DEPARTMENT OF ORAL &

MAXILLOFACIAL SURGERY

MANAGEMENT OF
OSTEOMYELITIS
 OSTEOMYELITIS
Definition:
Osteomyelitis can be defined as the inflammation of bone
and bone marrow along with surrounding periosteum.
Inflammatory condition involve all the structure of bone eg.
Bone marrow, Haversian system, Periosteum and Epiphysis.

GOALS OF MANAGEMENT
 Attenuate and eradicate proliferating pathological organisms
 Promote healing
 Reestablish vascular permeability
 TREATMENT GUIDELINES
 Disrupt infectious foci
 Debride any foreign bodies, necrotic tissues or sequestra.
 Culture and identify specific pathogens for definitive antibiotic
treatment
 Drain and irrigate the region
 Consider adjunctive treatment to enhance microvascular
reperfusion
- Trephination
- Decortication
- Vascular flaps
- Hyperbaric oxygen therapy
 Reconstruction
 SUCCESSFUL TREATMENT IS BASED ON
FOLLOWING FUNDAMENTAL PRINCIPLES
 Early diagnosis

 Bacterial culture and sensitivity testing

 Adequate, appropriate and prompt antibiotic therapy.

 Adequate pain control

 Proper surgical intervention

 Reconstruction
 INVESTIGATIONS PRIOR TO
MANAGEMENT
1. Bacterial culture or sensitivity testing
2. Radiograph
- Till at least 30-60% destruction of mineralized portion
of bone takes place – this destruction is not visible on
radiograph.
- Acute osteomyelitis – not visible on radiograph
- Chronic osteomyelitis – moth eaten appearance
3. CT Scan
- More accurate – Compared to radiograph
4. MRI

- More accurate as compared to CT scan.

- Bone marrow changes and soft tissue changes are

seen more accurately in MRI when compared to a
CT scan.

5. Scintigraphy/Bone scanning/ Radionuclide Scanning

- Measures physiological changes in bone

 MANAGEMENT

[A] Conservative management [B] Surgical management

(Medical management)

[A] Conservative management

1. Complete bed rest
2. Supportive therapy
Nutritional support – High protein diet
− High caloric diet
− Adequate multivitamins
3. Rehydration
- Hydration orally
- Administration of I.V. fluids
4. Blood transfusion
- If RBC, Hb% are low
5. Control of Pain
- Analgesic and sedation

6. Antibiotic therapy
(a) Systemic antibiotics
- Penicillin – Antibiotic of choice for osteomyelitis of jaw
- Metronidazole
- Cephalosporin
- Ciprofixacin
- Clindamycin, etc.
Note: Use antibiotics for 2-4 months.
(b) Local antibiotics
(i) Closed wound irrigation – suction
 To achieve the desired effect locally it may be required to
give very high doses of antibiotic systematically which on other
hand will produce unwanted side effects.
 To overcome this problem, local application of the antibiotic
may be effective.

(ii) Antibiotic impregnated beads:

 PMMA (Poly methyl methocrylate) beads impregnated with
antibiotics may be placed into the disease bone.
7. HYPERBARIC OXYGEN CHAMBER
- MONOPLACE
Hyperbaric Oxygen Therapy:
Hyperbaric oxygen is effective in treatment of osteomyelitis because:
 Hyperbaric oxygen enhances lysosomal degradation.
 The oxygen free radicals are formed which are toxic to anaerobic
pathogens.
 The elevated partial pressure of oxygen created which inactivate
the exotoxins released by the pathogens.
 The tissue oxygen level is elevated which enhances the healing.
 It helps in neoangiogenesis by encouraging endothelial
proliferation.

Increased Vascularity
[B] Surgical management
1. Extraction of offending teeth
2. Incision and drainage
3. Sequestrectomy
Removal of sequestrum (dead nerotic bone). Once the
sequestrum is formed in bone, it can undergo many
changes-
• It may get infected and form a chronic infective focus
• May remain dormant with no changes in it.
• May get revascularized and healing takes place
• May get resorbed completely.

Note: Since the sequestrum is avascular,

antibiotics will not be able to penetrate into it.
4. Saucerisation
Removal of bony hollow cavity/ dead space
After removal of Sequestrum

A hollow cavity/dead space occurs Bone destruction due to

osteomyelitis

A large clot form in the cavity

The clot will most likely to get infected

So the margins of the bone which lodge the Saucerisation

sequestra are trimmed down

This create a saucer shaped defect instead of

a deep hollow cavity.

This saucer shaped defect can’t accumulate Bone defect after

saucerisation
5. Decortication (Mowlem’s decorticetomy)

 Surgical procedure in which the

lateral and inferior cortical bone is
Extensive bone
removed (then underlying destruction
cancellous bone can be irrigated
and debrided effectively)

 Cancellous bone is removed till

the uninvolved area. This can be
Decortication (removal of lateral
differentiated by the presence of inferior cortex of mandible)
bleeding point in vital bone
compared to the necrotic bone
which shows no bleeding when it is
cut.

Bone defect after

decortication
6. Resection and Reconstruction:
All the above procedures are not effective completely
eliminating the infective process. It may be necessary to resect the
infected part of jaw.
Once the part of the jaw is resected, it may be
reconstructed using autologous bone graft or reconstruction
plates.

7. Post operative care:

 Continued use of antibiotics
 Warm saline mouth rinses
 Adequate hydration
Complete bed rest