sinus present on the left inferior border of the mandible[Figure 1]. His past dental history revealed that he underwent extraction of mandibular posterior tooth by dentist 1 year back. Painful swelling with discharging sinus occurred in the submandibular region after 2 months of extraction, which was treated by incision and drainage by the general surgeon. Six months later, pus discharge recurred, which was treated a second time by incision and drainage by a general surgeon, and this did not subside. He had no known allergies and denied any tobacco or alcohol use. On examination, a discharging extraoral sinus was present 2 cm below the lower border of the mandible [Figure 1], with tender left submandibular lymphnode. Two extraoral scars were observed, one on the skin 1 cm above the left side of the lower border of the mandibular region and another large scar on the left neck region postero-inferior to the left angle of the mandible, indicating poorly planned surgical intervention by the general surgeon [Figure 1]. There was limitation of mouth opening without any paraesthesia of the lower lip and mental area. On intra-oral examination, the patient had a reasonably well-maintained dentition.
|
Figure 1: Extraoral photograph showing draining sinus and two unesthetic scars resulting from previous interventions by a general surgeon
|
On radiological investigation, the panoramic view showed a localized mottled area of radio-opacity at the sigmoid notch, which was ovoid in shape and measured 20 mm at its greatest diameter. The radiographs suggested that there might be the presence of sequestrum [Figure 2]. There was a radiolucent line at the subcondylar region, suggestive of pathological fractures of condyle [Figure 2]. Based on clinical and radiographic findings, the patient was diagnosed as CSO of the condylar region. Treatment planned for the patient was pre-operative antibiotics for 1 week and sequestrectomy and removal of the pathologically fractured condyle followed by post-operative antibiotics for 1 week. Under general anesthesia, intra-oral incision was placed posterior to the third molar region, extending superiorly along the anterior border of the ramus. With careful reflection of the mucoperiosteum, it was surprising to see the discolored coronoid process showing the features of compromised blood supply and infected coronoid process. On table, we planned for coronoidectomy and sequestrectomy. Standard pre-auricular incision was placed with careful dissection of various layers to expose the temporomandibular joint and the pathologically fractured condyle was removed. Post-operative antibiotics were continued for 1 week.
|
Figure 2: Panoramic view showing a radio-opaque lesion in the sigmoid notch area (sequestrum) and radiolucent fracture line in the condylar neck region
|
The histopathological report revealed chronic inflammatory cell infiltration, with areas of resorption of bony trabacula. These findings, in combination with the clinical picture and radiological features, were consistent with CSO. The draining sinus healed well with improved mouth opening at 1 week post-operatively. The pre-auricular region also healed well without scar [Figure 3]. Three months and 6 months after the original surgery, repeat radiographs were taken. There was no clinical or radiological evidence of residual infection[Figure 4] and [Figure 5].
|
Figure 3: Post-operative photograph showing well-healed pre-auricular region without scar
|
|
Figure 4: Axial computed tomography scan of the patient
|
|
Figure 5: Seven-month post-operative orthophantamograph
|
Osteomyelitis is an inflammatory condition of the bone that involves the medullary cavity and has a tendency to progress along this space and involve the adjacent cortex, periosteum and soft tissue. [4] It is more common in the mandible than in the maxilla because of the dense, poorly vascularized cortical plates and the single blood supply from the inferior alveolar neurovascular bundle. [4] The primary cause of the chronic osteomyelitis is usually microbiologic and results from an odontogenic infection, post-extraction complications, inadequate removal of necrotic bone, early termination of antibiotic therapy, inappropriate selection of antibiotics, diagnostic failure, trauma, inadequate treatment for fracture or irradiation to the mandible. [1] The most common bacteriologic results reported to the treating clinicians were mixed oral flora or mixed anaerobic flora. [2] The distribution of osteomyelitis in the jaws dominated by cases that occurred in the mandible, with the highest frequency found in the angle and the body regions. [2] In chronic secondary osteomyelitis, the clinical findings usually are limited to fistulas, induration of soft tissue and thickened or wooden character to the affected area, with pain and tenderness on palpation. In cases of recurrence, symptoms often occurred immediately adjacent to the decorticate area. [5] Culture, bone biopsy, conventional radiography, radioisotope bone scanning, laser Doppler flowmetry, computerized tomography and magnetic resonance imaging are used to diagnose chronic osteomyelitis. [1]
Management entailed a course of antibiotics in combination with surgical debridement. In CSO of the mandible, several authors recognize resistance to therapy as an infrequent but possible problem. Topazian recommends to continue post-surgical treatment for 2-4 months after the resolution of the symptoms where as Bartkowski et al. use intravenous therapy for 10-24 days. This is consistent with the published protocols of Van Merkesteyn et al. It has been suggested that antibiotic therapy combined with surgical intervention is effective in the treatment of CSO. [6] Some reports have also advocated the use of hyperbaric oxygen in the treatment of this condition, especially in the irradiated mandible. In the present case, the patient was prescribed a course of antibiotics, which, in combination with surgical intervention, was successful.
Proper diagnosis and treatment planning is of utmost importance to cure any disease. In this case, improper diagnosis and treatment plan resulted in the recurrence of lesion with unesthetic scars in a young adult. Considering clinical presentation and course of the disease with successive previous treatment failure, our emphasis was given to the source of infection, which was successfully treated by surgery and antibiotic course.
| 1. |
Kim SG, Jang HS. Treatment of chronic osteomyelitis in korea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:394-8.
|
| 2. |
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.
|
| 3. |
Baltensperger M, Gr?tz K, Bruder E, Lebeda R, Makek M, Eyrich G. Is primary chronic osteomyelitis a uniform disease? Proposal of a classification based on a retrospective analysis of patients treated in the past 30 years J Craniomaxillofac Surg 2004;32:43-50. |
| 4. |
Fullmer JM, Scarfe WC, Kushner GM, Alpert B, Farman AG. Cone beam computed tomographic findings in refractory chronic suppurative osteomyelitis of the mandible. Br J Oral Maxillofac Surg 2007;45:364-71.
|
| 5. |
Montonen M, Iizuka T, Hallikainen D, Lindqvist C. Decortication in the treatment of diffuse sclerosing osteomyelitis of the mandible: Retrospective analysis of 40 cases between 1969 and 1990. Oral Surg Oral Med Oral Pathol 1993;75:5-11.
|
| 6. |
Van Merkesteyn JP, Groot RH, van den Akker HP, Bakker DJ, Borgmeijer-Hoelen AM. Treatment of chronic suppurative osteomyelitis of the mandible. Int J Oral Maxillofac Surg 1997;26:450-4.
|
|
Teaching Files
