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Osteomyelitis and osteoradionecrosis of jaw
DR PRAJESH DUBEY DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
Dr. Prajesh Dubey, Subharti Dental College, SVSU 2 Content
Osteomyelitis Incidence Osteoradionecrosis
Factors predisposing Etiopathogensis osteomyelitis Etiology Clinical features Pathogenesis Treatment
Microbiology Prevention of Classifications osteoradionecrosis
Clinical presentations Postirradiation dental care Imaging Treatment Types of osteomyelitis Dr. Prajesh Dubey, Subharti Dental College, SVSU
3 OESTEOMYLITIS
It is defined as an inflammation of the bone marrow with a tendency to progression.
This is what differentiates it in the jaw from the dentoalveolar abscess, “dry socket” and “osteitis,” seen in infected fractures.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 4
It is described as an inflammatory condition of bone that usually begins as an infection of medullary cavity rapidly involves the haversian system and quickly extends to periosteum of that area.
Pus that formed in this area thereby compromise its periosteal blood supply.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 5 Incidence
Much higher in the mandible due to poorly vascularized cortical plates and the blood supply primarily from the inferior alveolar vessels.
Diminished host defenses, both local or systemic like diabetes, autoimmune states, malignancies, malnutrition, and acquired immunodeficiency syndrome.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 6 Factors- predisposing osteomyelitis
Dr. Prajesh Dubey, Subharti Dental College, SVSU 7 ETIOLOGY
Odontogenic infections
Trauma
Infections derived from periostitis following gingival ulceration
Infections derived by hematogenous route—furuncle on face, wound on the skin, upper respiratory tract infection, middle ear infection
Dr. Prajesh Dubey, Subharti Dental College, SVSU 8 Pathogenesis
Osteomyelitis primarily occurs as a result of contiguous spread of odontogenic infections or as a result of trauma. Primary hematogenous osteomyelitis generally occurs in the very youngs. Whereas in adults, process is initiated by inoculation of bacteria into the jawbones that can occur with the extraction of teeth, root canal therapy, or fractures of the maxilla or mandible.
Dr. Prajesh Dubey, Subharti Dental College, SVSU Additiona Hyperemia and Inflammatio l increased blood n leukocyte 9 flow s
If it is formed in bone marrow it causes decreased blood supply of Pus is formed the region due to elevated intramedullary pressure
Pus spread via haversian and Perforation of Volkmann’s canals to medullary the cortical and cortical bones. bone
Compromised periosteal Collection of the pus blood supply under the periosteum
Dr. Prajesh Dubey, Subharti Dental College, SVSU 10 Microbiology
Earlier said to be S. aureus and S. epidermidis ranged between 80 to 90%; remaining bacteria are mainly streptococci, pneumococci, typhoid and acid fast bacilli. Now osteomyelitis is recognized as a disease caused primarily by streptococci and oral anaerobic bacteria present in oral cavity. Clinician must begin antibiotic treatment, includes penicillin and metronidazole as dual-drug therapy or clindamycin as a single-drug treatment. And definitive therapy should be based on the final culture and sensitivities. Dr. Prajesh Dubey, Subharti Dental College, SVSU 11 FINDINGS HELPFUL IN PURE AEROBIC/MIXED AEROBIC ANAEROBIC INFECTION
Foul smelling exudate Slouging necrotic tissue Gas & black discharge Gram stain revealing multiple organism of diff morphological characters Presence of sequestra
Dr. Prajesh Dubey, Subharti Dental College, SVSU 12 Classification
BASED UPON DURATION OF 1 MONTH -ACUTE A) Contiguous focus B). Progressive c). Hematogenous -SUB ACUTE -CHRONIC A) Recurrent multifocal B) Garré’s C) Suppurative or nonsuppurative D) Sclerosing Dr. Prajesh Dubey, Subharti Dental College, SVSU 13 Waldvogel classification system for osteomyelitis:
Hematogenous osteomyelitis
Osteomyelitis secondary to a contiguous focal infection.
Osteomyelitis with or without associated peripheral vascular disease.
Chronic osteomyelitis.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 14 ON THE BASIS OF PRESENCE OF PUS
SUPPURATIVE • NON SUPPURATIVE • ACUTE SUPPURATIVE • DIFFUSE SCLEROSING • CHRONIC SUPPURATIVE • FOCAL SCLEROSING • (PRIMARY- No acute phase (CONDENSING OSTEITIS) preceding) • PROLIFERATIVE PERIOSTITIS • (SECONDARY- follows acute (GARRE’S SCLEROSING OM) phase) • OSTEORADIONECROSIS • INFANTILE OSTEOMYELITIS Dr. Prajesh Dubey, Subharti Dental College, SVSU 15 Classification based on clinical picture and radiology
I. Acute/subacute osteomyelitis II. Secondary chronic osteomyelitis III. Primary chronic osteomyelitis
Hjorting-Hansen E, Decortication in treatment of osteomyelitis of the mandible. Oral Surg Oral Med Oral Pathol 1970 May;29(5):641-55
Dr. Prajesh Dubey, Subharti Dental College, SVSU Classification based on clinical picture, 16 radiology, etiology, and pathophysiology
Acute osteomyelitis
1. Associated with Hematogenous spread
2. Associated with intrinsic bone pathology or peripheral vascular disease
3. Associated with odontogenic and nonodontogenic local processes Mercuri LG Acute Osteomyelitis of the Jaws Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2, May 91, 355-65 Chronic osteomyelitis 1. Chronic recurrent multifocal osteomyelitis of children 2. Garrè's osteomyelitis 3. Chronic suppurative osteomyelitis – Foreign body related – Systemic disease related – Related to persistent or resistant organisms 4. True chronic difuse sclerosing osteomyelitis
Marx RE Chronic Osteomyelitis of the Jaws Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2, May 91, 367-81 17 CIERNY-MADER STAGING SYSTEM (1985)
Classification and staging for osteomyelitis 1ANATOMIC TYPE: STAGING SYSTEM:
Stage 1: Medullary osteomyelitis –no cortical involvement , usually hematogenous
Stage2: Superficial osteomyelitis-less than 2cm bony defect without cancellous bone.
Stage3: Localized osteomyelitis –less than 2cm bony defect, without involving both cortices.
Stage4: Diffuse osteomyelitis-Larger than 2 cm
Dr. Prajesh Dubey, Subharti Dental College, SVSU 18
2.PHYSIOLOGIC TYPE: A. Host: Normal host B. Host Systemic compromise Local compromise. Systemic and local compromise. C. Host: Treatment worse than disease.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 19 Clinical Presentation
4 types can be observed clinically- 1) Acute suppurative osteomyelitis- Deep pain, high fever, paresthesia and anesthesia of the lower lip, usually deep carious associated teeth, Swelling is minimal, tooth are not loose and fistulas are usually not present.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 20
2) Sub acute suppurative- After 10 to 14 days of acute form, pus extends through haversian canals to accumulate under the periosteum. Pain, fever, malaise are present, teeth begins to loose and tender, pus exudes around gingival sulcus, fistula formation and fetid odor.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 21
3) Secondary chronic ( begins as acute phase)- clinical findings are fistulas, induration of soft tissue and thickened or ‘wooden’ character to the affected area. 4) Primary chronic- (Not preceded by acute) slight pain, slow increase in jaw size, and gradual development of sequestra, often without fistulas.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 22
Dr. Prajesh Dubey, Subharti Dental College, SVSU 23 Maxillofacial imaging for osteomyelitis
Radiographic presentation lag behind the clinical presentation since cortical involvement is required for any change to be evident. Therefore, it takes several weeks before bony changes appear.
Orthopanoramic view
CBCT
CT scans
Dr. Prajesh Dubey, Subharti Dental College, SVSU 24
• Worth’s Criteria (1969) • ‘Moth-eaten’ appearance (enlargement of medullary spaces and widening of Volkmann’s canals) • Islands that is ‘seqeustrum’ evidence of trabecular pattern and marrow spaces Dr. Prajesh Dubey, Subharti Dental College, SVSU 25
MRI can help in early diagnosis by loss of the marrow appears before cortical erosion or sequestrum of the bone. The technetium 99 with the addition of gallium 67 or indium 111 as contrast agents, differentiate areas of infection from trauma or postsurgical healing as these agents specifically bind to white blood cells.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 26 Conventional radiograph
Positive Negative (suspected)
Technetium bone scan
Positive Negative
Ga 67 or WBC scan
Positive Negative
Drainable abscess- MRI, Sequestrum- CT
Dr. Prajesh Dubey, Subharti Dental College, SVSU 27 Treatment
Usually medical and surgical interventions required. Overall treatment plan includes- Evaluation and correction of host defense deficiencies Gram staining, culture and sensitivity Administration of antibiotics Removal of loose teeth and sequestra, Administration of culture guided antibiotics Sequestrectomy, saucerization, debridement, direct placement of antibiotic, HBO therapy, resection of infected bone, reconstruction. Dr. Prajesh Dubey, Subharti Dental College, SVSU 28
Inhitial management is administration of high dose intravenous antibiotic therapy. Identify and correct host compromise factors, and treat the cause. For hospitalized pt- Aqueous penicillin, 2 million U IV 4 hourly, plus metronidazole, 500mg 6 hourly, when improved for 48 to 72 hours- switch to- penicillin V, 500mg PO 6 hourly, plus metronidazole 500mg PO 6 hourly for an additional 4-6 weeks.
For outpatients- Penicillin V 2g, plus metronidazole 400mg 8hourly PO, for 2-4 weeks. Clindamycin should be prescribed if pt is allergic to penicillin. Dr. Prajesh Dubey, Subharti Dental College, SVSU 29
Whenever possible, specimens should be obtained for gram staining, aerobic and anaerobic cultures, and antibiotic sensitivity testing. A foul- smelling, dark exudate- suggest anaerobic osteomyelitis. A thick creamy pus from a localized abscess indicates a staphylococcal infection.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 30 Local antibiotic therapy
Closed wound irrigation- suction- Irrigation without surgical debridement to the point of bleeding bone is unlikely to be effective, prolongs the process, and delays definitive treatment. Various agents containing antibiotics, proteolytic enzymes, wetting agents may be used. Antibiotics may be placed in direct contact with the bone manually or with an implantable pump. Dr. Prajesh Dubey, Subharti Dental College, SVSU 31
Antibiotic-impregnated Beads- They can be used to deliver high concentrations of antibiotics into the wound bed. Antibiotic leaches from the beads, and produce high local concentrations and low systemic concentrations. Tobramycin or gentamycin is generally used as AIB. Beads and drain are left in place for 10 to 14 days.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 32 Surgical management
Necessary with medical therapy. Surgical management is removal of loose teeth, bone fragments, I&D of fluctuant areas and if necessary sequestrectomy, saucerization, decortication, or resection and then reconstruction.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 33 Sequestrectomy
Sequestra are generally seen after 2 weeks of onset of infection. Once fully formed, sequestra persists for several months before they are resorbed. Once the sequestra has formed completely, it can be removed with the minimum of the surgical trauma.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 34 Saucerization
Saucerization is “Unroofing” of the bone to expose medullary cavities for thorough debridement. The margins of necrotic bone overlying the focus of osteomylities are excised allowing visualization of sequestra and exision of affected bone.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 35
Steps- 1) Buccomucoperioseteal flap is reflected.
2) loose teeth and bone segment are removed.
3) lateral cortex of the mandible is reduced using burs.
4) All granulation tissue and loose bone fragments are removed from the bone bed using curettes.
5) buccal flap is trimmed and a medicated ¼ or ½ inch pack is inserted for hemostasis and to maintain the flap in a retracted position until initial healing occurs.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 36 Decortication
First described for jaw osteomyelitis in 1917 by Mowlem. It refers to the removal of chronically infected cortical bone. Lateral and inferior cortex is removed 1 to 2 cm beyond the affected area thus providing access to the medullary cavity. Usually granulation tissue and pus exists within the medullary cavity that antibiotics cannot penetrates.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 37
Steps- 1) Creation of a buccal flap by a crestal incision extending along the neck of teeth. 2) Reflection of the mucoperiosteal flap to inferior border. 3) Removal of the teeth of the involved area. 4) Removal of the lateral cortical plate and the inferior border with chisels. Dr. Prajesh Dubey, Subharti Dental College, SVSU
38 Resection and reconstruction-
Used in cases of- Pathological fracture Persistent infection after decortications Marked closure of both cortical plates.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 39 Types of osteomyelities
1) Osteomyelitis associated with fractures- Develops when failure to use effective methods of reduction, fixation and immobilization, as debris and microorganisms gain access to the fracture site. Overzealous use of intraosseous wiring, bone plates, screws that devascularize bone segment.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 40 2)- Infantile Osteomyelitis
Occurs most often a few weeks after birth and usually affects maxilla. It believed to occur by hematogenous route or from perinatal trauma of the oral mucosa. Have risk of involvement of eye, extension to dural sinuses, and the potential for facial deformities and loss of teeth. Clinically patient has cellulitis centered around the orbit.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 3)- Proliferative periostitis (garre’s 41 sclerosing osteomyelitis)
Resembles infectious osteomyelitis and affects mainly children. First described by Carl Garre in 1893. Characterized clinically by- Localized, hard, non tender, unilateral bony swelling of the lateral and inferior aspects of the mandible. Skin appears normal, Associated with carious first molar with a history of past toothache.
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Radiographically- laminated or Onion skin appearance. It is considered a response to a low grade infection or irritation that influence the potentially active periosteum of young individual to lay down new bone. D/D- Ewing’s Sarcoma, Osteosarcoma, cortical hyperostosis. T/t- removal of identifiable source of inflammation.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 43 CHRONIC SCLEROSING OSTEOMYELITIS
1)- Chronic diffuse sclerosis osteomyelitis-
Inflammatory, non-suppurative, painful disease with a protracted course. It occurs only in the mandible and affects the both the basal bone and the alveolar process, involve the entire height of the mandible.
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Bone is often mildly expanded and tender. Episodes of recurrent swelling and pain occur. Mainly seen in adult in their 3rd decade. 2/3rd times in females. Radiographically, a diffuse intramedullary sclerosing with poorly defined margins defect can be seen.
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2)- Florid osseous dysplasia- Multiple, exuberant, lobulated densely opaque masses, restricted to the alveolar process in either or both jaw. Most often in black women.
Focal sclerosing osteomyelitis- Localized area of bone sclerosing associated with the apex of a carious tooth and peripheral periodontitis.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 46 Actinomycotic osteomyelitis-
Chronic, slowly progressive infection with both granulomatous and suppurative features, Affects soft tissue only and occasionally, bone. It forms external sinuses that discharge distinctive sulfur granules and spreads unimpeded by anatomical structures.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 47
Actinomyecitis are not fungi but rather gram positive, microaerophilic, non spore forming, non acid-fast bacteria.
Firm, soft tissue masses are present on the skin, they have purplish, dark red, oily areas with occasional small zone of fluctuance.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 48 Fungal Osteomyelitis
Very rare and generally presents in an indolent fashion. Fungal infections are opportunistic infections and devastating to patients if it is invasive in nature. These frequently enter the body due to a decrease in host defense or through an invasive gateway, such as a dental extraction. Candidal infection is more often encountered when compared to other fungal infection, i.e. mucormycosis, aspergillosis etc.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 49
The clinical presentations of fungal osteomyelitis are similar to the bacterial osteomyelitis (e.g. Exposed bone with varying pain). Involvement of maxillary sinus with a complaint of sinusitis in maxillary fungal osteomyelitis has been seen more. The fungus invades the arteries leading to thrombosis that subsequently causes necrosis of hard and soft tissues. Mucormycosis is frequent in diabetic patients because a favorable environment is created due to an excess of ketone bodies in diabetic patients.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 50
It is extremely rare to find candidal osteomyelitis in the maxilla and because of nonspecific symptoms, diagnosis is very challenging. Aspergillosis is the second most common fungal infection after candida. It is usually invasive in nature when involving maxillary sinus though noninvasive forms have also been reported and does not cause bone destruction when compared to mucormycosis.
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Osteoradionecrosis is a radiation OSTEORADIONECROSIS induced non –healing, hypoxic wound rather than true osteomyelitis of irradiated bone.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 52
Infection is usually initiated by injury to irradiaated tissue According to Marx it is a chronic, nonhealing wound caused by hypocellularity , hypovascularity and hypoxia of the irradiated tissue.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 53 Etiopathogenesis of osteoradionecrsis
Radiation Trauma Infection Effect of irradiation depends upon: Quality and quality of radiation Size of the portals used Location and extent of the lesion Condition of teeth and peridontium
Dr. Prajesh Dubey, Subharti Dental College, SVSU 54
Mandible is more commonly affected than maxilla. Radiation often has serious effects: -Mucositis -Atrophic mucosa -Xerostomia -Radiation caries etc. Breakdown occur because the tissue cannot maintain normal cellular turnover and collagen synthesis such tissue is susceptible to spontaneous breakdown, breakdown from other trauma especially tooth extraction.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 55 Clinical features of osteoradionecrosis
Pain and evidence of exposed bone (grey to yellow color) Trismus Elevated temperature Pathological fractures Tissue surrounding the exposed bone may be indurated and ulcerated. Nutritional deficiencies
Dr. Prajesh Dubey, Subharti Dental College, SVSU 56 Treatment:
1) Hospitalized to allow parental antibiotic and fluids. 2) Penicillin plus metronidazole or clindamycin alone is recommended. 3) Gentle, pulsating irrigation of the soft tissue margin is useful in removing debris and reducing inflammation. But high pressure irrigation should be avoided because debris might be pushed deeply into the tissue. 4) Supportive treatment with fluids and a liquid or semiliquid diet, high in protein and vitamin is desirable.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 57
6)- Exposed bone then is mechanically debrided and smoothened with large round or barrel shaped burs and covered with a pack saturated with zinc peroxide and neomycin. 7) Irrigation and packing repeated weekly until sequestration occurs or the bone is penetrated by granulation tissue. Pentoxyfylline and tocopherol (Vit E) are the usually used medical treatment for ORN. Pentoxyfylline- 400mg TDS, Improves blood flow by decreasing its viscosity.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 58
Ultrasound therapy: Promotes neo-vascularity and neo-cellularity of ischemic tissue. Bone resection: Patient who are not candidates for extensive treatment because of their medical condition may achieve pain relief by resection of the segment of the involved bone.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 59 HYPERBARIC OXYGEN THERAPY:
The therapeutic principle of HBOT lies in its ability to drastically increase in the oxygen transport capacity of the blood. At normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin and very little oxygen is transported by blood plasma. Oxygen transport by plasma, however, is significantly increased using HBOT because of the higher solubility of oxygen as pressure increases.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 60
HBO therapy causes an increase in the arterial and venous oxygen tension; the additional oxygen is carried in physical solution in the plasma. HBO therapy consists of breathing 100% oxygen through a face mask or a large chamber at 2.4 absolut atmospheres pressure for 90 minute sessions for as many as 5 days a week, totaling 30 or more sessions often fallowed by another 10 more sessions. Dr. Prajesh Dubey, Subharti Dental College, SVSU 61
Oxygen under increased tension enhances healing by a direct bacteriostatic effect on micro-organisms and by enhancing phagocytic activity. Neoangiogenesis, fibroblastic changes and collagen synthesis also occurs. Osteomyelitis and osteoradionecrosis patients may be candidates for HBO treatment in conjunction with antibiotic and surgical care.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 62 Marx-University of Miami Protocol
Stage-I Cutaneous fistula, - 30 X (100% O2for 90 mins at 2.4 ATA) Pathological fracture - Examine exposed bone Resorption of inferior border of mandible Nonresponders Responder (Formation of healthy granulation tissue) Stage- II Decortication sequestretomy, saucirization etc till bleeding - 10 X (100% O2for 90 mins at 2.4 ATA) margins
- 10 X (100% O2for 90 mins at 2.4 ATA)
Nonresponders Responder Stage III Healing without exposed bone Excision of the nonvital bone, Fixation of the mandibular segments,
10 X (100% O2for 90 mins at 2.4 ATA) Reconstruction after 3 months No further HBO required
Dr. Prajesh Dubey, Subharti Dental College, SVSU 63 PREVENTION OF OSTEORADIONECROSIS:
Preirradiation dental care: Preventive dental measures are effective in reducing the risk of osteoradionecrosis. The radiotherapist should seek dental consultation sufficiently early before initiation of radiation therapy to allow achievement of optimal oral health.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 64
1. All non-restorable teeth in the direct beam of radiation and teeth with significant periodontal disease should be extracted 10 to 14 days before radiation therapy begins. 2. Judicious alveoplasty should performed to permit a liener closure of the mucoperiosteum. 3. All remaining teeth should be restored and periodontal therapy be completed within 2 weeks interval.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 65 Postirradiation dental care:
Dentures should not be used in the irradiated arch for 1 year after radiotherapy . A saliva substitute may be used to lubricate the mouth. (Pilocarpine). If postirradiated pulpitis develops endodontic treatment should be provided.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 66
Necessary extraction should be limited to one or two teeth per appointment. Removal of teeth should be performed as atraumatic as possible. No attempt should be made to raise mucoperiosteal flap or linear closure. A plain local anesthecis should be used. A suggested regimen is 2 grm penicillin V plus 500mg metronidazole orally 1 hour before surgery and 500mg of both drugs given four times a day for 1 week after extraction. Alternatively 600mg of clindamycin 1 hour before surgery and 300mg three times a day for a week is recommended. Dr. Prajesh Dubey, Subharti Dental College, SVSU 67
Thankyou
Dr. Prajesh Dubey, Subharti Dental College, SVSU 68 Classification of osteomyelitis:
1. Acute form of osteomyelitis ( suppurative or nonsuppurative) A. Contignuous focus I. 1.Trauma II. 2.Surgery III. 3.Odontogenic infection
Dr. Prajesh Dubey, Subharti Dental College, SVSU 69
B) Progressive I. 1.Burns II. 2.Sinusitis III. 3.Vascular insufficiency C) Hematogenous (metastatic) i. Developing skeleton (children) ii. Developing dentition (children)
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2) Chronic forms of osteomyelitis A) Recurrent multifocal i. Developing skeleton (children) ii. Escalated osteogenic activity (<25yrs) B) Garres osteomyelitis i. Unique proliferative subperiosteal reaction ii. Developing skeleton
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C). Suppurative nonsuppurative i. Inadequately treated forms ii. Systemically compromised forms. iii. Reractory forms (chronc refractory osteomyelitis (CROM)) D). Sclerosing: i. Diffuse-
a) Fastidious microorganisms
b) Compromised host and pathogen interface.
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ii) Focal a predominantly odontogenic B. Chronic localized injury.
Dr. Prajesh Dubey, Subharti Dental College, SVSU 73 APPLIED SURGICAL ANATOMY
The bone has essentially three structures, a cortical bone, a cancellous bone and the periosteum. The cortical bone is present outside and is covered by the periosteum, while the cancellous bone lies within the cortical bone
Figs 18.1A to D: Haversian system of the bone Dr. Prajesh Dubey, Subharti Dental College, SVSU