Juvenile mandibular chronic osteomyelitis: a distinct clinical entity

Collaborative approach to paediatric chronic non-bacterial osteomyelitis of the mandible: Great Ormond Street Hospital case series

This paper outlines a 10-patient case series of chronic non-bacterial osteomyelitis (CNO) of the mandible at a tertiary paediatric hospital in the UK. Our findings highlight the homogeneous presenting signs and symptoms of an intermittently painful, swollen angle and ramus of the mandible. We present the typical laboratory investigative findings (normal inflammatory markers) and imaging appearances (sclerosis and periosteal oedema). Our paper outlines an investigation protocol, including recommendations for extraoral bone biopsies and systemic magnetic resonance imaging (MRI). We explain the importance of multidisciplinary care, with combined care by rheumatologists and infectious disease specialists. Finally we demonstrate the efficacy of our treatment algorithm for oral non-steroidal anti-inflammatory drugs (NSAIDs), and in those cases refractory to NSAIDS, intravenous pamidronate. This paper provides a useful addition to the literature by informing OMF surgeons of this rare condition and given the clinical equipoise in treatments, it can hopefully guide clinicians in an investigation pathway and management protocol.

Recurrent osteomyelitis with proliferative periostitis after segmental resection and reconstruction of the mandible: a case report

A 50-year-old patient presented with a two-year history of chronic osteomyelitis of the left mandibular body. It was treated by wide segmental resection of the left hemimandible and reconstruction with a free vascularized fibular graft. Six months after surgery, the patient returned with pain, swelling, and moth-like lesions in the transplant in combination with appositional bone formation surrounding the ossified fibular bone. Radiographic and histological examination led to the diagnosis of a recurrent osteomyelitis with proliferative periostitis affecting the resected and reconstructed mandible. Application of ibandronate led to a significant symptom decrease.

The dilemma of juvenile fibrous dysplasia versus chronic osteomyelitis of the posterior mandible: A case report

The clinical and radiographic dilemma of fibrous dysplasia versus osteomyelitis is highlighted in this case of a 4‐year‐old girl with a bony hard swelling in mandibular body and ramus. Rather than relying on histopathological appearance alone, dental professionals should be familiar with the radiographic differences between the two conditions.

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.

Diagnostic Challenge Involving Diffuse Mandibular Swelling in Mixed Dentition: Use of Cone-beam Radiography

Aim and objective

This case report aims to discuss a case of chronic osteomyelitis with proliferative periostitis (COPP) in which cone-beam computed tomography (CBCT) played a key role in the diagnosis and identification of the disease.

Background

Osteomyelitis is frequently seen in the maxillofacial region, with the mandible being more affected as compared to the maxilla. Chronic osteomyelitis with proliferative periostitis is often seen in children and young adults, which occurs due to the spread of infection from a bacterial focus.

Case description

A 12-year-old boy presented with a swelling on the right side of the mandible. Extraorally, the swelling appeared diffuse, non-tender, hard on palpation, and was associated with right submandibular lymphadenopathy. Intraorally, a hard bony protrusion was found on the buccal aspect of the edentulous space of the first premolar region obliterating the vestibular depth. It was provisionally diagnosed to be a case of chronic alveolar abscess with respect to deciduous molar, with a suspicion of some underlying bony pathology. Blood investigations showed a raised value of erythrocyte sedimentation rate and alkaline phosphatase. Cone-beam computed tomography examinations showed bony laminations parallel to each other and the underlying cortical bone in the axial and sagittal images and these were present both buccally and lingually. The CBCT descriptions led to the diagnosis of Garre's osteomyelitis in this case which was later confirmed by histopathological examination.

Conclusion

The detailed imaging as well as the three-dimensional reconstruction of the images has helped to reach out to a differential diagnosis in this case.

Clinical significance

This case report emphasizes the importance of newer techniques such as CBCT in reaching out at a diagnostic conclusion in challenging clinical cases.

How to cite this article

Passi S, Gupta J, Mehta A, et al. Diagnostic Challenge Involving Diffuse Mandibular Swelling in Mixed Dentition: Use of Cone-beam Radiography. Int J Clin Pediatr Dent 2021;14(3):430–433.

Methicillin-resistant Staphylococcus aureus (MRSA)-associated juvenile osteomyelitis of mandible: a rare variant

Mandibular osteomyelitis in paediatric population presents as painful swelling with progressive trismus. Often the aetiology for this form of progressive osteomyelitis is inconclusive. The infective aetiology in this condition is difficult to assign as bone tissue culture is found to be seldom positive. We present a case of an 11-year-old girl, with hearing and speech impairment, who presented with report of painful right-sided mandibular swelling with progressive trismus. Clinical, radiographic and histopathological findings were suggestive of sclerotic osteomyelitis. Bone tissue culture grew Methicillin-resistant Staphylococcus aureus, indicating a rare infective variant. Unlike the common belief, where osteomyelitic mandible needs a combination of medical and surgical management, our case was managed conservatively with only antibiotic therapy. Our patient responded well to the treatment with reduction in pain and gradual improvement in the mouth opening. Radiographically the mandibular involvement also showed complete regression.

Non-surgical treatment of adults with chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible

Non-surgical therapy has proved to be effective in chronic diffuse sclerosing osteomyelitis (DSO) of the mandible in children. Therefore we aimed to investigate the effect of non-surgical therapy in adult DSO patients. We included consecutive patients with DSO who received non-surgical therapy in our center. They all received occlusal splint therapy, counselling about the disease, and/or physiotherapy by a specialised team. The use of analgesics, preferably nonsteroidal anti-inflammatory drugs, was advised for symptomatic control during periods of exacerbation. Sixteen patients (11/5 female/male) aged 39.9 ± 15.0 years with DSO of the mandible were included. The mean duration of symptoms was 39.7 ± 26.3 months before referral to our center. Patients were treated with a broad range of treatments before referral. All patients underwent non-surgical treatment. In 12 patients this led to remission. Four patients still had complaints after 12 months of non-surgical therapy and started with intravenous bisphosphonate therapy. In our center, DSO of the mandible was successfully treated with non-surgical therapy, despite a long duration before referral and extensive pre-treatment. Considering this high success rate, we recommend this non-surgical approach as the first treatment option for DSO of the mandible. In case of persistence, alternative treatments such as bisphosphonates should be explored.

Diagnostic Challenge and Clinical Management of Juvenile Mandibular Chronic Osteomyelitis

Juvenile mandibular chronic osteomyelitis (JMCO) is a rare, idiopathic disease of chronic bone inflammation without suppuration, sinus tract formation, or sequestration. As the name suggests, this condition predominately affects children. The few cases of JMCO reported in the literature describe different treatments, and thus a standard therapy protocol has not yet been established. The aim of this paper is to report a clinical case in a 9-year-old girl that was misdiagnosed and unsuccessfully treated for 1 year. After experiencing persistent symptoms, a correct diagnosis was subsequently rendered based on the physical and radiographic examination as well as successful treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The patient received drug therapy followed by periods of remission over a 4 year follow-up period. Diagnosis and treatment of JMCO is a challenge given the rarity and nonspecific signs and symptoms of this condition. Treatment with NSAIDs and regular follow-up is a conservative option for these patients.

Craniofacial disorders

The complexity of the craniofacial patient mandates the cooperation of a multidisciplinary team that can systematically evaluate each individual and ensure that a protocol-driven pathway is undertaken for the best patient care. Oral and maxillofacial surgeons contribute to surgical care in this setting with specific knowledge of growth and development of the face. This enables optimum timing for early skeletal correction where appropriate, and definitive surgery following the cessation of growth to maximize function and aesthetics. This chapter will describe the major principles in managing patients with specific craniofacial anomalies and provide examples of the outcomes possible.

Trends in maxillofacial imaging

Maxillofacial imaging encompasses radiology of the teeth and jaws, including the temporomandibular joints. Modalities used include intra-oral radiographs, panoramic tomography, cephalograms, cone-beam computed tomography, computed tomography, magnetic resonance imaging, ultrasound, and radionuclide imaging. Common indications for imaging are impacted and supernumerary teeth, dental implants, inflammatory dental disease, and fibro-osseous lesions, cysts, and masses of the jaws. Osteonecrosis of the jaws may follow radiotherapy or the use of bisphosphonates and other drugs. Imaging of the temporomandibular joints and the potential role of imaging in obstructive sleep apnoea are also discussed.

Chronic suppurative osteomyelitis with proliferative periostitis related to a fully impacted third molar germ: a report of two cases

In prolonged chronic osteomyelitis, chronic inflammation and low-grade infections can result in new periosteal bone formation. Chronic osteomyelitis with proliferative periostitis (traditionally termed Garré's sclerosing osteomyelitis) mainly affects children and young adults. Here, we present two rare cases of an 11-year-old and a 12-year-old patient with suppurative chronic osteomyelitis with proliferative periostitis without any definitive infection source, such as dental caries or periodontitis. The source of infection was likely to be related to the development of a lower right third molar germ with follicular space widening. Management involved antibiotics and the removal of the third molar germ and surgical debridement. Disease remission and a normal appearance was observed at the six-month follow-up visit.

Pediatric Chronic Nonbacterial Osteomyelitis of the Jaw: Clinical, Radiographic, and Histopathologic Features

PURPOSE

Chronic nonbacterial osteomyelitis (CNO) is a focal sterile inflammatory osteitis in children that most commonly develops in the long bones, but can occur in any bone. The disease course is variable, ranging from acute and self-resolving isolated lesions to chronic recurrent multifocal osteomyelitis (CRMO), which is frequently associated with extraosseous inflammatory disease. The purpose of this study was to present our clinical experience with CNO of the mandible in children. The specific aims were to 1) document the clinical characteristics, radiographic findings, and histologic features of CNO and 2) determine the percentage of our sample with multifocal disease (CRMO).

MATERIALS AND METHODS

This is a retrospective case series of patients with mandibular CNO. To be included, patients had to have a mandibular lesion radiographically consistent with osteomyelitis without infection, onset before aged 18 years, and complete records. Medical records were reviewed for history, clinical features, imaging, and pathology. Descriptive data were summarized.

RESULTS

The sample included 22 patients (13 female and 9 male patients) with disease onset at a mean age of 9.05 ± 2.4 years. On presentation, all patients reported mandibular pain and swelling, and 45% had trismus. All had clinical and/or radiographic findings of multifocal intraosseous disease and/or extraosseous inflammatory lesions. Of the patients, 12 (54%) had a documented family history of autoimmune or autoinflammatory disease and 15 (68%) had elevated erythrocyte sedimentation rates during a flare. Computed tomography scans typically showed expansion of the affected mandible with sclerosis of the medullary space, small foci of poorly defined lytic destruction with a lamellated periosteal reaction, and swollen muscles of mastication. Four distinct histologic features were noted including parallel and interconnected osteoid seams, atypical osteoid, areas of woven bone and hypocellular fibroblastic stroma resembling fibrous dysplasia, and patchy nodular fibrosis.

CONCLUSION

Pediatric CNO of the mandible has characteristic radiographic and pathologic features and is usually found as one of multiple disease foci in CRMO rather than as an isolated lesion.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics

PURPOSE

To document outcomes of management of juvenile mandibular chronic osteomyelitis (JMCO) using a standardized treatment protocol including open biopsy, decortication, microbial culture, and long-term antibiotic therapy.

MATERIALS AND METHODS

This was a retrospective case study of pediatric patients with JMCO treated at Massachusetts General Hospital for Children from 1996 through 2014. Inclusion criteria included age younger than 18 years, diagnosis of JMCO, management by the protocol, adequate clinical and radiographic data in the record, and follow-up of at least 1 year after initial treatment. Inpatient and outpatient records were reviewed for demographics, clinical and radiographic findings, and histologic and laboratory evaluations. The predictor variable was the standardized treatment protocol and the primary outcome variables were disease status at end of treatment and complications of treatment.

RESULTS

Twenty patients (mean age at onset, 10.7 yr; range, 3 to 14 yr) were treated, 12 (11 girls) of whom met the inclusion criteria. Management of all patients consisted of biopsy (extraoral when feasible, n = 9; intraoral, n = 3), decortication, cultures, and long-term antibiotic therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered only as needed for pain control. There was complete resolution of osteomyelitis with no recurrence in 7 of 12 patients (mean follow-up, 4.3 yr; range, 1 to 11 yr). Five patients had partial responses, with decreased frequency and severity of disease recurrence. These were well controlled with short courses of antibiotics (4 to 12 weeks) with NSAIDs only as needed for pain control (mean follow-up, 1.4 yr; range, 1 to 3 yr). There were no major complications related to antibiotic therapy. Minor complications included rash (n = 2), nausea and vomiting (n = 1), and vaginal candidiasis (n = 1).

CONCLUSION

The results of this study indicate that 58.3% of patients were cured and had no recurrent symptoms (mean follow-up, 4.3 yr). The remaining patients continue on intermittent treatment with antibiotics for recurrent episodes of swelling and pain. Favorable responses to antibiotic therapy support the hypothesis that JMCO is an infectious disease and that negative cultures might represent a failure of standard culture techniques to isolate the responsible organisms.

[Importance of SPECT/CT for resolving diseases of the jaw]

CLINICAL/METHODICAL ISSUE

Diseases of the jaw, such as osteomyelitis, condylar hyperactivity and tumors need adequate imaging to evaluate the extension and activity for therapy planning.

STANDARD RADIOLOGICAL METHODS

Conventional planar scintigraphy, orthopantomography, computed tomography (CT) and magnetic resonance imaging (MRI) can be used for the evaluation of jaw diseases.

METHODICAL INNOVATIONS

Single photon emission computed tomography/computed tomography (SPECT/CT) provides metabolic and morphologic information in one imaging step and is becoming increasingly more available in larger hospitals.

PERFORMANCE

The SPECT/CT is superior to planar scintigraphy alone, CT and orthopantomography in the evaluation of the extension and activity of osteomyelitis and jaw tumors.

ACHIEVEMENTS

In our hospital SPECT/CT has replaced the other imaging modalities in the evaluation of osteomyelitis and condylar hyperactivity.

PRACTICAL RECOMMENDATIONS

If available SPECT/CT should be performed for the evaluation of osteomyelitis of the jaw.

Craniofacial fibrous dysplasia

Despite recent advances in the understanding of the natural history and molecular abnormalities, many questions remain surrounding the progression and management of fibrous dysplasia (FD). In the absence of comorbidities, the expected behavior of craniofacial FD (CFD) is to be slow growing and without functional consequence. Understanding of the pathophysiologic mechanisms contributing to the various phenotypes of this condition, as well as the predictors of the different behaviors of FD lesions, must be improved. Long-term follow-up of patients with CFD is vital because spontaneous recovery is unlikely, and the course of disease can be unpredictable.

Juvenile mandibular chronic osteomyelitis: multimodality imaging findings

BACKGROUND AND PURPOSE

Juvenile mandibular chronic osteomyelitis is a rare entity that predominantly affects children and adolescents, but little is known about the factors that contribute to the recurrent course and eventual resolution of this disease. Here, we describe new findings of soft tissue and mandibular nerve canal involvement.

MATERIALS AND METHODS

Four patients with mandibular diffuse sclerosing osteomyelitis are presented; all were followed with CT, a few also with MRI and bone scan. We recorded imaging findings of lesion location, pattern of bone formation, presence and evolution of lytic lesions, mandibular nerve, and soft tissue involvement.

RESULTS

In all patients we found enlargement of the mandibular nerve canal and soft tissue changes on CT and MRI (when available). All patients had ground glass bone patterns in conjunction with lamellated/onion skin new periosteal bone formation on CT, and all patients with follow-up CT had change in lytic lesion locations.

CONCLUSION

Mandibular nerve canal enlargement, soft tissue abnormalities, and change in location of lytic lesions may represent a diagnostic pattern in mandibular diffuse sclerosing osteomyelitis (Garré) that was not previously entirely recognized as such.

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.

Titanium Mesh Fracture in Mandibular Reconstruction

Mandibular reconstruction is important for providing good functional and cosmetic results after the resection of a mandibulary segment. Reconstruction plates and titanium meshes are usually used to reconstruct the bony defects in mandible. Although their complications are well known there is not a report on the fractures of a titanium mesh after mandible reconstruction in the literature. We reported a case of a broken titanium mesh after mandible reconstruction.