Surgical Management of Primary Chronic Osteomyelitis: A Long-Term Retrospective Analysis

Pediatric mandibular chronic nonbacterial osteomyelitis: A case report with 12 years of radiologic follow-up

Chronic nonbacterial osteomyelitis (CNO) is histologically characterized by nonspecific osteitis. This inflammatory disorder, which lacks an infectious origin, typically presents with chronic pain and swelling at the affected site that can persist for months or even years. However, it is rare for CNO to affect the mandible. A 10-year-old girl presented with a primary complaint of pain in her left mandible. She had no significant medical or dental history. On examination, swelling was visible on the left buccal side, and imaging revealed radiolucent bone deterioration within the left mandible. This case report presents the radiological changes observed over a 12-year follow-up period. Variations in radiopacity, radiolucency, and periosteal reactions were noted periodically. This case highlights the radiological characteristics and findings that are crucial for the diagnosis of CNO, a condition for which no clear diagnostic criteria are currently available.

Identifying Risk Factors Associated with Major Complications and Refractory Course in Patients with Osteomyelitis of the Jaw: A Retrospective Study

Despite improved knowledge regarding the diagnosis and treatment of osteomyelitis of the jaw (OMJ), it remains a clinical challenge for oral and maxillofacial surgeons. This study aimed to identify risk factors associated with severe forms of OMJ, i.e., related to the occurrence of major complications or the refractory course of the disease. A retrospective study was performed based on the medical records of all patients diagnosed with OMJ from the past 20 years. Collected data included demographic information, medical and dental history, clinical, radiological, and bacterial findings as well as treatment modalities. The main outcome variables were the onset of major complications and treatment results. Fifty-four patients were included. Our results showed that alcohol and smoking habits, as well as malnutrition, were significantly associated with the occurrence of major complications. We also established that dental implant-induced OMJ should be considered an aggressive subtype of OMJ. Finally, clinical bone exposure was significantly associated with unfavorable outcomes, whereas dental causes or radiological evidence of periosteal reaction were predictive of successful outcomes. Identifying such factors could be useful in preventing serious complications and informing patients about the refractory course of the disease based on the presence of these factors.

The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review

OBJECTIVES

Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.

STUDY DESIGN

A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.

RESULTS

Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.

CONCLUSIONS

Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

In vitro drug release and antibacterial activity evaluation of silk fibroin coated vancomycin hydrochloride loaded poly (lactic-co-glycolic acid) (PLGA) sustained release microspheres

Currently, the treatment of osteomyelitis poses a great challenge to clinical orthopedics. The use of biodegradable materials combined with antibiotics provides a completely new option for the treatment of osteomyelitis. In this study, vancomycin hydrochloride (VANCO) loaded poly (lactic-co-glycolic acid) (PLGA) microspheres were prepared by a double emulsion solvent evaporation method, and the in vitro drug release behaviors of the drug loaded microspheres were explored after coating with different concentrations of silk fibroin (SF). Drug loading, encapsulation efficiency, Scanning electron microscopy, particle size analysis, Fourier transform infrared spectroscopy, hydrophilicity, in vitro drug release, and in vitro antibacterial activity were evaluated. The results showed that the drug loading of vancomycin loaded PLGA microspheres was (24.11 ±1.72)%, and the encapsulation efficiency was (48.21 ±3.44)%. The in vitro drug release indicated that the drug loaded microspheres showed an obvious initial burst release, and the drug loaded microspheres coated with SF could alleviate the initial burst release in varying degrees. It also can reduce the amount of cumulative drug release, and the effect of microspheres coated with 0.1% concentration of SF is the best. The time of in vitro drug release in different groups of drug loaded microspheres can be up to 28 days. The microspheres coated with (0.1%SF) or without (0%SF) SF showed a cumulative release of (82.50±3.51)% and (67.70±3.81)%,respectively. Therefore, the surface coating with SF of vancomycin loaded microspheres can alleviate the initial burst release, reduce the cumulative drug release, potentially prolong the drug action time, and improve the anti-infection effect.

Chronic Osteomyelitis With Proliferative Periostitis of the Mandible in a Child: Report of a Case Managed by Immunosuppressive Treatment

BACKGROUND

Osteomyelitis with proliferative periostitis is a relatively uncommon inflammatory condition of the jaws, mainly characterized by periosteal formation of reactive bone. It primarily affects children and adolescences, also referred to as Garre's osteomyelitis, more frequently involving the molar region of the mandible. Cases lacking an obvious source of infection may have an immunologically mediated etiopathogenesis, falling under the spectrum of primary chronic osteomyelitis or chronic recurrent multifocal osteomyelitis (CRMO).

CASE REPORT

Herein, we present a case of chronic osteomyelitis in a 6.5-year-old girl, who suffered from recurrent painful episodes of swelling of the mandible for the last 2 years, previously requiring hospitalization and administration of intravenous (IV) antibiotics and NSAIDs with limited responsiveness. The biopsy showed features consistent with osteomyelitis with proliferative periostitis. The patient was initially managed with an IV combination antibiotic regimen with only partial improvement. The possibility of an autoimmune mechanism in the context of primary chronic osteomyelitis or CRMO was considered, and immunosuppressive therapy (TNF inhibitor etanercept along with corticosteroids and methotrexate) was administered, resulting in clinical resolution.

CONCLUSIONS

Osteomyelitis and its childhood variants are relatively rare and their management presents several challenges. Although typically treated with administration of antibiotics, possibly along with surgical intervention, other treatment modalities may be necessary for resilient and persistent cases. In a subset of cases, especially in the absence of local infectious factors, immunologically mediated mechanisms may play an important role and appropriate immunosuppressive therapy may be effective.

Is Operative Management Effective for Non-Bacterial Diffuse Sclerosing Osteomyelitis of the Mandible?

PURPOSE

Operative management has been reported to show varying degrees of therapeutic effects for non-bacterial diffuse sclerosing osteomyelitis of the mandible (DSOM). The purpose of this study was to retrospectively analyze and summarize the operative outcomes for non-bacterial DSOM.

METHODS

In this retrospective cohort study, patients with non-bacterial DSOM who received operative treatment were enrolled at the Peking University Hospital of Stomatology between 2012 and 2019. The primary predictor variables were the type of operative treatment and number of operations. The outcome variables were operative outcomes (symptom relief or ineffective) and time to recurrent symptoms after operations. Other study variables were demographics, including sex, age, and non-bacterial DSOM onset time. The χ² test and Kaplan-Meier model were used to evaluate differences.

RESULTS

The sample was composed of 72 patients with a mean age at onset of 26.1 ± 17.8 years and showed a female predilection. Decortication was performed for 68 patients with non-bacterial DSOM, and 4 patients underwent segmental mandibulectomy. Symptom relief was achieved in 37 (54.4%) patients after the first decortication, and the median time to symptom recurrence was 2.0 months. Furthermore, the longest time to symptom recurrence was not more than 6 months in all patients. Among the 4 patients who underwent segmental mandibulectomy, 2 who received fibula repair experienced recurrence of symptoms at 4 and 5 months after the operations, respectively, and their normal mandible and the transplanted fibula also presented with imaging manifestations of osteomyelitis.

CONCLUSIONS

Decortication and segmental mandibulectomy were not effective for non-bacterial DSOM. This finding is consistent with the results of other reports, and this condition may be best managed non-operatively by rheumatologists.

Primary chronic osteomyelitis of the jaw: Rapid improvement after hormonal suppression in a girl with precocious puberty

Primary chronic osteomyelitis (PCO) of the jaw is a non-infectious, inflammatory state of the jawbone of unknown etiology. In recurrent periods, these patients often exhibit swelling of the cheek, impaired ability to open their mouth as well as pain. Available treatments today include anti-inflammatory or antiresorptive drugs, hyperbaric oxygen, surgical decortication or resection followed by reconstruction where none of them have been described to lead to restored anatomy and complete relief of symptoms. We here report the unexpected complete regression of all clinical symptoms of PCO within three months after initiating pubertal suppression therapy with a gonadotropin-releasing hormone analogue in a 9-year-old girl with PCO of the jaw and early onset of pubertal development. Radiology of the jawbone confirmed complete PCO remission when performed 18 months after starting the hormone suppression therapy. To our knowledge, total regression of PCO in such a short period of time has not been described earlier suggesting an effect of the anti-hormonal therapy per se. In this case report, we discuss possible underlying mechanisms and hypothesize that anti-hormonal treatment could be a potential effective treatment in patients with PCO of the jaw.

Mandibular osteomyelitis after hyaluronic acid injection

BACKGROUND

Mandibular osteomyelitis after filler injection is extremely rare.

AIMS

We reported a case of mandibular osteomyelitis after hyaluronic acid injection.

PATIENTS

A 33-year-old woman received 1 mL hyaluronic acid injection on her chin 1 year ago, after which her chin kept swelling and painful, and gradually ulcerated with pus flowing out. She received antibiotics, debridement procedures, negative pressure wound therapy, and hyperbaric oxygen therapy without symptoms improved. Cone-beam computed tomography scan showed local bone destruction, sequestrum formation, and tissue calcification on the right mandible body. The patient was diagnosed with mandibular osteomyelitis and received local curettage for the removal of necrotized bone.

RESULTS

Literature search found no case reports on mandibular osteomyelitis after filler injection so far.

CONCLUSION

Minimizing the risk of contamination and infection is strictly required during the filler injection process. Once the patient shows signs of incurable mandibular infection postoperation, clinicians should consider the possibility of osteomyelitis.

Surgical Management of Primary Chronic Osteomyelitis of the Jaws: The Use of Computer-Aided-Design/Computer-Aided Manufacturing Technology for Segmental Mandibular Resection

The term osteomyelitis of the jaws identifies different pathological patterns characterized by the involvement of the cortical bone and bone marrow in osteoarticular infections.At the head and neck level, the segment most affected by osteomyelitis is the mandible and in most of the cases the cause of the infection is bacterial, as a result of pulp or periodontal infections, post-extraction alveolitis, foreign bodies and fractures. The mandibular PCO often presents with an insidious onset, without a striking acute phase, and it is characterized by recurrent episodes of pain, swelling, lockjaw, latero-cervical lymphadenopathy, without signs of suppuration.Three patients have been collected and recorded for the study.The authors believe that in the more advanced cases of PCO in adult patients, in which the mandibular bone appears almost entirely sclerotic and deformed, and that are not responsive to pharmacological therapy or to conservative surgical therapies such as decortication, it is necessary to perform a complete removal of the portion affected by osteomyelitis, with lower alveolar nerve preservation and contextual reconstruction with free microvascular bone flap.Our review aims to describe the clinico-pathological features of a rare pathological entity, propose a surgical treatment algorithm using computer-aided-design/computer-aided manufacturing technology and review the existing literature.

Differential Diagnosis of Periapical Radiopacities and Radiolucencies

Periapical pathoses represent changes noted at the apices of teeth within the alveolar process that are suspected on examination, visualized via imaging, and confirmed via histopathology. They can be bone forming or destructive. There are pathologic entities that show both types of changes at the apical regions. These lesions must be identified if they are odontogenic in origin because treatment modalities differ. This article discusses identification of radiopaque and radiolucent lesions noted on radiographs. The common opacities and lucencies are described. When required, advanced imaging is used to depict changes within the bone near the periapical regions of mandibular and maxillary teeth.

A boy with recurrent swelling of the jaw

We present a 10-year old boy with recurrent swelling of the right mandibular region. Based on the diagnosis of chronic recurrent parotitis, he received only supportive treatment. Because of frequent relapses, the diagnosis was reconsidered. Magnetic resonance imaging, scintigraphy and biopsy were compatible with chronic osteomyelitis. This lead to a diagnosis of mandibular primary chronic osteomyelitis, an uncommon non-suppurative inflammatory disease of unknown origin. After decortication of the mandible, the patient recovered well. Because there were no further complaints, the follow-up was ended 18 months after the operation.

Emergency 1-stage anterior approach for cervical spine infection complicated by epidural abscess

It was a retrospective analysis.The aim of the study was to explore the safety and reliability of emergency 1-stage radical debridement and reconstruction using titanium mesh filled with autologous bone for patients with cervical spine infection complicated by epidural abscess.At present, cervical spine infection complicated by epidural abscess is known as a severe spine disease. Recently, case report of this disease is showing quite an increasing tendency, particularly in economically undeveloped areas and countries. Regarding the treatment of this disease, 1-stage radical debridement and reconstruction has been widely adopted; however, emergency 1-stage anterior approach surgery without medication is considered as a relatively taboo, since it is generally acknowledged that such operation would possibly cause unexpected infection. Nevertheless, regular elective surgery may require longer time for preparation. In addition, long hour compression and stimulation of the abscess may leave the patients with irreversible spinal neural impairment. However, our department has finished 14 cases of cervical spine infection complicated with epidural abscess without 1 single case of postoperative infection.A retrospective study was conducted on 14 patients (9 males and 5 females; average age 57.4 years) who were diagnosed with cervical spine infection complicated by epidural abscess from January 2005 to December 2014. All the patients were admitted to hospital with varying degrees of neurological function losses, and then underwent 1-stage anterior focal debridement and reconstruction using titanium mesh within 24 hours after admission. They received postoperative standard antibiotic chemotherapy for 10 to 12 weeks. They were followed up for 18 to 36 months, an average of 27.4 months. X-ray, computed tomography (CT), and MRI (magnetic resonance imaging (MRI) were used to determine the fusion state and vertebral stability. American Spinal Injury Association (ASIA) international standards for neurological classification were adopted, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were evaluated to infection activity, and Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) criteria were used to judge clinical efficacy.All the 14 patients had no postoperative spread of infection. No recurrence of infection was found during the last follow-up. ASIA grade, VAS score, and JOA score were significantly improved (P < .05) after the operation. WBC, ESR, and CRP became normal after the operation (P < .05). Postoperative follow-up imaging results showed no significant loss of cervical curvature, collapse of the grafted bone or implant displacement but good spinal canal volume.Emergency 1-stage radical debridement and reconstruction using titanium mesh filled with autologous bone, combined with antibiotic chemotherapy, is a safe and effective surgical therapy for cervical infection complicated by epidural abscess.

Osteomyelitis of the jaws: A retrospective series of 40 patients

INTRODUCTION

The caseload of jaw osteomyelitis seem to have decreased considerably over the last fifty years thanks to the progress of oral hygiene, the appearance and the use of antibiotics, and early screening. 'Limited osteitis' remains frequent in general practice (alveolitis after dental extraction), but osteomyelitis is much rarer as evidenced by the lack of current literature and the low number of reported patients in the published series. The aim of this study was to analyze retrospectively all the cases of maxillo-mandibular osteomyelitis treated in a large academic department of Stomatology and Maxillofacial Surgery over a period of 6 years and to compare the results to data from the literature.

MATERIAL AND METHOD

All patients diagnosed with maxillo-mandibular osteomyelitis by one of the staff surgeons between January 2009 and December 2015 was included. An epidemiological record (sex, age, ethnic background, risk factors, clinical, origin of disease, imaging and biology, treatments and progression) were collected for each patient. Osteomyelitis cases were classified according to the Zurich Classification System. Results were compared to data from the literature.

RESULTS

Forty patients were retained. Three presented acute osteomyelitis, 26 secondary chronic osteomyelitis and 11 a primary chronic osteomyelitis. Osteomyelitis affected predominantly the mandible (87%). Dental origin was found in 90% of cases. Nine patients (22.5%) recovered and 29 (90%) were clinically improved. Ten of the 11 patients with primary chronic osteomyelitis were improved.

DISCUSSION

This cohort study is one of the largest series currently available and presents results comparable to those of the literature of the last 25 years.

A Pathological Fracture of the Mandible due to Osteomyelitis following a Full Dental Clearance

Orofacial infections following dental extractions are a common referral to an oral and maxillofacial department as an emergency, especially when combined with swelling and limited mouth opening. The case presented demonstrates a rare complication of chronic suppurative osteomyelitis with bilateral pathological fractures of the mandible, which occurred following a staged dental clearance. CPD/Clinical Relevance: Dental extractions are one of the most common treatments carried out by oral surgeons and general dental practitioners. This case highlights a rare but encountered complication of routine oral surgery and demonstrates when it is necessary to make an immediate referral to the local oral and maxillofacial surgery unit.

Primary Chronic Osteomyelitis of the Jaws in Children: An Update on Pathophysiology, Radiological Findings, Treatment Strategies, and Prospective Analysis of Two Cases

Objective. Primary chronic osteomyelitis (PCO) of the jaws in children is associated with pain, trismus, and swelling. In children, temporomandibular joint involvement is rare and few studies have been published due to the relatively low incidence. This paper presents two cases of mandibular PCO in children with the involvement of the collum mandibulae. In addition, a review of the literature regarding demographic data, histological, radiological, and laboratory findings, and treatment strategies of PCO was also performed. Material and Methods. Prospective analyses of two PCO cases. A PubMed search was used and the articles were sorted according to their corresponding key area of focus. Results. Review of the literature revealed twenty-four cases of PCO with two cases of mandibular condyle involvement. The mean age was 18 years; the male to female ratio was 1 : 3. Most of the patients were treated with anti-inflammatory drugs in combination with decortication. Clinical recurrence was seen in 7 cases. Conclusion. A combination of anti-inflammatory drugs and surgical intervention appears to be the first choice of treatment. However, surgical removal of necrotic tissue adjacent to collum mandibulae has its limitations in children. Further investigations are of utmost importance in order to increase our knowledge and understanding of this disease.

Chronic osteomyelitis of the mandible: diagnosis and management--an institution's experience over 7 years

PURPOSE

The objective of this study was to retrospectively evaluate and report the associated factors with the diagnosis and management of 24 patients with chronic osteomyelitis of the mandible seen at the authors' institution during the past several years.

PATIENTS AND METHODS

Only cases of chronic osteomyelitis of the mandible not associated with antiresorptive medications or radiotherapy to the maxillofacial region were included in the study. After confirmation of the diagnosis, initial clinical and radiologic findings, treatment approach, and outcome were evaluated for each patient. Fourteen male and 10 female patients (average age, 53.75 yr; range, 22 to 83 yr) were included.

RESULTS

The peak incidence of the disease was recorded in the fifth and sixth decades of life. An uneventful healing was observed in 20 patients (83.3%). One of 18 patients (5.5%) who underwent segmental resections developed a secondary infection and was managed with intravenously administered antibiotics. Three of 6 patients (50%) who were treated with marginal resections remained symptomatic after surgery.

CONCLUSION

Independent of the cause and presentation of the disease, complete resolution of the infection should be the main focus of management in patients with chronic osteomyelitis of the mandible, and findings of this retrospective study indicate that a conservative surgical approach is more likely to result in a less than ideal outcome.

Clinical management of suppurative osteomyelitis, bisphosphonate-related osteonecrosis, and osteoradionecrosis: report of three cases and review of the literature

In the past, osteomyelitis was frequent and characterized by a prolonged course, treatment response uncertainty, and occasional disfigurement. Today, the disease is less common; it is believed that the decline in prevalence may be attributed to increased availability of antibiotics and improvement of overall health patterns. Currently, more common osteomyelitis variants are seen, namely, osteoradionecrosis (ORN) and bisphosphonate-related osteonecrosis of the jaws (BRONJ). Osteomyelitis, ORN, and BRONJ can present with similar symptoms, signs, and radiographic findings. However, each condition is a separate entity, with different treatment approaches. Thus, accurate diagnosis is essential for adequate management and improved patient prognosis. The aim of this paper is to report three cases of inflammatory lesions of the jaws—osteomyelitis, ORN, and BRONJ—and to discuss their etiology, clinical aspects, radiographic findings, histopathological features, treatment options, and preventive measures.

Osteomyelitis of maxilla in poorly controlled diabetics in a rural Indian population

OBJECTIVES

To retrospectively analyze all patients who were diagnosed with Osteomyelitis of jaws in our unit.

STUDY DESIGN

31 patients with Osteomyelitis of jaws were analyzed retrospectively from 2002 to 2008 at the Department of Oral & Maxillofacial Surgery, S.D.M College of dental sciences and hospital, Dharwad, India. Parameters considered were age, gender, jaws involved, clinical features, surgical management & complications.

RESULTS

Of the 31 patients, maxilla was involved in 16 patients and mandible was involved in the remaining 15. 11 out of the 16 patients with maxillary osteomyelitis were immuno-compromised. The predominant etiology noted was odontogenic infection. With the treatment protocol we have adopted, all our patients showed satisfactory resolution of the condition by 6 weeks.

CONCLUSION

Incidence of maxillary osteomyelitis & their association with diabetes mellitus was higher in our series compared to others. The cause for this high incidence was analyzed in our study. Based on our results we conclude that a conservative surgical method with an attempt to preserve vital bone and an appropriate antibiotic therapy with the correction of the underlying medical problems is adequate to treat Osteomyelitis of jaws.

Surgical management of primary chronic osteomyelitis of the jaws in children: a prospective analysis of five cases and review of the literature

INTRODUCTION

Primary chronic osteomyelitis (PCO) of the jaws is an uncommon non-suppurative inflammatory disease of unknown origin. Although the disease is not age-specific, only sparse cases with onset during childhood or adolescence have been reported in the literature.

PURPOSE

This study seeks to present five cases of maxillofacial PCO in children and to evaluate the effectiveness of the applied therapeutic protocol. A review of the literature concerning diagnosis and treatment of PCO with special emphasis on surgical therapy is also performed.

PATIENTS AND METHODS

Demographic data, clinical, radiographic and histopathologic findings, blood tests results, and the treatment protocol applied to five young patients suffering from PCO and referred to the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou Children's Hospital" over the past 5 years are presented. Decortication and contouring of the affected bone were performed; antibiotics were administered for a short period of time and the patients remained under follow-up evaluation.

RESULTS

The posterior mandible was affected in four cases and the maxilla-zygomatic bone in one case. All patients showed remission of signs and symptoms after surgical treatment. The postsurgical clinical course was uneventful in all cases. However, recurrences have been noted, as reported in the literature.

CONCLUSION

PCO of the jaws is a complex clinical entity, presenting both a diagnostic and therapeutic challenge, especially in young patients. Surgical treatment in conjunction with antibiotics and non-steroid anti-inflammatory drugs proved to be beneficial and to improve considerably the patients' quality of life. Nevertheless, exacerbation of the disease may appear and regular follow-up of the patients is required.