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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 66-70

Pathological fracture of the mandible secondary to osteomyelitis: A case report


Department of Oral and Maxillofacial Surgery, MES Dental College and Hospital, Perinthalmanna, Kerala, India

Date of Submission24-Apr-2021
Date of Acceptance28-Apr-2021
Date of Web Publication28-Jun-2021

Correspondence Address:
Dr. Sooraj Soman
Department of Oral and Maxillofacial Surgery, MES Dental College and Hospital, Perinthalmanna, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_16_21

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  Abstract 

Osteomyelitis is an inflammatory condition of the bone. Pathological fractures associated with osteomyelitis are difficult to manage and are time-consuming, as fractures have to be treated along with the underlying disease. This article describes a case report on the pathological fracture of the mandible secondary to chronic osteomyelitis.

Keywords: Antibiotic beads, osteomyelitis, pathological fracture


How to cite this article:
Mangalath U, Soman S, Aslam S, Kalathil LS, Thomas T, Nair R. Pathological fracture of the mandible secondary to osteomyelitis: A case report. Int J Oral Care Res 2021;9:66-70

How to cite this URL:
Mangalath U, Soman S, Aslam S, Kalathil LS, Thomas T, Nair R. Pathological fracture of the mandible secondary to osteomyelitis: A case report. Int J Oral Care Res [serial online] 2021 [cited 2021 Aug 6];9:66-70. Available from: https://www.ijocr.org/text.asp?2021/9/2/66/319594




  Introduction Top


The word “osteomyelitis” is derived from the Greek word “osteon,” meaning bone and “myelitis,” meaning inflammation of the marrow. In 1991, Marx described osteomyelitis as a true infection of the bone.

Osteomyelitis showcases a wide range of clinical symptoms. The symptoms mostly depend on the host resistance, virulence of the microorganisms, and the inflammatory response of the periosteum.[1]

The patient’s history, clinical findings, radiographic findings, and biopsies help in diagnosing osteomyelitis. Conventional radiographs, computed tomography (CT), PET scan, laser doppler flowmetry, MRI, and nuclear scans are some of the imaging tools used in diagnosing osteomyelitis.[2]

Pathological fractures are defined as fractures that occur or develop due to any substantive pathological process. Pathological fractures of the mandible are rare and account for only about 2% of the mandibular fractures.[3] Pathological fractures can occur as a result of osteomyelitis, osteoradionecrosis, bisphosphonate-related osteonecrosis, or any benign, malignant tumors, or any cystic lesions. They can also occur after third molar removal or after the placement of an implant.

Treatment for pathological fractures is complex, as the patient may have an underlying medical condition, poor nourishment, or bone pathology, all of which impair the bone-healing capacity.[4]

Pathological fractures that occur as a result of osteomyelitis are managed by the use of antibiotics, resection of the infected bone followed by rigid fixation with or without reconstruction.


  Case Report Top


A 62-year-old female patient had reported to our division with a chief complaint of pain and swelling on right side of the face for two months. The pain was moderate in intensity, dull aching in nature, an intermittent type that was non-radiating, and one that was not relieved on taking medication.

A solitary swelling of approximately 2 × 2 cm in size that was gradually increasing in size was noted on the right side of the face, extending superiorly 1cm above the corner of the mouth, inferiorly 1cm below the inferior border of the mandible on the right side, medially to the corner of the mouth, and laterally 3cm below the tragus of the ear [Figure 1]. The surface of the swelling appeared smooth with diffuse edges. On palpation, the swelling was soft in consistency, non-fluctuant, and tender with a local rise in temperature and it was not fixed to the underlying structures.
Figure 1: Pre-operative profile and worm view

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The patient had given a history of extraction of the 47 region three years ago and two weeks later had a complaint of pus discharge from the extraction site for which pus drainage was done intraorally. One year later, the patient again had pain and pus discharge from the same site for which curettage was done and antibiotics were prescribed. Two years later, the patient again developed pain and pus discharge from the same area with a complaint of paraesthesia on the right side of the lower jaw. An orthopantamogram (OPG) was advised. The OPG revealed a well-defined radiolucency of approximately 1.5 x 1cm in size distal to the 46 region. An alteration of trabecular pattern [Figure 2] was seen in the periapical 44, 45, and 46 region, which was suggestive of decalcification. Extraction of 46 was done, and curettage of the lesion was done. The specimen was sent for histopathological examination, which was suggestive of “radicular cyst.” Five months later, the patient reported back with pain and pus discharge from the same region for which curettage was done and antibiotics were prescribed. One month later, the patient had a complaint of pain and swelling at the same site, for which pus drainage was done intraorally. The pus was sent for testing culture and sensitivity. Staphylococcus Aureus was isolated from the pus. Antibiotics (Ciprofloxacin and later levofloxacin) were prescribed. The patient was asymptomatic for a month, after which she had a complaint of mild swelling and pain while having food with no history of pus discharge. On palpation, bony tenderness and crepitus was elicited on the right posterior region of the mandible.
Figure 2: OPG shows fracture of right body of mandible with a “moth-eaten” appearance. CT with axial and 3D reconstruction image

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A diagnosis of “pathological fracture of the mandible secondary to recurrence of radicular cyst” was made provisionally.

The following differential diagnosis was put forward: Pathological fracture secondary to osteomyelitis, ossifying fibroma, osteosarcoma, Ewing’s sarcoma, and chondrosarcoma.

OPG and CT were advised. OPG and CT [Figure 2] revealed a fracture on the right body of the mandible distal to 45. A break in continuity involving the lower border of the mandible with irregular borders was noted, showing a “moth-eaten appearance.”

Segmental resection and reconstruction of the right mandible was done using a reconstruction plate (patient-specific implant), and the bony defect was packed with vancomycin (1g) + gentamycin (3cc) impregnated absorbable caso4 beads under general anaesthesia[Figure 3]. The excised bone was sent for histopathological examination. The final diagnosis presented as osteomyelitis. One year postoperative OPG image shown in [Figure 4] shows no signs of infection.
Figure 3: Intraoperative images: (A) Exposure of the lesion. (B) Segmental resection of the mandible. (C) Reconstruction of the mandible using Recon Plate. (D) Bony defect packed with gentamycin-impregnated CaSO4 absorbable beads

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Figure 4: One-year postoperative OPG

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  Discussion Top


Osteomyelitis is defined as “an inflammatory condition of the bone that begins as an infection of the medullary cavity and Haversian system of the cortex and extends to involve the periosteum of the affected area.”

In the pre-antibiotic era, the chances of osteomyelitis were more with an initial acute onset progressing to a chronic phase eventually. However, after the introduction of antibiotics, osteomyelitis can be treated in the acute phase itself.[5]

Osteomyelitis commonly affects adults and is rare in children due to the abundant blood supply.

It can occur as a result of any infectious microorganisms, inadequate fracture reduction, irradiation to the mandible, or after any extraction or maxillofacial surgery.[6] There are certain factors that affect the host immunity and the jaw vascularity, all of which predispose to osteomyelitis.


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Osteomyelitis mostly affects the mandible due to its dense cortical plates and poor vascular supply.[8]

There are numerous classifications put forward by various authors: Schelhorn P et al,[9] Bernier et al,[10] and Wassmund.[11] The commonly used and accepted classification is by Topazian el al in 1994.[7]

Diagnosis of the osteomyelitis is done through biopsy and imaging. Imaging helps in detecting, staging the disease, perfecting the treatment, and putting forward the differential diagnosis.[12] Plain radiographs, OPG, CT, MRI, and radionuclide scanning are some of the imaging modalities. Plain radiographs and OPG are helpful in detecting acute osteomyelitis where an ill-defined radiolucency is adjacent to or involving a carious tooth or extraction socket with destruction and demineralization of trabeculae.[13] However, there has to be a loss of bone density by 50% to detect the changes in plain radiographs. Other changes noted are the widening of the periodontal ligament space and loss of lamina dura. In subacute osteomyelitis, some of the changes are new bone and sequestra formation that are difficult to be detected in plain radiographs. Chronic osteomyelitis is denoted by the presence of mixed radiolucency and radiopacity, indicating the bony sclerosis and thickening of the cortical bones. Radionuclide scanning helps in the early detection of osteomyelitis two to three days after the onset of symptoms.[14] The specificity with radionuclide scanning is less when technetium Tc 99m (99 mTc)-labeled bisphosphonates is used; however, it is better when WBCs tagged with indium In 111 or 99 mTc hexamethylpropyleneamine oxime (HMPAO) are used.[15]

The treatment principles of osteomyelitis are:

  • Early diagnosis


  • Correction of any host defence deficiencies


  • Imaging to rule out bone tumors


  • Gram staining, pus culture and sensitivity


  • Removal of loose teeth and sequestra


  • Culture-guided antibiotic coverage


  • Surgical drains, polymethyl methacrylate (PMMC) beads


  • Sequestrectomy, debridement, decortication, resection, and reconstruction


  • Supportive therapy


  • Hyperbaric oxygen therapy


  • Pathological fractures of the mandible are rare and account for less than 2% of all the fractures.[16] Fractures of the mandible can occur after the removal of third molars, after an implant placement and they can be associated with a benign cystic lesion or tumors, osteomyelitis, osteoradionecrosis, bisphosphonates-related osteonecrosis of the jaw, and Gorham’s disease.[17]

    Fractures associated with osteomyelitis develop between 1 and 75 years with a male: female ratio of 1.5:1. The common site of occurrence is the mandibular angle and body.[18],[19] Pathological fractures of the maxillofacial region are classified based on the etiology as follows:[20]

    1. Hereditary

      • • Osteogenesis imperfecta


      • • Osteopetrosis


    2. Infectious
      • • Acute osteomyelitis


      • • Chronic osteomyelitis:
        • - Sclerosing osteomyelitis


        • - Tuberculous osteomyelitis


    3. Iatrogenic
      • • Osteoradionecrosis


      • • Bisphosphonate osteonecrosis


      • • Cryotherapy


      • • Surgery:
        • - Wisdom teeth


        • - Implants


    4. Benign pathology
      • • Cysts/tumors


    5. Malignant pathology
      • • Primary cancer invasion


      • • Metastatic disease


      • • Hemopoietic:
        • - Leukemia


        • - Lymphoma


        • - Myeloma


    6. Metabolic
      • • Osteomalacia


      • • Osteoporosis


    7. Idiopathic
      • • Gorham’s disease


    8. Degenerative
      • • Mandibular atrophy


    The clinical features of pathological fracture associated with chronic osteomyelitis are pain, malaise, anorexia, paresthesia of inferior alveolar nerve, mobile teeth, intraoral/extraoral fistula formation, malocclusion, step deformity, and segmental mobility.[21]

    According to Cope, pathological fractures occur due to the physiological activity of the depressor muscles anteriorly and elevator muscles posteriorly.[22]

    Traumatic fractures of the maxillofacial region is usually aimed at restoring the function and anatomy that can be achieved through surgery, is successful as the bone is healthy with a normal physiology and results in an uneventful healing. However, the treatment of pathological fractures is more challenging as the bone is unhealthy, there is a lack of the buttressing, due to the presence of any medical conditions, or impoverished nourishment, all of which hinder the healing capacity.[23] Thus, the principal and initial aim is to improve the patient’s medical and nutritional status.

    The management involves the use of antibiotics against the causative organisms intravenously for six weeks, sequestrectomy or resection of the affected bone with or without reconstruction, and conservative or fracture fixation.[24] According to Ogasawara et al. and Chrcanovic et al., conservative management of fractures with IMF is considered to be the ideal treatment to prevent further bone necrosis after the placement of the plate.[25],[26]

    However, with a proper surgical approach and dissection keeping the soft tissue intact, immediate reconstruction is possible. Reconstruction options include the use of a reconstruction plate alone, a reconstruction plate with a primary bone graft, a reconstruction plate with a secondary bone graft, or reconstruction using a microvascular graft. Non-vascular grafts can be used in osseous defects less than 6cm, whereas microvascular grafts can be used for osseous defects larger than 6cm.

    Other adjunctive treatment includes the use of:[27]

  • Bioactive hydrogels for bone regeneration


  • Composite biodegradable scaffolds as an antibiotic drug delivery system


  • Vancomycin-incorporated gelatin coatings coupled with a Tio2-coated surface


  • Absorbable gentamycin-loaded calcium sulfate


  • In our patient, we have used the vancomycin-loaded calcium sulfate resorbable beads in the bony cavity after resection of the affected bone. They help in delivering high concentrations of antibiotics that are localized to the respective area of interest with the least systemic toxicity. Absorbable beads are far superior to the PMMC beads, as PMMC beads can cause local immune compromise and further require a secondary surgery for their removal. Antibiotic-impregnated CaSO4 resorbable beads are known to have good elution properties. The antibiotics commonly used along with CaSO4 for osteomyelitis are gentamycin, vancomycin, and tobramycin.

    Hyperbaric oxygen therapy is defined as the inhalation of 100% oxygen above a pressure of 103 kPa. It is indicated in chronic osteomyelitis ineffective after adequate treatment and in systemic diseases that compromises the vascularity.The therapy impedes hypoxia and induces neovascularity. Hyperbaric oxygen therapy acts by suppressing the action of inflammatory cytokines, activation of macrophage chemotaxis, and mobilization of osteogenic and vasculogenic cells from the bone marrow.

    Considering the age of the patient, the treatment modality for the case described in the article was quite challenging.

    Thus, the treatment of pathological fractures secondary to osteomyelitis is difficult and controversial. The treatment strategy adopted is dependent on the patient’s general condition, health, nutritional status, the surgeon’s skills, and equipment availability.


      Conclusion Top


    The early detection of osteomyelitis is important, as its late recognition can lead to a prolonged treatment course and increased surgical morbidity. Pathological fractures secondary to osteomyelitis are difficult to manage due to the compromised bone healing. Treatment should be primarily aimed at improving the functional and nutritional status of the patient. Thus, the treatment strategy adopted is specific to each patient.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, 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

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Jones J, Amess TR, Robinson PD. Treatment of chronic sclerosing osteomyelitis of the mandible with calcitonin: A report of two cases. Br J Oral Maxillofac Surg 2005;43:173-6.  Back to cited text no. 1
        
    2.
    Nezafati S, Ghavimi MA, Yavari AS. Localized osteomyelitis of the mandible secondary to dental treatment: Report of a case. J Dent Res Dent Clin Dent Prospects 2009;3:67-9.  Back to cited text no. 2
        
    3.
    Boffano P, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: A review of the literature of the last two decades. Dent Traumatol 2013;29:185-96.  Back to cited text no. 3
        
    4.
    Carlsen A, Marcussen M. Spontaneous fractures of the mandible concept & treatment strategy. Med Oral Patol Oral Cir Bucal 2016;21:e88-94.  Back to cited text no. 4
        
    5.
    Bünger B. Primary chronic osteomyelitis in the jaw. ZWR 1984;93:704-07, 11-12.  Back to cited text no. 5
        
    6.
    Aitasalo K, Niinikoski J, Grénman R, Virolainen E. A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible. Head Neck 1998;20:411-7.  Back to cited text no. 6
        
    7.
    Topazian RG. Osteomyelitis of jaws. In: Topazian RG, Goldberg MH, editors. Oral and Maxillofacial Infections. 3rd ed. Philadelphia, PA: Saunders; 1994. p. 251-86.  Back to cited text no. 7
        
    8.
    Prasad KC, Prasad SC, Mouli N, Agarwal S. Osteomyelitis in the head and neck. Acta Otolaryngol 2007;127:194-205.  Back to cited text no. 8
        
    9.
    Schelhorn P, Zenk W. [Clinics and therapy of the osteomyelitis of the lower jaw]. Stomatol DDR 1989;39:672-6.  Back to cited text no. 9
        
    10.
    Bernier S, Clermont S, Maranda G, Turcotte JY. Osteomyelitis of the jaws. J Can Dent Assoc 1995;61:441-2, 445-8.  Back to cited text no. 10
        
    11.
    Wassmund M. Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer. Leipzig: Meusser; 1935.  Back to cited text no. 11
        
    12.
    Koorbusch GF, Deatherage JR, Curé JK. How can we diagnose and treat osteomyelitis of the jaws as early as possible? Oral Maxillofac Surg Clin North Am 2011;23:557-67, vii.  Back to cited text no. 12
        
    13.
    Schuknecht B, Valavanis A. Osteomyelitis of the mandible. Neuroimaging Clin N Am 2003;13:605-18.  Back to cited text no. 13
        
    14.
    Reinert S, Widlitzek H, Venderink DJ. The value of magnetic resonance imaging in the diagnosis of mandibular osteomyelitis. Br J Oral Maxillofac Surg 1999;37:459-63.  Back to cited text no. 14
        
    15.
    Weon YC, Yang SO, Choi YY, Shin JW, Ryu JS, Shin MJ, et al. Use of tc-99m HMPAO leukocyte scans to evaluate bone infection: Incremental value of additional SPECT images. Clin Nucl Med 2000;25:519-26.  Back to cited text no. 15
        
    16.
    Gerhards F, Kuffner HD, Wagner W. Pathological fractures of the mandible. A review of the etiology and treatment. Int J Oral Maxillofac Surg 1998;27:186-90.  Back to cited text no. 16
        
    17.
    Boffano P, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: A review of the literature of the last two decades. Dent Traumatol 2013;29:185-96.  Back to cited text no. 17
        
    18.
    Nakamura M, Matsuura H. Pathological fracture of the mandible resulting from osteomyelitis successfully treated with only intermaxillary elastic guiding. Int J Oral Maxillofac Surg 2008;37:581-3.  Back to cited text no. 18
        
    19.
    Kato H, Matsuoka K, Kato N, Ohkubo T. Mandibular osteomyelitis and fracture successfully treated with vascularised iliac bone graft in a patient with pycnodysostosis. Br J Plast Surg 2005;58:263-6.  Back to cited text no. 19
        
    20.
    Coletti D, Ord RA. Treatment rationale for pathological fractures of the mandible: A series of 44 fractures. Int J Oral Maxillofac Surg 2008;37:215-22.  Back to cited text no. 20
        
    21.
    Koorbusch GF, Deatherage JR, Curé JK. How can we diagnose and treat osteomyelitis of the jaws as early as possible? Oral Maxillofac Surg Clin North Am 2011;23:557-67, vii.  Back to cited text no. 21
        
    22.
    Cope MR. Spontaneous fracture of an atrophic edentulous mandible treated without fixation. Br J Oral Surg 1982;20:22-30.  Back to cited text no. 22
        
    23.
    Carlsen A, Marcussen M. Spontaneous fractures of the mandible concept & treatment strategy. Med Oral Patol Oral Cir Bucal 2016;21:e88-94.  Back to cited text no. 23
        
    24.
    Boffano P, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: A review of the literature of the last two decades. Dent Traumatol 2013;29:185-96.  Back to cited text no. 24
        
    25.
    Ogasawara T, Sano K, Hatsusegawa C, Miyauchi K, Nakamura M, Matsuura H. Pathological fracture of the mandible resulting from osteomyelitis successfully treated with only intermaxillary elastic guiding. Int J Oral Maxillofac Surg 2008;37:581-3.  Back to cited text no. 25
        
    26.
    Chrcanovic BR, Custódio AL. Mandibular fractures associated with endosteal implants. Oral Maxillofac Surg 2009;13:231-8.  Back to cited text no. 26
        
    27.
    Chakraborty S, Gowda DV, Vishal Gupta N. Development of biodegradable scaffolds loaded with vancomycin micropartricles for the treatment of osteomyelitis. Int J Res Pharm Sci 2019;10:2612-21.  Back to cited text no. 27
        


        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4]
     
     
        Tables

      [Table 1], [Table 2]



     

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