|Year : 2020 | Volume
| Issue : 4 | Page : 411-413
Osteomyelitis of maxilla: An unusual case
SriMallika Dasam1, Tatapudi Ramesh1, Moturi Kishore2, Ravikanth Manyam3
1 Department of Oral Medicine and Radiology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
2 Department of Oral Surgery, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
3 Department of Oral Pathology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
|Date of Submission||17-Apr-2020|
|Date of Decision||17-Oct-2020|
|Date of Acceptance||24-Oct-2020|
|Date of Web Publication||28-Dec-2020|
Dr. SriMallika Dasam
Department of Oral Medicine and Radiology, Vishnu Dental College, Bhimavarm - 534 202, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Osteomyelitis of facial bones is a common condition. It tends to occur more commonly in the mandible than in the maxilla as the maxilla has collateral blood flow, a thin cortical bone, which makes it less prone to infections. We report an unusual case of maxillary osteomyelitis involving the left half of the maxilla in a 43-year-old, systemically healthy male with a literature review. Intraoral examination revealed exposed denuded bone in the left maxillary region. Radiograph investigations confirmed the diagnosis of osteomyelitis of the left maxilla.
Keywords: Cone beam computed tomography, denuded bone, hemimaxillectomy, osteomyelitis
|How to cite this article:|
Dasam S, Ramesh T, Kishore M, Manyam R. Osteomyelitis of maxilla: An unusual case. J Indian Acad Oral Med Radiol 2020;32:411-3
| Introduction|| |
Osteomyelitis in oral and para oral structures is one complications of the trauma, or a consequence of odontogenic infections, is rarely seen in the maxilla. It occurs more commonly in the mandible than in the maxilla as the blood supply is more extensive, thin cortical plates and the relative lack of medullary tissues in the maxilla prevent confinement of infections within the bone and permit dissipation of edema and pus into the soft tissues and paranasal sinuses. In the mandible, the regions affected in decreasing frequency, are the body, symphysis, angle, ramus, and the condyle. However, when the condition occurs in the maxilla, it may cause dreaded consequences like infection of the cranial cavity and brain. To avoid that, it is necessary to diagnose the maxillary osteomyelitis and treat aggressively. Here, we present an unusual case of maxillary osteomyelitis in an adult, otherwise healthy male, with its diagnosis and a review of the literature.
| Patient Information|| |
A 43-year-old male patient reported to our outpatient department of Oral Medicine and Radiology with the chief complaint of an unpleasant smell from his mouth for one month. His past dental history revealed that he underwent extraction of seven teeth in the upper left back tooth region within a single visit which was traumatic, and sutures were placed. After 15 days, he developed pain. Pain was lancinating localized, aggravating while taking food, and he took medication (analgesic ) from the pharmacist, and the pain got relieved. He noticed pus discharge and clumps of exposed yellow pieces-like structures, and foul odor after 10 days. His past medical history was not significant. Family history was non contributory. Personal history revealed that the patient did'nt have any deleterious habits.
| Clinical Findings|| |
The patient's general examination revealed that all the parameters were normal, with no signs of pallor and icterus. There was no history of fever and joint pains. Vital signs were within normal limits. The patient was moderately built, and his appetite was normal. Extra-oral examination revealed no gross abnormalities in facial symmetry. No paresthesia was present. A left single submandibular lymph node was palpable, soft in consistency, movable, non-tender, and measuring about 1cm in size. Intraoral examination (IOE) [Figure 1]a showed that the incisors, canines, premolars, and molars were missing in the second quadrant. IOE further revealed that an exposed denuded bone was seen on the left maxillary alveolar ridge measuring 2 × 3 cm in size, yellowish, in the left posterior maxillary region in the edentulous area of 24, 25, 26, 27. Dental caries in 36, 45, 46, was present. Generalized attrition was present. A foul smell was observed. On palpation, mucosa was swollen and firm surrounding the bony fragments with erythematosus alveolar mucosa . No pus discharge or sinus opening was present from that alveolus region. It was non-tender, with a bleeding tendency.
|Figure 1: (a) Showing exposed necrotic maxillary alveolar bone. (b) Preoperative OPG|
Click here to view
| Time Line of History|| |
| Diagnostic Assessment|| |
Based on the clinical presentation and history given by the patient, a provisional diagnosis of chronic osteomyelitis involving the left maxilla was made. As the periphery of the alveolar mucosal structure surrounding the fragment was indurated with inflamed stuffed like tissue on palpation, malignancy was included in the differential diagnosis.
Routine blood investigations were done. The blood counts of the patient were normal. Orthopantomogram (OPG)[Figure 1]b showed unhealed extraction sockets with a defect involving the alveolar bone and an ill-defined radiopaque border seen at the alveolar ridge of 26 suggestive of the sclerotic border. Cone-beam computed tomography (CBCT) was advised to figure out the actual extension of the lesion three dimensionally. CBCT [Figure 2] revealed that the axial view showed an extensive mixed density lesion involving the left alveolar process of maxilla with a moth-eaten appearance. Also, the coronal view showed breach of a maxillary sinus on the left side with soft tissue intensity of sinus suggestive of mucosal thickening with blocked sinus ostium. All the above features suggested osteomyelitis involving the left maxilla. Malignancy was included in the differential diagnosis, as the bone remodeling was not initiated at the extraction site, altered trabecular pattern with the erosion of cortical plates depicting the aggressiveness of lesion after two months. The prognosis was moderate.
| Therapeutic Intervention|| |
Surgical intervention of subtotal hemimaxillectomy was performed, followed by intense intravenous antibiotic therapy (Augmentin 1.2 g IV and Metronidazole 500mg IV) for 4 weeks, and part of the lesional tissue was sent for the histopathological examination.
| Follow-up and Outcomes|| |
The postoperative histopathological report confirmed areas showing normal-appearing bone, sclerotic bone, and bits with empty lacunae and bone resorption. Many bacterial colonies with a diffuse mixed inflammatory response with areas of degeneration, necrosis, and hyalinization were seen that was suggestive of chronic suppurative osteomyelitis [Figure 3]. Postoperative follow up after 20 days revealed no adverse and unanticipated events. [Figure 4].
|Figure 3: Histopathological picture-presence of a sclerotic bone, bone bits with empty lacunae|
Click here to view
| Discussion|| |
Osteomyelitis is considered as one of the most challenging cases to treat due to its heterogeneous nature in terms of pathophysiology, clinical presentation and management. Progressive bone destruction and formation of sequestrum are a characteristic feature of the disease.
Osteomyelitis can result from hematogenous spread, the contiguous spread of infection, or direct inoculation of microorganisms into the intact bone.
Maxillary osteomyelitis is rare compared to mandibular osteomyelitis because of the extensive blood supply and strut like bone of the maxilla which makes it less prone to chronic infection.
The present case report describes the occurrence of chronic suppurative osteomyelitis of the maxilla in a 27-year-old systemically healthy male. The specific etiological factor responsible for osteomyelitis, in this case, could not be traced; however, the fact that the patient underwent dental extractions at the same site which were traumatic contemplated as one of the potential causes of infection. The differential diagnosis for this case included peripheral squamous cell carcinoma because the lesion involved the alveolar mucosa. Fungal infections were ruled out because the patient was systemically healthy and not debilitated. However, as the patient did not have any tobacco habit and exposure of the denuded bone was seen, the possibility of osteomyelitis was more.
Chronic osteomyelitis in adults is generally treated with antibiotics and surgical debridement. Depending on the type of chronic osteomyelitis, patients may be treated with parenteral antibiotics such as Amoxicillin and Clavulanic acid combination (Augmentin 1.2 g IV BD) for 2–6 weeks. However, without adequate debridement, chronic osteomyelitis does not respond to most antibiotic regimens, irrespective of the duration of the therapy.
Susceptibilities and treatment include antimicrobial therapy and debridement with the management of resultant dead space and stabilization of bone.
Surgical intervention forms one of the mainstay treatments for the definitive management of osteomyelitis of the jaws. It aims to provide drainage to the area of infection, removal of the sequestrum and other foreign bodies, and getting new blood supply to the area. It ranges from simple sequestrectomy to segmental resection and reconstruction in recalcitrant cases. To test the effect of biofilms on hematopoietic during bone marrow infection, a 3D osteomyelitis model was developed.
The uniqueness of the present case is that chronic suppurative osteomyelitis was diagnosed in a healthy patient with no typical associated local and systemic causes.
| Patient Perspective|| |
There were no adverse effects or complications that affected their quality of life from the perspective of the patient.
| Conclusion|| |
Osteomyelitis of the jaws is inadequately treated real bony infection of the complex craniofacial anatomy and associated craniofacial skeletal and because of proximity to vital structures. This article highlights the significance of diagnosis with a sequence of the approach of various investigations. The possibility of such rarities reflected in the present case helps refresh the young minds of future dentists. It should be kept in mind that such rarities can still occur, so every case should be attempted with utmost care.
Declaration of patient consent
We, being authors of this case report, certify that we have obtained all appropriate patient consent forms. In the way, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh M, Singh S, Jain J, Singh KT.Chronic suppurative osteomyelitis of maxilla mimicking actinimycotic osteomyelitis: A rare case report.Natl J Maxillofac Surg 2010;2:153-6.
Storoe W, Haug RH, Lillich TT. The changing face of odontogenic infections. J Oral Maxillofac Surg 2001;59:739-48.
Shamanna K, Rao R, Banu A. Osteomyelitis of maxilla: A rare case. J Pub Health Med Res 2014;2:50-2.
Yadav S, Malik S, Mittal HC, Puri P. Chronic suppurative osteomyelitis of posterior maxilla: A rare presentation. J Oral Maxillofac Pathol 2014;18:481.
] [Full text]
Dhaval Trivedi, Rakesh Shah, Megha Vyas, Gaurang Sachdev. Combination of pharmacological and surgical management for pathological fracture of mandible associated with chronic suppurative osteomyelitis-A case report. IEJDTR 2015;3:308-11.
Mohite AS, Motwani MB, Assudani PV. An unusual case of maxillary osteomyelitis in a young female. J Indian Acad Oral Med Radiol 2017;29:141-4. [Full text]
Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, et al
. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. Am J Pathol. 2020;190:1151-63.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]