ACUTE ODONTOGENIC OSTEOMYELITIS OF THE JAWS: CLINICAL COURSE, DIFFERENTIAL DIAGNOSIS, PREVENTION, TREATMENT (SURGICAL, MEDICATIONAL, PHYSIOTHERAPEUTICAL, ETC.), COMPLICATIONS.

Osteomyelitis Jaw

Osteomyelitis is an infection of the bone. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including:

• An open injury to the bone, such as an open fracture with the bone ends piercing the skin.

• An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis).

• A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.

• Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.

• A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

Osteomyelitis affects about two out of every 10,000 people. If left untreated, the infection can become chronic and cause a loss of blood supply to the affected bone. When this happens, it can lead to the eventual death of the bone tissue.

Osteomyelitis can affect both adults and children. The bacteria or fungus that can cause osteomyelitis, however, differs among age groups. In adults, osteomyelitis often affects the vertebrae and the pelvis. In children, osteomyelitis usually affects the adjacent ends of long bones. Long bones (bones of the limbs) are large, dense bones that provide strength, structure, and mobility. They include the femur and tibia in the legs and the humerus and radius in the arms.

Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including:

• People with diabetes

• Patients receiving hemodialysis

• People with weakened immune systems

• People with sickle cell disease

• Intravenous drug abusers

• The elderly

Symptoms of osteomyelitis

The symptoms of osteomyelitis can include:

• Pain and/or tenderness in the infected area

• Swelling and warmth in the infected area

• Fever

• Nausea, secondarily from being ill with infection

• General discomfort, uneasiness, or ill feeling

• Drainage of pus through the skin

Additional symptoms that may be associated with this disease include:

• Excessive sweating

• Chills

• Lower back pain (if the spine is involved)

• Swelling of the ankles, feet, and legs

• Changes in gait (walking pattern that is a painful, yielding a limp)

Diagnosing osteomyelitis

To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis:

• Blood tests: When testing the blood, measurements are taken to confirm an infection: a CBC (complete blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body.

• Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment.

• Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media.

• Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism.

• Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when X-ray findings may only show normal findings.

Treating and managing osteomyelitis

The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease as soon as possible.

Drainage: If there is an open wound or abscess, it may be drained through a procedure called needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over often-unreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are drained by open surgical procedures.

Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone. The dosage and type of antibiotic prescribed depends on the type of bacteria present and the extent of infection. While antibiotics are often given intravenously, some are also very effective when given in an oral dosage. It is important to first identify the offending organism through blood cultures, aspiration, and biopsy so that the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to starting antibiotics.

Splinting or cast immobilization: This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children, although motion of joints after initial control is important to prevent stiffness and atrophy.

Surgery: Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteria involved in the infection are then intensively administered during the hospital stay and for many weeks afterward.

With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to treatment that amputation may be required; however, this is rare. Also, over many years, chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the chronic drainage site, should be evaluated by a physician experienced in treating chronic bone infections. Because it is important that osteomyelitis receives prompt medical attention, people who are at a higher risk of developing osteomyelitis should call their doctors as soon as possible if any symptoms arise.

Osteomyelitis for Jaw Treatment

Osteomyelitis occurs when a bone becomes infected. Though osteomyelitis most often occurs in the bones of the limbs, spine and pelvis, it can also affect the jaw. Osteomyelitis in the jaw is a rare condition that once had been thought incurable, however advances in medicine make the condition treatable. It can present itself in either acute or chronic forms. Osteomyelitis is a serious condition and if proper treatment is not sought, it can destroy your bones.

Symptoms

The symptoms for people with osteomyelitis in the jaw include pain and tenderness, swelling around the jaw, drainage in the sinus cavity, loss of teeth, discharging of pus and necrotic bones. Factors that can lead to osteomyelitis include tobacco, anaemia, viral infections and malnutrition. Since the condition exhibits symptoms that are common in many other diseases, osteomyelitis can be difficult to diagnose at first. If you have chronic osteomyelitis, debilitating fatigue is also very common symptom.

Diagnosis

If your doctor suspects osteomyelitis, he will order various tests before he can make a firm diagnosis. Though a blood test does not define an osteomyelitis diagnosis, a high level of white blood cells will indicate that body is fighting off an infection. If your osteomyelitis is advanced, an X-ray will show the extent of the damage. If you need a better image, your doctor may recommend a CAT scan or MRI. Your doctor may also remove a piece of your bone for a biopsy. This biopsy will check for the strain of bacteria that has infected your bone.

Treatment

Most often infections of the jaw are polymicrobial oral flora so a regimen of antibiotics are used to treat the infection. You doctor may prescribe penicillin, clindamycin and metronidazole. Depending on the extent of the infection, surgery may be required. Your doctor will decide which procedure is best based on the damage caused by the infection. Some bone and tissue may need to be removed, fractures repaired and rotten teeth extracted. You may also want to consult with an oral-maxillofacial surgeon to see if facial reconstruction is required.

Osteomyelitis
Osteomyelitis is a rare complication of tooth-related infections (incidence of 25 in 100,000).  In most cases, it is the result of spread of infection from a dento-
alveolar (tooth) or periodontal (pyorrhoea / gum disease) abscess or from the para-nasal sinuses, by way of continuity through tissue spaces and planes.  It occasionally occurs as a complication of  jaw fractures or as a result of manipulations during surgical procedures.
Most patients are adult males with infection of the mandible (lower jaw).
Osteomyelitis of the maxilla (upper jaw) is a rare disease of neonates (newly born) or infants after either birth injuries or uncontrolled middle ear infection.
It is classified as acute or chronic osteomyelitis.
Acute Osteomyelitis
In the acute form (which rarely, may also be of hæmatogenous origin [i.e. seeded from the blood stream]), the infection begins in the medullary cavity (bone marrow) of the bone.  The resulting increase of intra-bony pressure leads to a decreased blood supply (and hence diminution of white blood cells and other immune
components) and spread of the infection, by way of the Haversian canals of the bone, to the cortical bone (definition) and periosteum (below the periosteum, a thick
fibrous two-layered membrane covering the surface of bones).  This aggravates the ischæmia (decreased blood supply), resulting in necrosis (the death of cells or tissues from severe injury or disease, especially in a localised area of the body.  Causes of necrosis include inadequate blood supply [as in infarcted tissue], bacterial infection, traumatic injury and hyperthermia) of the bone.
Acute Osteomyelitis of the Jaws — Potential Sources of
Infection

• Peri-apical infection

• A periodontal pocket involved in a fracture

• Acute gingivitis or pericoronitis (even more rarely)

• Penetrating, contaminated injuries (open fractures or
  gunshot wounds)

Important Predisposing Conditions for Osteomyelitis
Local Damage to / Disease of the Jaws

• Fractures, including gunshot wounds

• Radiation damage

• Paget’s disease

• Osteopetrosis

Impaired Immune Defences

• Acute leukaemia

• Poorly-controlled diabetes mellitus

• Sickle cell anaemia

• Chronic alcoholism or malnutrition

• AIDS

 

• Infection from micro-organisms with great virulence.  
  In such cases, even a peri-apical abscess may be
  implicated in osteomyelitis.

Acute Osteomyelitis of the Jaws — Key Features

• Mandible mainly affected, usually in adult males

• Infection of dental origin – anærobes are important

• Pain and swelling of jaw

• Teeth in the area are tender; gingivæ (gums) are red
  and swollen

• Sometimes paræsthesia of the lip

• Minimal systemic upset

• After about 10 days, X-rays show ‘moth-eaten’
  pattern of bone destruction

• Good response to prompt antibiotic treatment and
  debridement

The mandible (lower jaw), due to decreased vascularity (blood supply & flow), is
involved 6 times more often than the maxilla (upper jaw).
The mandible has a relatively limited blood supply and dense bone with thick bony
(cortical) plates.  Infection causes acute inflammation in the medullary (bone
marrow) soft tissues and inflammatory exudate (a fluid with a high content of
protein and cellular debris which has escaped from blood vessels and has been
deposited in tissues or on tissue surfaces, usually as a result of inflammation. It
may be septic or non-septic) spreads infection through the marrow spaces.  It also
compresses blood vessels confined in the rigid boundaries of the vascular canals.

Thrombosis (the formation or presence of a thrombus [a clot of coagulated blood
attached at the site of its formation] in a blood vessel) and obstruction then lead to
further bone necrosis.

Dead bone is recognisable microscopically by lacunae (a cavity, space, or
depression, especially in a bone, containing cartilage or bone cells) empty of
osteocytes (a cell characteristic of mature bone tissue.  It is derived from
osteoblasts and embedded in the calcified matrix of bone. Osteocytes are found in
small, round cavities called lacunae and have thin, cytoplasmic branches) but filled
with neutrophils (white blood cells) and colonies of bacteria which proliferate in the
dead tissue.

Pus, formed by liquefaction of necrotic soft tissue and inflammatory cells, is forced
along the medulla and eventually reaches the sub-periosteal region by resorption
(an organic process in which the substance of some differentiated structure that
has been produced by the body undergoes lysis and assimilation) of bone.  
Distension of the periosteum by pus stimulates sub-periosteal bone formation but
perforation of the periosteum by pus and formation of sinuses on the skin or oral
mucosa are rarely seeow.

At the boundaries between infected and healthy tissue, osteoclasts (a specialised
bone cell that absorbs bone) resorb the periphery of the dead bone, which eventually becomes separated as a sequestrum (a fragment of dead bone separated from healthy bone as a result of injury or disease).  Once infection starts to localise, new bone forms around it, particularly sub-periosteally.
Where bone has died and been removed, healing is by granulation with formation of
coarse fibrous bone in the proliferating connective tissue.  After resolution, fibrous
bone is gradually replaced by compact bone and remodelled to restore normal
bone tissue and structure (and function).
Piercing, deep and constant pain predominates in the clinical presentation in adults,
while low or moderate fever, cellulitis, lymphadenitis, or even trismus may also be
noted.
In the mandible, changes in sensation affecting the lower lip (paræsthesia or
dysæsthesia of the lower lip) may accompany the disease.  When the disease
spreads to the peri-osteum (definition) and the surrounding soft tissues, a firm
painful œdema (definition) of the region is observed, while the tooth becomes loose
and there is discharge of pus from the periodontium.  Radiographic examination
reveals osteolytic (definition) or radiolucent (definition) regions.
Therapy entails combined surgical (incision, drainage, extraction of the tooth and
removal of sequestrum) and chemo-therapeutic treatment (with antibiotics).
Summary of Treatment of Osteomyelitis
Essential Measures

• Bacterial sampling and culture

• Vigorous (empirical) antibiotic treatment

• Drainage

• Give specific antibiotics based on culture and sensitivities

• Give analgesics

• Debridement

• Remove source of infection, if possible

Adjunctive Treatment

• Sequestrectomy

• Decortication if necessary

• Hyperbaric oxygen*

• Resection and reconstruction for extensive bone destruction

*Mainly of value for osteo-radionecrosis and possibly, anærobic infections.

Anæsthesia of the lower lip usually recovers with elimination of the infection.  Rare
complications include pathological fracture caused by extensive bone destruction,
chronic osteomyelitis after inadequate treatment, cellulitis due to spread of
exceptionally virulent bacteria or septicæmia in an immuno-deficient patient.

Chronic Osteomyelitis

 

Formation of a sequestrum: (A), sound bone; (B), new bone; (C), granulations lining involucrum; (D), cloaca; (E), sequestrum.

Chronic osteomyelitis is characterised by a clinical course lasting over a month.  It
may occur after the acute phase or it may be a complication of tooth-related
infection without a preceding acute phase.  The clinical presentation is milder, with
painful exacerbations and discharge of pus or sinus tracts.

Osteomyelitis – Inflammation of the Bone

The terms osteomyelitis, periostitis and ostitis are frequently used as synonyms for inflammation of the bone.

Let’s have a quick look at the definition of the terms. Since the bone itself (the calcium structure) cannot get inflamed osteomyelitis (meaning bone marrow inflammation) and periostitis (meaning bone lining inflammation) would be the correct descriptions for an inflammation of the bone. Nevertheless ostitis is becoming more and more the term used.

The cause of an inflammation of the bone can come from outside – (exogenous factors) or from inside (endogenous factors). When both factors occur at the same time then we speak of combined forms. The so called idiopathic factors may also be regarded as a fourth form, consisting of bone inflammations of unidentifiable origin. Exogenous factors include, for example, numerous bacteria, viruses and fungi. They are potential pathogenic agents. If these pathogens find their way into our body they can cause an inflammation. If the inflammation gets into the bone then it’s a bone inflammation.

In the case of endogenous factors the cause lies in our own bodies. For example, in the case of diabetics the raised level of sugar of a diabetic leads to ever-increasing thickening of the walls of the blood vessels and thus an ever-poorer flow of blood.

The flow of blood can get so bad that certain areas of the body are no longer reached by it any more and the affected tissues die due to lack of oxygen and will be destroyed as a consequence of an inflammatory reaction – this can also occur in the bones, as shown in the animation and that would be an example of an endogenous osteomyelitis.

X-ray of Jaw Structure

Idiopathic osteomyelitis means to the patient that, at the end of the day the doctor cannot find an adequate explanation for it.

In the area of the jaw the most common causes of bone inflammation are exogenous or, more accurately, iatrogenous (caused by the doctor). Thus often extractions and/or badly root-treated teeth lead to bone infections.

In the picture you can see an x-ray of an extraction wound (circled in blue), the bone in this area is inflamed (circled in red) – osteomyelitis. In order to diagnose osteomyelitis an x-ray is usually required. In the same picture you can see a tooth (circled in green), which has an inflammation of the bone going on at the tip of the root (circled in red), as can be seen from the dark spot.

An x-ray can provide a lot of information about the bone but if precision is needed then a CT or MRT scan is very useful. This brings us to the diagnosis of osteomyelitis – CT and MRT scans are very reliable diagnostic aids at a certain stage of the osteomyelitis but at a very early stage of the illness their usefulness is rather limited.

Nuclear medical examinations such as skeletal cintography (Tc-99m) are frequently being made use of in order to detect osteomyelitis. The radioactive element technetium will be seen to be concentrated in the areas with raised bone metabolism after being applied intravenously. This increased concentration can be seen from the outside by means of a special camera (the darker spots in the exposure). Unfortunately it is not possible with this method to distinguish between the different causes of the raised bone metabolism.

Is the cause an inflammation or only an innocent build-up of bone after all?

With the addition of special factors (marked anti-granulocyte antibodies for additional investigation) the examination can however be made more specific. Blood tests are likewise not specific and unfortunately the blood values of the inflammation do not always correlate with the values of the osteomyelitis – especially in the jaw area. A bone biopsy is usually the most reliable means of diagnosis, as this way the bone can be viewed very precisely under the microscope (histological examination), and it may be possible to isolate the offending pathogen on the culture glass (bacteriology). If this succeeds then an antibiogram can be carried out in order to find the antibiotic with which to destroy the pathogen.

Bone Scan Scintigraphy

However, biopsy has a couple of disadvantages. The examination is invasive (therefore a wound is unavoidable) and not all areas of bone can be biopsied easily. Sometimes the bacteriological investigations are not successful or it may happen that during the taking of the sample there is contamination of the sample, for example by non-specific bacteria from the mouth.

Finally, let us take a look at the treatment options for osteomyelitis. There are various treatment options available – in the worst case the affected bone must be removed but this is very seldom necessary. The most frequent and simplest treatment option is the prescription of antibiotics, which can be swallowed or applied intravenously. The latter gives a higher concentration of the active ingredient in the blood.

By means of oxygen therapy we enrich the concentration of oxygen in the blood, since within the inflamed bone there is frequently insufficient blood supply and consequently, too little oxygen, ideal conditions for the multiplication of bacteria which do not tolerate oxygen – anaerobic bacteria as they are known. Oxygen-rich blood should have an effect on them, as per the motto: a little blood but very rich.

Another very much talked about treatment is the removal of the sick bone and the filling of the resultant gap with replacement donor bone which has been enriched with an antibiotic. In the animation you can see how the donor bone with the antibiotic (shown in green here) is put in place. The inflamed bone (shown in red here) will be removed and the donor bone will be inserted in the resulting cavity. The antibiotic will then pass continually into the body over months and simultaneously the replacement bone can regenerate.

The advantage of this treatment is that far higher concentrations of medication can be placed specifically in the affected area unlike with the usual means of application (orally or intravenously). Examination over a long period of time is still needed in order to evaluate this treatment over several years.

Ideally you want to avoid it getting to that stage. At least the iatrogenic forms of osteomyelitis can be avoided through sterilisation and cleanliness in the dental clinic.

Osteomyelitis

Odontogenic infection via a root canal, a periodontal pocket or an extraction wound is the most common local cause of osteomyelitis of the jaws. Rarely, a fracture serves as in infection route. Haematogenous spread of an infective agent from another part of the body also occurs. A distinct type of osteomyelitis, osteoradionecrosis, occurs after therapeutic irradiation of oral and neck malignancies.

Figure 20.
An ill-defined periapical and interdental osteolytic lesion in the mandibular anterior region three weeks after onset of clinical symptoms of osteomyelitis.

Figure 21.
Chronic suppurative osteomyelitis with three sequestra (arrows). Osteolytic as well as sclerotic areas are present.

Osteomyelitis is more common in the mandible than in the maxilla. In the mandible, it occurs predominantly in the posterior parts, the ramus included, whereas in the maxilla, it is more frequent in the anterior than in the posterior parts. In the acute phase, osteolysis is not visible radiographically until one or two weeks after the onset of clinical symptoms which are: pain, fever, local lymphadenopathy, increased white blood cell count, and teeth sensitive to percussion. Numbness of the lower lip is another common sign of mandibular osteomyelitis.

The initial radiographic changes are blurring and thinning of the trabeculae and subsequent enlargement of the bone marrow spaces. Without treatment, large volumes of the bone tissue can rapidly become involved, causing loosening of the teeth (Fig. 20).

If acute osteomyelitis becomes chronic, it is frequently possible to distinguish between chronic suppurative osteomyelitis (Fig. 21) and chronic sclerosing osteomyelitis (Fig. 22), both of which have ill-defined borders. In the suppurative form, radiolucent areas alternate with sclerotic, giving the bone a “moth-eaten” appearance. This is further enhanced when sequestra develop. In chronic sclerosing osteomyelitis, radiolucent areas occur, but there is a predominance of radiopaque changes due to the formation of sclerotic bone. The bone is often enlarged through periosteal bone formation (Figs. 22, 23). Over time, the distribution of sclerotic and radiolucent areas varies, indicating disease activity.

Figure 22.
Chronic sclerosing osteomyelitis of right mandible with some osteolytic areas. Ramus is enlarged.

b

Figure 23.
a) Right mandibular molars in a young patient. The alveolar bone is unevenly sclerotic; chronic sclerosing osteomyelitis.
b) Occlusal view of the same patient. Periosteal bone formation (arrow) on the buccal side of the mandible.

Fig. 1.

Cropped panoramic radiograph of suppurative osteomyelitis at the right mandible. Osteolytic change is observed from around the molar tooth roots to the body of the mandible (arrows).

How to Diagnose Osteomyelitis

Osteomyelitis is an infection of the bone, generally caused by the Staphylococcus Aureus bacteria. This bacteria infects the bones because it travels through the blood from other infected areas. It can also come directly from a wound and travel straight to the bone. A common cause of Osteomyelitis is an open fracture, where not only the bone breaks, but the skin breaks too.

 

Instructions

1.       Perform a physical examination of the patient. Be sure to take a complete medical history and list any medications the patient is already taking. Also ask about any recent problems with the area the patient says is painful.

2.       Take a blood sample to perform a blood test to pinpoint if the patient’s white blood cell count is high, which is often a sign of infection. Look for signs of infection in the body, such as areas that are inflamed, red and warm.

3.       Send the patient for a bone x-ray. A bone x-ray can show if there is an infection in the bone, but might not be as accurate for someone who has just started complaining of pain. If the bone x-ray does not come back positive, but the patient exhibits signs of Osteomyelitis, send them for a bone scan, which gives you a more detailed view of the bone.

4.       Follow up with an MRI, if the bone scan indicates osteomyelitis. MRIs are a valuable test to run. In addition to diagnosing osteomyelitis, the MRI can also help determine how long the infection has been in the bone.

Osteomyelitis may manifest itself in acute, subacute, or chronic forms. Chronic osteomyelitis will result in variable sclerosis and deformity of the affected bone. After the age of 50, the majority of the blood supply to the mandible comes from the overlying periosteum and attached musculature, due to age and atherosclerosis-related involution of the inferior alveolar artery. With an infection of the bone, the subsequent inflammatory response will elevate this overlying periosteum, leading to a loss of the nourishing vasculature, vascular thrombosis, and bone necrosis, resulting occasionally in formation of sequestra. These become areas that are more resistant to systemic antibiotic therapy due to lack of the normal Haversian canals that are blocked by scar tissue, inflammatory exudate, and necrotic bone. At this point, not only systemic antibiotic therapy, but also surgical debridement maybe required to remove the affected bone and prevent disease propagation to adjacent areas. The relative hypoxia seen in infected bone will impair leukocyte bacterial killing, and impede fibroblastic collagen production that is required to support angiogenesis. Thus, it is not surprising that the concomitant use of hyperbaric oxygen therapy maybe beneficial in cases refractory to medical management alone or in patients with a severely compromised immune response. Generally, 20 dives (2.8-3.0 at 100% oxygen for 90 minutes) are administered preoperatively, followed by 20 dives after the debridement of necrotic tissue.

Radiographic imaging may be deceptively unremarkable in acute osteomyelitis, particularly with plain x-rays. Computed tomography (CT) scanning is the standard for evaluating the bone for sequestrum formation. Generally, one sees areas of lytic destruction and overlying periosteal reaction. It is much more common to find cortical plate disruption in the buccal plate than in the lingual plate. Technetium⁹⁹ bone scanning is often positive within 24 hours of an acute infection. Unfortunately, persistent uptake maybe present for 2 years after eradication of osteomyelitis. Gallium^-67 scanning normalizes after successful treatment of mandibular osteomyelitis.

In acute osteomyelitis, or in chronic forms without evidence of formation of sequestra, culture-driven antibiotic therapy is important to allow for disease eradication and decrease the likelihood of formation of antibiotic resistant strains resulting from inadequate subtherapeutic antibiotic therapy. Occasionally, repeated cultures may be required to allow for pathogen isolation, especially in cases of chronic osteomyelitis. Open biopsy of the bone allows for the most accurate culture results. Alpha hemolytic streptococcus, often in conjunction with oral anaerobes, is the most commonly isolated organism noted today. Although acute osteomyelitis is often adequately treated with a culture-driven 6- to 8-week course of antibiotic therapy, chronic osteomyelitis generally requires surgical debridement as well. Antibiotic therapy should be continued for 4 to 6 weeks from the date of last debridement, from resolution of the patient’s symptom complex and/or normalization of the gallium scan (if performed). Refractory osteomyelitis may benefit from the addition of hyperbaric oxygen therapy. Vancomycin or clindamycin are generally effective in the treatment of group A or B streptococci. However, as stated, culture-driven antibiotic therapy is required. With the propagation of multidrug-resistant varieties, treatment with nontraditional antibiotic regimens, such as fluroquinolones, may be required. Attention to optimal management of any underlying systemic immunocompromising conditions, such as diabetes mellitus, steroid usage, and HIV infection is important in all cases.

Clinical features, Radiographic features and treatment of Chronic Osteomyelitis of mandible

Clinical feature:
1. Site: Mandible
2. At early stage:
a. General constitutional symptoms:
• Intermittent fever
• Malaise
• Nausea, vomiting
• Anorexia
b. Pain:
• Deep seated
• Paresthesia of the lower lip

Radiology of Chronic OML• Facial cellulitis

• Trismus
• Swelling
3. Established case of OML:
a. Deep pain
b. Loosening of involved teeth
c. Pain on percussion
d. Sensitivity
e. Purulent discharge of pus
f. Regional lymphadenopathy
g. Trismus
Radiological feature:
1. In early stage, there are no findings
2. The changing begins 4-6 weeks after infection
3. In ate stage of Osteomyelitis, we find sequesterum, involucrum, scattered area, moth eaten appearance in conventional radiograph.
4. For specialized image, we do: CT scan, Radionucleido bone scan, Positron emission tomography.

Treatment:
1. Conventional treatment:
a. Complete bed rest
b. Supportive therapy:
• Nutritional support
• High protein diet
• High calorie and multivitamin diet
c. Rehydration by IV fluid
d. Blood transfusion
e. IV antimicrobial agent
2. Surgical treatment:
a. Incision and drainage   b. Extraction of the offending tooth   c. Debridement of the affected area by irrigating with H2O2 and normal saline  d. Sequestrectomy e. Decortication f. Saucerisation  g. Resection
Post operative care:
1. Continuous use of antibiotics
2. Analgesics
3. Adequate hydration
4. Complete bed rest
5. Follow up

Suppurative mandibular osteomyelitis

Suppurative mandibular osteomyelitis refers to agents that invasion of the mandible, the bone tissue as a whole, including the periosteum, cortical bone, bone marrow and the blood vessels, nerves, inflammation, alveolar abscess, periodontitis, and the third molar crown weeks go far odontogenic infection from which the highest incidence of mandibular osteomyelitis.

Disease Overview

When agents that invaded the jaw, will cause the entire jaw organizations, including the periosteum, cortical bone, bone marrow, and one of the blood vessels, nerve inflammation range of leisure, known as purulent maxillary osteomyelitis. Classification of Diseases 1 performance classification, according to the clinical pathology of suppurative odontogenic mandibular osteomyelitis lesions originating in the maxillary central cancellous bone and bone marrow, known as the Central osteomyelitis, lesions originating in the periosteum and cortical bone of the jaw around the , called the edge of osteomyelitis, according to the nature of the lesions can be divided into acute and chronic phase, the scope of the validation can be divided into localized or diffuse suppurative disease cause of mandibular osteomyelitis of up to alveolar abscess, periodontitis, third molar pericoronitis go far odontogenic infection from, followed by invasive infection due to a comminuted fracture or gunshot wound in open injury to bone by the blood circulation of sepsis or sepsis infection. this situation occurred in the maxilla of the infants and young children, very few of the infection of facial skin or oral mucosa directly affect the jaw. put the treatment of oral cancer or nasopharyngeal carcinoma, osteomyelitis common major pathogens Staphylococcus aureus bacteria, followed by Streptococcus, a few other pyogenic bacteria, stereotypes of mixed infections. pathophysiology of mandibular osteomyelitis compared with the previous mandibular osteomyelitis is more common condition than maxillary bone marrow serious, this is because the upper jaw bone dense fascia and strong muscles, present jaw infection, pus is not left around the puncture drainage poor blood supply of the mandible, infection of vascular thrombosis, it is easy to form a large sequestrum. diagnostic tests 1, details incidence and its treatment, consultation, attention to the relationship with the teeth, identify pathogen teeth. 2, with or without empyema sense of volatility, can be used to puncture confirmed suspicious when pus for bacterial culture and antibiotic sensitivity determination. fistula, exploration probes and other instruments with or without sequestrum sequestrum separation, X-ray, chronic identifying bone destruction, with or without sequestrum formation or infection of the low toxicity to the bone cortical hyperplasia. .

Clinical symptoms

Symptoms characteristic of central mandibular osteomyelitis, acute early inflammation is often restricted to the alveolar bone or bone marrow of the mandibular body, and then invasion of mandible, from the center to the edges of cortical bone and periosteum. 2. stage, patients may feel a severe toothache, pain along the trigeminal nerve distribution area for radiation lesions of the gingival mucosa hyperemia and edema, teeth percussion pain and loose, and may have gingival sulcus overflow pus or the formation of alveolar abscess , this stage of the lesion has not been timely drainage, the infection will continue to spread to the medullary cavity, can cause diffuse osteomyelitis or perforation of cortical bone formation in subperiosteal abscess, then patients with systemic poisoning symptoms became worse, and this when patients with serious manifestations of anemia, dehydration, exhaustion, body temperature increased to 39 ~ 40 ℃, blood test white blood cells increased significantly, local pain and soft tissue swelling in the affected region of the majority of teeth to loosen, some patients would be a serious concurrent disease, such as sepsis, intracranial infections, such as inflammation has not yet been brought under control, the maxilla infection can cause suppurative maxillary sinusitis and infraorbital cheek, or zygomatic, or pterygopalatine concave, temporal, concave and other regional proliferation. mandibular infection can spread to the inferior alveolar nerve caused by the lower lip numbness spread to the jaw weeks, stimulate the open jaw muscles, causing limited mouth opening, can be complicated by the jaw weeks more space infection, so that the face was seen in the swelling, and finally inflammation in the formation of blood clots within the jaw, resulting in jaw nutritional disorders and necrosis, and thus transferred to the chronic phase. 6, transferred from the acute to the chronic phase of about 2 to 3 weeks later, the pain and other systemic symptoms have begun reduced, but the mouth gums can form multiple fistula and pus. sequestrum with healthy bone will be in about a month later, new bone layer, caused by the separation of the sequestrum with healthy bone. this stage without surgical removal of involved regional fistula pus prolonged unhealed, can sometimes have a small piece of sequestrum discharged from the fistula osteomyelitis of the mandible can cause large sequestrum formation of pathogenic pathologic fracture, marginal mandibular osteomyelitis clinical features , limitations with young people, the lesions occurred, with chronic symptoms, does not appear large sequestrum. 2, occurred in young people under the jaw, the lesion is more limited spread of the infection pathway is not the first damage to bone marrow, but in the periosteum inflammation or subperiosteal abscess on the basis of the first involving the cortical bone, but also to the deep development involving the bone marrow, but rarely large sequestrum formation of the infections originated in the mandibular third molar crown Zhou Yan, can cause masseter muscle space infection subperiosteal abscess, resulting in the mandible of the ascending branch and corner Nutrition disorders of the cortical bone necrosis, showing chronic symptoms, local mild chronic inflammatory swelling and pitting edema due to masseter muscle and pterygoid muscle involvement, and limited mouth opening. pericoronitis infection if not controlled, often repeatedly made. 5, the edge of mandibular osteomyelitis after repeated anti-inflammatory medication, could easily lead to pathogen resistance, the formation of low toxicity and infection jaw inflammation.

Signs and symptoms

In particular, according to the clinical pathology of suppurative odontogenic mandibular osteomyelitis lesionsoriginating in the maxillary centralBone trabecular and bone marrow, known as the Central osteomyelitis lesions originating in the periosteum and cortical bone of the jaw around, known as the edge of osteomyelitis according to the nature of the lesions can be divided into acute and chronic phase, according to The scope of the validation can be divided into localized or diffuse. central mandibular osteomyelitis: the maxilla than the mandible more common in teeth with severe pain, persistent, and radiating pain along the trigeminal nerve distribution. teeth and adjacent teeth loose, percussion pain, vestibular groove fullness, cheek swelling. mandibular alveolar abscess, the pus is not easy worn develop into acute diffuse osteomyelitis and lack of drainage, the patients with systemic symptoms get worse, fever, chills, leukocyte, dehydration and other toxic manifestations. mandibular osteomyelitis refers to agents that invaded the jaw, causing the entire bone tissue, including periosteum, cortical bone, bone marrow and the blood vessels, nerve inflammation, Chinese medicine called ‘bone slot wind ‘or’ wear gills were sharply acute onset of high fever, increased white blood cells, can shift to the left. body poisoning, and with general malaise, headache, loss of appetite and other symptoms can occur in patients toothache, and the pain along the trigeminal nerve distribution area of ​​radiation, and can quickly spread to the adjacent teeth. the short term, there may be multiple tooth mobility, periodontal pocket pus, inferior alveolar nerve by inflammatory damage to the lower lip numbness due to the spread of inflammation to the surrounding maxillofacial swelling which can occur, such as infection spread to the masticatory muscles can be trismus such as infection control in a timely and quickly to the infraorbital, inferior temporal, the pterygopalatine concave and by the mandibular foramen caused the wing jaw space infection. systemic complications such as sepsis, and intracranial infection may also occur.

Disease etiology

Suppurative osteomyelitis of jaw up to the alveolar abscess, periodontitis, the third molar pericoronitis go far odontogenic infection from, followed by open injury due to comminuted or anger injury caused by bone invasive infection, sepsis or infections, sepsis and blood circulation more than occurred in the maxilla of infants and young children, very few of the infection of facial skin or oral mucosa directly affect the jaw. major pathogens Staphylococcus aureus, followed by Streptococcus few other pyogenic bacteria stereotypes mixed infection.

Pathophysiological

Mandibular osteomyelitis compared with maxillary osteomyelitis more common condition than the maxilla bone marrow serious, this is because the upper jaw bone is dense, and some surrounding fascia and strong muscles, present jaw infection, pus left After puncture drainage poor blood supply of the mandible, infection of vascular thrombosis, easy to form a large sequestrum.

Diagnostic tests

A detailed consultation incidence after treatment, and attention teeth identify pathogen teeth.

2, with or without empyema sense of volatility suspicious can be used for puncture confirmed. 3, pus for bacterial culture and antibiotic sensitivity determination, with or without fistula, probes and other instruments to probe whether the sequestrum sequestrum separation. 5, X-ray, the chronic phase to identify bone destruction, with or without sequestrum formation or infection of the low toxicity of the bone cortex hyperplasia type.

Disease Prevention

No special

Safety Tips

 1, the disease mostly occurs in the infant’s maxillary marginal mandibular osteomyelitis: more common in young people, the acute phase is difficult to find common chronic phase 2, the timely treatment of the crown Zhou Yan, the periapical Yandeng odontogenic infection to prevent occurrence of mandibular osteomyelitis. has formed should be a thorough treatment to avoid to chronic osteomyelitis, in the acute phase.

 

Treatment programs

 Acute systemic antibiotics, local incision and drainage or removal of loose teeth, diffuse patient performance Decline thirsty, systemic poisoning, severe anemia, in addition to general supportive therapy, but also a small amount of multiple transfusions and enhance systemic resistance to the chronic phase sequestrum curettage and extraction of teeth lesions mainly purulent maxillary bone marrow after a course of inflammation, and generally can be divided into two phases of acute and chronic phase. to The sequestrum began to take shape used to be collectively referred to as the acute phase by the onset, generally about 3 to 4 weeks if the infection fails to be completely controlled in the acute phase, into the chronic phase. must be used in sufficient quantities and effective antimicrobial treatment. use drugs in order to control the infection in the acute phase, use of antibiotics against Staphylococcus aureus and mixed infections, the other based on bacterial culture and susceptibility to choose effective antibiotics. In the initial stages of infection, but also with the physical therapy. When the infection into the suppuration of Early incision and drainage. wait for his condition slightly eased, the mouth opening slightly improved, should try to extraction, so that the pus from the socket to get the drainage, to prevent the spread of infection in the bone of acute suppurative osteomyelitis oncoming acute, severe illness, can cause blood and brain complications, and therefore close observation, as early as the appropriate emergency treatment of acute systemic application of antibiotics, local incision and drainage removal of loose teeth mainly diffuse patient performance decline thirsty, systemic poisoning, severe anemia, in addition to general supportive therapy, but also a small amount of multiple transfusions, enhanced systemic resistance to the chronic phase to sequester scrape and lesions in tooth extraction based. 1, the disease occurred in the maxilla of infants and young children. marginal mandibular osteomyelitis: more common in young people, the acute phase is difficult to find common chronic phase. and timely treatment of pericoronitis, periapical go far odontogenic infection, on the prevention of mandibular osteomyelitis. such as formation of osteomyelitis in the acute phase should be a thorough treatment so as not to become chronic. acute phase of infection control, enhance the body resistance-based, anti- infection drugs should be selected according to the sensitivity of pathogenic bacteria. mandibular osteomyelitis more mixed bacterial infection, it is appropriate in order to use broad-spectrum antibiotics. In addition, as has been clear for odontogenic infection, early removal of the lesions teeth in order to facilitate drainage, to avoid more extensive bone destruction. case of subperiosteal abscess or infection jaw week gap, it is timely incision in chronic phase, the lesion has been limited or has been sequestrum formation, while the surgical treatment of the main supplemented by drug treatment. marginal mandibular osteomyelitis are generally large sequestrum formation, mostly for the proliferation of subperiosteal cortical bone, the texture is more loose, and should be completely clear, pus foci of cortical bone surface where infection and the granulation organizers should be scraping, postoperative use of antibiotics to control infection in 7 to 14 days to avoid relapse.

Clinical manifestations

Clinical presentation of osteonecrosis of the jaw. (A) Typical lesion of osteonecrosis of the jaw showing exposed infected bone involving the mylohyoid ridge. (B) Osteonecrotic bone below a dental implant. (C) Spontaneous exfoliated teeth with underlying exposed dead bone. (D) Operative picture showing well-demarcated dead bone involving the whole alveolus. (From Badros A, Weikel D, Salama A, et al. Osteonecrosis of the jaw in multiple myelomoa patients: clinical features and risk factors. J Clin Oncol 2006;24:948; with permission. Copyright © 2006 by American Society of Clinical Oncology.)

Suppurative mandibular osteomyelitis from the clinical course of disease, pathogens, routes of infection and lesions involving the siteCan be manifested as acute and chronic stages, and often divided into two types of central and edge (a central mandibular osteomyelitis is usually odontogenic inflammation spread to the bone marrow, spread to the bone from the jaw center around cortex and periosteum in the bone marrow of early acute inflammation is often restricted to the alveolar bone or the mandibular body, patients feel severe toothache, pain along the trigeminal nerve distribution of radiation lesions of the gingival mucosa hyperemia and edema, teeth that is, obvious pain and loose, and can gingival sulcus septic overflow or the formation of alveolar abscess. acute phase has not been timely drainage, infections continue to spread to the medullary cavity can cause disseminated osteomyelitis or perforation of cortical bone formation in subperiosteal abscess. exacerbate symptoms of systemic poisoning at this time, the body temperature to 39 ~ 40 ℃, blood test white blood cells increased significantly, local pain and soft tissue swelling the affected regions the majority of loose teeth. If the inflammation is not brought under control, the maxillary infection can cause purulent maxillary sinusitis and infraorbital, buccal, zygomatic or pterygopalatine concave, temporal concave and other areas to spread. mandibular infection can spread to the inferior alveolar nerve caused by the lower lip numbness spread to the jaw week to stimulate the open jaw muscles, causing limitation of mouth opening can be complicated by the infection of the jaw week more than the gap, so that the face was seen in the swelling, and finally inflammation in the formation of blood clots within the jaw, resulting iutritional disorders of the jaw and necrosis, and thus transferred to the chronic phase. turn by the acute phase into the chronic phase of about two to three weeks later, pain and other systemic symptoms began to ease, but the mouth gums can form more than one fistula and pus out about a month later, the sequestrum with healthy bone between the new bone layer, causing the separation of the sequestrum with healthy bone without surgical removal of involved regional fistula pus prolonged unhealed, can sometimes have a small piece of sequestrum discharged from the fistula. osteomyelitis of the mandible can cause large piece of dead bone formation, can be pathogenic pathological fractures appear bite (occlusal disorders. Suppurative mandibular osteomyelitis (two marginal mandibular osteomyelitis spread of the infection pathway is not the first damage to bone marrow, but the basis of periostitis or subperiosteal abscess the first involving the cortical bone occurred in adolescents mandible, more limited lesions, infections originated in the mandibular third molar pericoronitis inflammation, caused by the masseter muscle space infection and subperiosteal abscess, resulting in lower jaw of the ascending branch and the corner of cortical bone nutritional barriers necrosis. clinical manifestations of chronic symptoms, the symptoms of the acute phase of infection and jaw week gap coexist but often overlooked in local mild chronic inflammatory swelling and pitting edema due to the chewing muscles and wing muscle involvement and limited mouth opening. lesions confined to the cortical bone, or to the deep development involving the bone marrow, but rarely large sequestrum formation. pericoronitis infections if not controlled, often repeatedly made by anti-inflammatory drugs after treatment, could easily lead to pathogen resistance, the formation of low toxicity and infection, no obvious purulent and sequestrum formation process and significant cortical hyperostosis, sclerosis and periosteal thickening of cortical bone lysis little part the formation of small abscess and granulation tissue. cortical hyperplasia of the mandibular ascending branch of the Ministry of mandibular angle can cause facial asymmetry, X-ray showed obvious subperiosteal hyperostosis.

Osteomyelitis is an infection of the bone. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including:

• An open injury to the bone, such as an open fracture with the bone ends piercing the skin.
• An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis).
• A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.
• Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.
• A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

Osteomyelitis affects about two out of every 10,000 people. If left untreated, the infection can become chronic and cause a loss of blood supply to the affected bone. When this happens, it can lead to the eventual death of the bone tissue.

Osteomyelitis can affect both adults and children. The bacteria or fungus that can cause osteomyelitis, however, differs among age groups. In adults, osteomyelitis often affects the vertebrae and the pelvis. In children, osteomyelitis usually affects the adjacent ends of long bones. Long bones (bones of the limbs) are large, dense bones that provide strength, structure, and mobility. They include the femur and tibia in the legs and the humerus and radius in the arms.

Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including:

• People with diabetes
• Patients receiving hemodialysis
• People with weakened immune systems
• People with sickle cell disease
• Intravenous drug abusers
• The elderly

Symptoms of osteomyelitis

The symptoms of osteomyelitis can include:

• Pain and/or tenderness in the infected area
• Swelling and warmth in the infected area
• Fever
• Nausea, secondarily from being ill with infection
• General discomfort, uneasiness, or ill feeling
• Drainage of pus through the skin

Additional symptoms that may be associated with this disease include:

• Excessive sweating
• Chills
• Lower back pain (if the spine is involved)
• Swelling of the ankles, feet, and legs
• Changes in gait (walking pattern that is a painful, yielding a limp)

Diagnosing osteomyelitis

To diagnose osteomyelitis, the doctor will first perform a history, review of systems, and a complete physical examination. In doing so, the physician will look for signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness. The doctor will also ask you to describe your symptoms and will evaluate your personal and family medical history. The doctor can then order any of the following tests to assist in confirming the diagnosis:

• Blood tests: When testing the blood, measurements are taken to confirm an infection: a CBC (complete blood count), which will show if there is an increased white blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and measures inflammation in the body.
• Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and then placed into an environment that will support the growth of bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and tested against different antibiotics in hopes of finding the most effective treatment.
• Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media.
• Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism.
• Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive material, is injected intravenously into the body. If the bone tissue is healthy, the material will spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material and show an increased concentration of the radioactive material, which can be seen with a special camera that produces the images on a computer screen. The scan can help your doctor detect these abnormalities in their early stages, when X-ray findings may only show normal findings.

Treating and managing osteomyelitis

The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease as soon as possible.

Drainage: If there is an open wound or abscess, it may be drained through a procedure called needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over often-unreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are drained by open surgical procedures.

Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone. The dosage and type of antibiotic prescribed depends on the type of bacteria present and the extent of infection. While antibiotics are often given intravenously, some are also very effective when given in an oral dosage. It is important to first identify the offending organism through blood cultures, aspiration, and biopsy so that the organism is not masked by an initial inappropriate dose of antibiotics. The preference is to first make attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to starting antibiotics.

Splinting or cast immobilization: This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children, although motion of joints after initial control is important to prevent stiffness and atrophy.

Surgery: Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out. In the case of spinal abscesses, surgery is not performed unless there is compression of the spinal cord or nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics. After surgery, antibiotics against the specific bacteria involved in the infection are then intensively administered during the hospital stay and for many weeks afterward.

With proper treatment, the outcome is usually good for osteomyelitis, although results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of chronic osteomyelitis can be so resistant to treatment that amputation may be required; however, this is rare. Also, over many years, chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the chronic drainage site, should be evaluated by a physician experienced in treating chronic bone infections. Because it is important that osteomyelitis receives prompt medical attention, people who are at a higher risk of developing osteomyelitis should call their doctors as soon as possible if any symptoms arise.

What is jaw osteomyelitis?

Osteomyelitis is an inflammatory condition of bone that begins from an infection within the bone cavity. The infection is generally bacterial in origin and is most commonly caused by Staphylococcus aureus. Osteomyelitis can affect any bone in the body but has a predilection towards long bones and the jaw bones. Osteomyelitis affecting jaws is generally associated with dental complications. It was once a very serious disease with life threatening complication but these days it can be adequately treated with prompt medical intervention.

Jaw Osteomyelitis Symptoms

Osteomyelitis can be acute, subacute or chronic iature. The acute form of osteomyelitis of the jaws generally affects the mandible, the lower jaw. Common symptoms include fever, malaise, nausea, vomiting and dehydration. The affected area of jaws is associated with continuous, intense and deep bony pain. The lower lip is associated with tingling sensations or loss of sensations.

Acute Jaw Osteomyelitis

Facial cellulitis and a hard swelling over the affected area develops in acute forms of the disease. The teeth become tender on percussion. Difficulty in jaw opening is often present. A pus discharge into the oral cavity and over the skin through an opening is present in established cases of osteomyelitis. It may also be associated with a fetid odor.

Chronic Jaw Osteomyelitis

The chronic forms of osteomyelitis present with pain and tenderness over the affected area. Pain is minimal in such cases. It may also be associated with bony and overlying soft tissue wounds with firm to hard consistency. In chronic osteomyelitis the bone has a thickened, woody characteristic appearance. The teeth present in the region of the infection often become loose.

Jaw Osteomyelitis Causes

Acute osteomyelitis of the jaws is caused by pyogenic organisms. The chronic form occur secondary to untreated or incompletely treated acute infections. The commonly involved bacteria are Staphylococcus aureus but Streptococcus pyogenes and Spirochetes are also responsible.

The most common causes of infections are as follows :

• Dental infections including dental abscess ,periodontal disease, pericoronitis and infected cysts and tumor.
• Local traumatic injuries.
• Peritonsillar abscess (quinsy).
• Furuncle of skin.
• Blood borne infections.

Risk Factors

The risk factors for developing osteomyelitis are :

• Lowered immunity.
• Malnourished children.
• Systemic disease including diabetes and leukemia.
• Acute illnesses such as influenza, scarlet fever and pneumonia.
• Radiation to the head and neck.

Treatment of Jaw Osteomyelitis

The treatment includes antibiotic therapy, supportive masures, complete bed rest and surgery if necessary.

• Antibiotics that are generally prescribed include penicillins, penicillinase-resistant penicillins, clindamycin, cephalosporins, metronidazole and erythromycins.
• In acute forms of the disease analgesics or sedation may be given to reduce the pain.
• Intravenous fluids are administered to avoid dehydration.
• Blood transfusions may be required in cases with low hemoglobin levels.
• High protein diet and nutritional support is also recommended.
• Hyperbaric oxygen therapy is also very useful in treating osteomyelitis. It involves intermittent inhalation of 100% oxygen, humidified under pressure.

Surgery

Surgical procedures include :

• extraction of the offending tooth
• incision and drainage of an existing abscess

The infected portion of the bone can be surgically removed or entire segment of the jaw can be excised according to the extent of the disease. Immediate or delayed jaw reconstruction is carried out subsequently.

Primary Chronic Osteomyelitis Associated with Extraction of a Periodontally Involved Tooth

INTRODUCTION

Osteomyelitis (OM) is an inflammatory condition of bone that involves the medullary cavity and the adjacent cortex. It occurs more frequently in mandible than in the maxilla and is often associated with suppuration and pain.1 The osseous spaces are usually filled with exudates that can lead to pus formation. Chronic osteomyelitis can be the result of a non-treated acute mild inflammation or emerge without a precursor. When osteomyelitis occurs in the mandible, it is usually more diffused and widespread.1-6 Clinical examination alone is often enough to diagnose chronic mandibular osteomyelitis due to the progression of this disease and suppuration.1,2 In cases of chronic osteomyelitis, a radiolucent circumscribed image can be seen encapsulating central radiopaque sequestra, as well as radiopacities of the surrounding bone due to a local osteogenic reaction.7 Patients who present active chronic osteomyelitis usually require long-term use of antibiotic therapy and surgical intervention.7 Treatment requires both antibiotic therapy and surgical debridement, meaning the necrotic bone must be completely removed until the underlying bone starts bleeding.7 Although most cases of OM of the jaws result from dental origins, other sources of infection are possible.2 Although primary OM following extraction of periodontally involved teeth is rare, it is, however, of concern to both the patient and dentist. The following case report describes the presentation of OM and how it was managed.

CASE REPORT

A 62-year-old woman referred to our clinic for treatment of chronic infection and pain following extraction of the left mandibular second molar under local anesthesia by her general dentist. She was in good general health and did not have a history of drug use. Her pre-extraction radiographic examination confirmed the presence of a deep distal periodontal pocket (Figure 1). She then developed pain, chronic infection, and discharge following the extraction (Figure 2). She returned to her general dentist who prescribed amoxicillin 500 mg every 8 hours for 10 days. After multiple visits to her dentist, and no abatement of her symptoms after 5 months, she was referred to our clinic.

Intraoral clinical examination revealed that the socket of the left mandibular second molar tooth had chronic infection and a malodorous discharge. A sample of this fluid was collected for culture and antibiotic sensitivity. Culture was positive for non-A non-D streptococci sensitive to cephalexin. Radiographic examination confirmed the presence of a sequestrum in the socket (Figure 3).

Considering the clinical and radiographic presentation, a diagnosis of chronic osteomyelitis was made and the patient was scheduled for surgery. After general anesthesia, preparation, draping and packing the oropharynx; a flap was reflected and the sequestrum was removed with a curette. The socket was cleaned and irrigated. Nonvital necrotic bone was shaved using a round bur until vital bone was apparent (confirmed clinically by bone bleeders). The lesion was sent to the pathology laboratory and their report confirmed the diagnosis of chronic osteomyelitis. The patient was given cephalexin and metronidazole 500 mg every 6 hours for 2 weeks. A radiograph was that taken 3 months postoperatively showed bony consolidation of the socket (Figure 4). The patient has been symptom-free since the completion of the surgical treatment and antibiotic regimen.

DISCUSSION

Osteomyelitis may result from the direct extension of pulpal or periodontal infection without the formation of a granuloma or from acute exacerbation of a periapical lesion. It may also occur following penetrating trauma or various surgical procedures. Extension of the infection into adjacent soft tissue and fascial spaces is common, and often the presenting clinical symptoms are swelling, pain and suppuration. Sequelae to transcortical extension of the inflammatory process can include cortical destruction, fistulization and periosteal reaction. These changes can be evaluated by imaging techniques.5

Histopathology. The bone pathology presents various forms, depending on the virulence of the infecting microorganism, the host capacity of effective immune response and the kind of reaction of the periosteal and osseous tissues. Chronic osteomyelitis histopathology depicts irregular fragments of devitalized bone surrounded by dense fibrous tissue heavily infiltrated by plasma cells, lymphocytes, and only a few granulocytes (Figure 5).

Imaging. Appropriate evaluation of radiographic types of osteomyelitis is necessary for treatment planning. Kazunori Yoshiura6 classified mandibular osteomyelitis into four basic patterns, as lytic, sclerotic, mixed and sequestrum patterns. Our case presented with the latter pattern. In some cases computerized tomography or scintography may be necessary.1

Presentation. Patients can have swelling of the face, tenderness and pain (localized), draining sinus tracts, suppuration, tooth loss, possible necrotic bone fragment formation, and a low-grade fever. New bone and oral mucosa will occasionally regenerate beneath the sequestra, probably because of activation of periosteal osteoblasts. According to Reinert,6 clinical examination alone can be enough to diagnose mandibular chronic osteomyelitis, particularly at the onset of the disease. The radiographic characteristics of the osteomyelitis presented were a radiolucent area circumscribing a central bone sequestrum and radiopacity in the surrounding bone. Due to the characteristics of the pathology and the clinical history, there was no need for other exams.

Predisposing factors. Viral fevers (eg, measles), malaria, anemia, malnutrition, and use of tobacco are found to contribute to the development of osteomyelitis.

Management. Treatment goals include reversal of any predisposing conditions, long-term antibiotic therapy. Antibiotic therapy alone is not enough for the treatment of osteomyelitis, since the devitalized osseous tissue in combination with the capsule of the surrounding fibrous connective tissue protects the microorganisms from the drug action. Corticotomy can be used as treatment, and if not effective, bone resection can be done as a more radical alternative. However, aggressive treatment may cause loss of function, exposure of the inferior alveolar nerve and problems regarding the reconstruction.7 High doses of antibiotics should accompany any aggressive surgical treatment. Some authors feel that penicillin G is the medication of choice, followed by clindamycin.7 Since most of the osteomyelitis infections are polymicrobial oral flora (primarily facultative streptococci, Bacteroides spp, Peptostreptococcus, and Peptococcus), antibiotic treatment includes penicillin, metronidazole, and clindamycin. Operative interventions such as sequestrectomy, decortication, removal of nonviable bone (ie, mandibulectomy or maxillectomy), and dental extractions, are also needed. A wide incision to remove all the diseased tissue, as well as primary closure of the surgical wound is performed to ensure a successful operation.

Figure 1. Pre-extraction radiograph confirmed the presence of a deep periodontal pocket distal to the left lower molar tooth.

Figure 2. Postextraction radiograph showing the nonhealing socket.

Figure 3. Radiograph depicting the presence of a sequestrum in the socket.

Figure 4. Radiograph, at 3 months postoperatively, shows bony consolidation in the socket.

Figure 5. Chronic osteomyelitis histopathology (H&E x 400). Note the irregular fragment of devitalized bone. This is surrounded by dense fibrous tissue which is infiltrated heavily by lymphocytes, plasma cells, and a few granulocytes.

Mandibular osteomyelitis

 

     

[Introduction]

Overview: mandibular suppurative osteomyelitis can be divided into, specificity, radioactive and other types. Clinically, the most common pyogenic osteomyelitis jaw.

[Cause]

mandibular osteomyelitis is caused by what the?

mandibular osteomyelitis main sources of infection in three ways, namely tooth-borne, injury and blood-borne. Blood-borne mandibular osteomyelitis is less common, occurring mainly in children. The most common odontogenic mandibular osteomyelitis, accounting for 90% of all mandibular osteomyelitis. China due to medical conditions improve, the incidence rate has dropped significantly. Common odontogenic mandibular osteomyelitis, which is the mandible cortical bone bone density, muscle hypertrophy and around the fascia attached to the compact, easy to puncture the drainage canal accumulation of pus and other factors.

[Symptoms]

What are the early symptoms of Mandibular osteomyelitis?

(a) acute Mandibular osteomyelitis

rapid onset, systemic symptoms. Sense of pathogen local first tooth pain, and rapid extension of the adjacent teeth, causing pain and diffuse to the ipsilateral temporal. The corresponding parts of the facial swelling, gums and vestibular swelling, loose teeth more affected areas. Since periodontal pus often overflow. Mandibular osteomyelitis, due to masticatory muscle involvement, often with varying degrees of limitation of mouth opening. Inferior alveolar nerve involvement, may have affected the lower lip numbness. Maxillary osteomyelitis more common iewborns, infants, often the source of blood-borne infection. The local performance of the Ministry of significantly inferior orbital swelling, and often cause the eye until the eye could not open. The latter can, including canthus, nasal and oral puncture septic overflow.

(b) of chronic Mandibular osteomyelitis

acute maxillary osteomyelitis who fail to complete treatment, can be converted chronic. Common reason is simply the use of conservative medical treatment, pus worn on their own, poor drainage. During chronic maxillary osteomyelitis, most acute symptoms subside, have obvious symptoms, pain significantly reduced. Local fibrosis, swelling, stiff. Fistula, often overflow pus, discharge even small sequestrum. Lesions of multiple loose teeth, gum abscess overflow gap. When the lower body resistance or poor drainage can be acute. Such as delays in the course of time, can cause weight loss, anemia, physical weakness.

[Diet]

mandibular osteomyelitis ate?

therapeutic mandibular osteomyelitis (The following information is for reference only, details need to consult a doctor)

1, Daphne 15 g, 3 eggs, boil eggs with cooked, fresh eggs to the soup. 1 day, taken fasting, pediatric dosage reduce it.

2, wax gourd 500 grams, mussels 25 grams, 50 grams of mushrooms. To sub-cut melon, with mussels, mushrooms together spoil the broth.

3, cucumber 500 grams. Salted cucumber slices for 15 minutes, squeeze the water into the amount of sugar, vinegar mixed with food.

4, broiler 1, Panax 15 grams. Broiler hair removal to debris, 37 into the abdominal chicken, add wine, salt, ginger and other spices after the stew cook until the chicken when you can Decoction and fresh chicken Sulan.

5, wax gourd 500 grams tomatoes 200 grams. Peeled and diced melon, tomato slices, both with the soup, add salt, MSG seasoning.

mandibular osteomyelitis in patients with eating what does a body good?

1, the diet should be light.

2, eat more fresh fruits and vegetables.

3, eat more alkaline foods, alkaline foods, such as: tea, cabbage, persimmon, cucumber, carrots, spinach, cabbage, lettuce, taro, seaweed, citrus, figs, watermelon, grapes, raisins, chestnut, coffee, wine, and so on. Alkaline foods: tofu, peas, soybeans, green beans, bamboo shoots, potatoes, mushrooms, mushrooms, rape, pumpkin, tofu, celery, sweet potato, lotus root, onion, eggplant, pumpkin, carrots, milk, apples, pears, bananas, cherries and so on.

mandibular osteomyelitis patients what to eat is unhealthy?

1, eat fatty foods Hun , non-digestible food.

2, eat spicy food, such as pepper.

3, avoid alcohol and tobacco.

[Prevention]

mandibular osteomyelitis should be how to prevent?

health tips

1, for the prevention of radiatioecrosis and osteomyelitis of the jaw occurred, to take appropriate preventive measures.

2, before radiotherapy to eliminate both inside and outside the mouth all foci. full-mouth scaling; removal of incurable Bingya; treatment still retained dental caries, periodontal Bingya; remove the existing metal dentures in the mouth; dentures to be a period of time after termination of radiotherapy and then wear line, to avoid causing mucosal injury.

3, radiation therapy, the application of non-irradiated zone barrier material to be isolated; mouth ulcers, local antibiotic ointment applied to prevent infection in radiation therapy should be to strengthen the protection of non-radiation field organization, the organization, especially to reduce the radioactive teeth, jaw injury.

4, after radiation therapy , in the event of odontogenic inflammation, surgery or tooth extraction must be to minimize the surgical injury; surgery before and after effective antibiotics should be used to control secondary infection in radiation therapy, attention to oral hygiene, regular inspection, timely filling of dental caries, to avoid radiation therapy after three years in the extraction, in order to avoid radioactive maxillary osteomyelitis, such as teeth must be removed, and should try to reduce surgical trauma, the use of an appropriate amount of antibiotics to control secondary infection.

[Treatment]

mandibular osteomyelitis treatment considerations?

for the prevention of radiation necrosis and osteomyelitis of the jaw occurred, to take appropriate preventive measures. According to the nature of the tumor to select the appropriate radiation type, dose and radiation field. Inside and outside the mouth before radiotherapy to eliminate all foci. Full-mouth scaling; removal of incurable Bingya; treatment still retained dental caries, periodontal Bingya; remove the existing metal dentures in the mouth; dentures to be a period of time after termination of radiotherapy re-wear, to avoid causing mucosal injury. Radiotherapy for non-application of barrier material to be irradiated zone isolation; mouth ulcers, local antibiotic ointment applied to prevent infection. After radiation therapy, in the event of odontogenic inflammation, surgery or tooth extraction must be carried out, should minimize the surgical injury; before and after surgery should be the use of effective antibiotics to control secondary infection.

mandibular osteomyelitis Chinese medicine treatment methods

No information

mandibular osteomyelitis Western medicine treatment

treated pericoronitis, periapical dental sources go far infection, osteomyelitis of the jaw to prevent the occurrence of positive significance. Such as osteomyelitis has been formed, in order to avoid a thorough treatment of the acute phase should be chronic.

systemic treatment of acute maxillary osteomyelitis and cellulitis jaw the same week, mainly to enhance the body’s resistance to drugs to control infection (metronidazole, spiramycin). Treatment focuses on timely local incision and drainage, removal of pathogenic teeth.

chronic mandibular osteomyelitis should be efforts to improve patient body condition, maintaining unobstructed drainage, timely removal of pathogenic teeth to remove lesions, scaling or removal of sequestrum.

[Check]

mandibular osteomyelitis should be how?

detailed history, partial inspection, possible X-ray examination to confirm the diagnosis.

white blood cell count was elevated, a larger proportion of neutrophils. Abscess has formed, the needle can be removed from the Abscess pus center.

[Confused]

mandibular osteomyelitis and the diseases easily confused?

chronic phase of the X-ray diagnosis in maxillary sinus cancer and should be noted, with the central mandibular carcinoma should be differentiated, proliferative type of marginal bone osteomyelitis should be with osteosarcoma and ossifying fibroma and other similar identification, where necessary, for biopsy.

Infant maxillary osteomyelitis

infants and young children with acute maxillary osteomyelitis are infection, the most common pathogen was Staphylococcus aureus. Routes of infection are: from the mother’s infection, blood-borne infections, such as local infection spread directly. Damage caused by forceps delivery, reproductive tract infections, umbilical cord infection, nipple and sucking dirty pacifier when artificial feeding, sucking action may damage gum infection. Cavernous maxillary bone is extremely rich in blood vessels, is easy to cause disease.

prognosis: early use of effective antibiotic treatment may be cured. However, if treatment is not timely or inadequate treatment, can produce a variety of complications, such as maxillofacial fistula, brain abscess, sepsis, etc.

Osteomyelitis

Definition

Diagnosis

Treatment

Prognosis

Rehabilitation

Source: Medical Disability Advisor

 

Complications

Source: Medical Disability Advisor

 

Return to Work (Restrictions / Accommodations)

Source: Medical Disability Advisor

 

Failure to Recover

Infected fractures with or without bone loss

1. Diagnosis

Definition

Open fractures can generally be regarded as contaminated. Since fractures in the dentate area have communication with the oral cavity, these are considered open fractures.
Infections with clinical relevance show swelling, pain, fever, reddening, and secretion of pus. In the case of acute infection radiographic signs can be absent. Chronic cases exhibit the typical signs of osteomyelitis.

Special conditions influencing adequate internal fixation
Instability produces and maintains the infectious process.

Osteosynthesis of an acutely infected fracture or pseudarthrosis must be a safe procedure. Under these conditions, high rigidity (absolute immobility) is mandatory. Therefore the locking reconstruction system 2.4 is recommended. It is important not to place any screws into the infected bone area which must be spared from screw insertion. The reconstruction plate functions as a bridging device. Large areas of infected or necrotic bone require curettage and either immediate or delayed cancellous bone grafting. Antibiotic therapy alone does not eliminate the infection as long as the fracture is unstable.

Clinical findings
Fractures in the dentate area are regarded as open fractures because the gingiva is usually lacerated. These fractures are contaminated. An acute infection is not reflected in the x-ray examination. In chronic cases the bone becomes infected exhibiting the typical clinical and radiographic signs of osteomyelitis.

In addition there will be inflammatory signs such as swelling, pain, fever, reddening, and secretion of pus.

Clinical photograph showing an infected fracture between the first and second molar. The pericoronal gingiva of the second molar contains pus and the swelling fills the vestibular sulcus.

Imaging

OPG confirming the clinical diagnosis of an infected fracture site in the posterior mandibular body with radiolucency around the second molar and an extended fracture zone containing several bone sequestra.

PA view of the same case.

CT scans of the same patient detailing the condition of the fracture zone.

Additional considerations

Patients with infected fractures often present a constellation of problems:

• Noncompliance
• Alcohol addiction
• Drug abuse
• Self-neglect and social deprivation
• Imprisonment
• Dementia

Medical risk factors:

• Chronic corticoid medication
• Immune deficiency
• Diabetes mellitus
• Osteopathy

2. Principles

Formal pathogenesis

A predilection zone for infected fractures is the posterior mandibular body or the angle region. Contributing factors in this area are due to the occurrence of impacted or partially impacted wisdom teeth. The chronic infection leads to osteomyelitis with inflammatory resorption and sequestration of the bone in the proximity of the fracture line.

The current concept is that the infection and osteomyelitis are propagated by the instability and mobility of the fracture fragments.

When dealing with osteomyelitis, the infected fracture will be debrided and leave the patient with a defect fracture situation.

If the bony defect extends throughout the entire fracture, grafting will be necessary.

Choice of implant

Since the rigidity of large plates is defined by the number and diameter of the inserted screws, it is recommended to use reconstruction plates compatible with large diameter screws only, ie, 2.4 or 3.0 mm screws.

The span of the plate has to cover such a length that at least three screws on either side of the defect can be inserted into intact bone. Very often, with large span defects, it is advisable to have four or more screws on either side of the defect.

3. Sequestrectomy and debridement

Clearing of the infected area

After wide exposure of the outer bony surface the infected area must be cleared of any granulation tissue.
The extent of the exposure must anticipate the application of a large reconstruction plate allowing for the placement of at least three screws on either side away from the defect.

Sequestrectomy

Remove the dead bone (sequestra) and decorticate the bony surfaces of the fractured ends.

Smoothing bony edges

Sharp bony edges should be burred away. The remaining bone surfaces should have bleeding patches to make sure that the vascularization is maintained.
This will define the size of the eventual defect.

The mandibular nerve should be preserved, if not irreversibly damaged by the chronic infectious process.

Tooth and sequestra removed.

4. Load-bearing osteosynthesis

MMF and preliminary fragment fixation

The tooth bearing distal part of the fracture is secured via MMF. The condyle bearing part is positioned arbitrarily by pushing the condyle into the fossa and a small (adaptation) plate is applied onto the superior border of the defect in order to maintain the position of the fragments while the reconstruction plate is adapted and secured.

Contouring the plate

The load-bearing bridging plate is contoured to the lower border with the help of a malleable template.

The contour of the plate must match the template in all three dimensions.

Plate fixation

The bridging plate is firmly applied to the bone with plate forceps and the screws are inserted in the usual manner, starting with the screws closest to the defect zone.

Option: remove adaptation plate
After all screws are inserted, optionally, remove the adaptation plate at the superior border of the mandible.

Occlusion check

Load-bearing osteosynthesis is stable and cannot be influenced postoperatively using elastic tractions. Therefore, the occlusion must be checked after applying the plate. If it does not fit it must be decided whether the occlusion can be corrected by minimally grinding the teeth or repositioning of the bone and plate. The revision of the osteosynthesis may be difficult because of reduced quality of the bone and reduced bony buttressing.

Removal of arch bars
Usually, this type of fracture occurs in compromised or noncompliant patients. Therefore, one might consider removal of all MMF appliances prior to intraoral wound closure (at the tooth extraction site). This can facilitate oral hygiene.

5. Intraoral plastic soft-tissue coverage

The intraoral mucoperiosteum is closed using the envelope technique with a flap derived from the lateral vestibule.
This is done prior to any bone grafting in order to separate the defect from the oral cavity.

6. Same stage bone grafting

Bone harvesting

If immediate bone grafting is desired, bone is harvested from the anterior iliac crest or the tibial head according to preference and the amount of bone graft needed.

In this case a corticocancellous piece and cancellous chips were taken from the inner table of the iliac crest.

The corticocancellous piece was shaped approximately to the size of the defect. Holes were drilled to increase the bony surface in order to enhance revascularization.

Cancellous chips were harvested to augment and fill in the defect.

Applying the bone graft

All bone grafts are inserted through the external approach.
The shape of the corticocancellous bone graft is checked and introduced into the defect.

The remaining dead space is filled with cancellous chips which are further used to augment the area.

7. Extraoral wound closure

The use of suction drain is at the discretion of the surgeon. The external wound is closed in layers.

8. Completed osteosynthesis

Panoramic x-ray showing the plate osteosynthesis bridging the defect zone in the left posterior mandibular body.

Note: there are three screws on each side of the defect and these are placed away from the fracture. The defect zone appears opaque because of the bone graft.

A nasogastric tube is used to feed the patient to enhance intraoral hygiene.

9. Aftercare

If arch bars or MMF screws are used, they may be removed at the conclusion of surgery or may be maintained for several weeks at the discretion of the surgeon.
Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken at the 4–6 week interval.
It will be necessary to see the patient after approximately 1 week to assess the stability of the occlusion. In an infected mandibular fracture, the aftercare has to include the observation of a number of factors including the special wound situation, the general health condition (nutritional status, diabetes, and particular medication), psychosocial status, economical situation and specific local regimens. The surgeon must also evaluate patient response to the current antibiotic regimens and check for systemic parameters (for example, CRP, white cell blood count, erythrocyte sedimentation rate). Patients will have to be re-examined periodically to rule out recurring signs of infection. At each visit, the surgeon must evaluate patient ability to perform adequate oral hygiene and wound care. It may be necessary to provide additional instruction to assure appropriate hygiene and wound care.

If a malocclusion is detected, the surgeon must ascertain the etiology of it (using the appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to inadequate reduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery.
Follow-up appointments are at the discretion of the surgeon, and will also depend on the stability of the occlusiooted on the first visit. If a malocclusion is noted and treatable by using training elastics, at weekly appointments to determine the progression are recommended.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure thaormal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be takeot to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.