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Garre's Osteomyelitis: a Case Report

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Garre's Osteomyelitis: a Case Report PEDIATRICDENTISTRY/Copyright ~ 1981 by The American Academyof Pedodontics/Vol. 3, No. 3 Garre’s osteomyelitis:a case report Stephane Schwartz, DDS, MS Huan Pham, DOS, MS Abstract Palpation revealed a usually smooth, bone-hard le- Onecase of Garre’sosteomyelitis in volving the mandible sion which felt like an inherent part of the mandible. was seen, treated and documented.It was treated by extraction of the causal infected tooth with no supplement The size of the bone lesion could vary from a few cen- of antibiotics. The patient experienceda completeregression timeters to the whole length of the mandible, and of the lesion with six months. could expand as much as 2 cm laterally. All cases caused a noticeable asymmetryof the face. Introduction Unlike other forms of osteomyelitis, there is no Garre’s osteomyelitis was first described by Carl marked increase in fever, white blood cell count, sedi- Gaffe in 1893 as "a focal gross thickening of perios- mentation rate or alkaline phosphatase values. teum with peripheral reactive bone formation result- Radiographic Findings ing from infection, m It was reported only in long Panoramic and occlusal views would typically show bones, particularly in the tibia, until 1948 when a localized overgrowth of bone on the outer surface of Berger described a case involving the mandible. 2 In the cortex. This mass of bone, which is supracortical 1973, Batcheldor et al. 3 claimed that only six reports but subperiosteal, is smooth, fairly calcified, and is of proliferative osteomyelitis of the jaw had been often described as a duplication of the cortical layer of reported, and added two cases of their own. Since the mandible. then, a few more4,5 were presented and described in the Since panoramic and occlusal radiographs can only English literature. Authors agree that there are many demonstrate a vertical and a lateral apposition of more cases, but they are not recognized and therefore bone respectively, it can be helpful to take a lateral not reported. oblique view of the jaw in order to visualize the expan- Several connotations have been adopted for this en- sion of the lesion which tends to be both inferior and lateral to the lower border of the mandible. tity, but today the most commonly used is "Chronic 5 8 osteomyelitis’’6 with proliferative periostitis. Smith and Farman, and Rowe and Heslop Signs and Symptoms described on their radiographs the "onion peel" ap- Garre’s osteomyelitis occurs most commonlybefore pearance of the subperiosteal bone formation. the age of 20, though Thoma7 described such a lesion Intraoral radiographs would show a carious tooth, in a 53-year-old patient. In the young, there is still a radicular cyst, or a chronic infectious process in considerable activity of osteoblastic cells in the perios- approximation to the bony mass. teum, causing, therefore, a condensation of cortical Histologic Findings bone rather than an osteolytic process. It usually The main characteristic is formation of new bone, affects the mandible and results in a hard swelling or osteoid tissue, with bordering osteoblasts and some over the jaw, producing facial asymmetry with little areas of bone resorption. Lymphocytes are commonly or no pain. seen in marrowspaces. Approximately 55% of the patients described had All histologic examinations revealed young reactive no pain at all, even to palpation. The others experi- bone formation, arranged as trabeculae of lamellated enced little or moderate pain, with or without temper- bone separated by connective tissue. The trabeculae ature elevation. The overlying skin was normal, but were more or less close together, depending upon the cases. Ellis et al. 4 mentioned the trabeculae radially could occasionally be inflammed, mostly when pain 7 was present. arranged to the cortical bone. Thoma described them as being at a right angle to the cortex. All findings Accepted: December 20, 1980 included the presence of diffuse chronic inflammation PEDIATRIC DENTISTRY: Volume 3, Number 3 28:3 with infiltration of lymphocytes and plasma cells. Authors agree that the reaction is destructive in the early stage when osteoporosis can be observed in the adjacent medullary bone. However, as the layers Figure 1. Ten-year-old white of new bone arrange themselves around the lesion, the 8 female patient with mass at lytic lesions become more sclerotic. the right side of the mandible. Etiology and Evolution Microorganisms which are isolated in most cases are Staphylococci pyogenes, variety aureus or albus, although various Streptococci and some mixed organ- isms can be associated.10 Typical evolution of this lesion can be attributed to the fact that the high osteogenetic potential in young patients allows an osteoblastic process which is supe- patient failed to return until January, 1974, at which rior to the osteolytic one. This pattern is identical to time a panoramic radiograph showed a nearly com- that of condensing osteitis, which is frequently seen in pleted resolution of the lesion. Clinically, the man- the periapical areas of carious teeth, except that the dible had remodeled itself, and the child's face was proliferation of bone is of periosteal origin rather than symmetrical. Another panorex in 1978 showed com- endosteal. plete and permanent healing (Figure 4). Case Report Discussion and Conclusion A 10-year-old white female was seen at the Mon- This case exhibited the same characteristic features treal Children's Hospital in July, 1973, with a mass at as those reviewed in the literature: the right side of the mandible; the patient complained — A long-standing carious lesion or other odonto- of pain only in the lower left first molar (Figure 1). genic infectious process associated with a bony hard Clinical examination revealed a non-tender, bone- swelling lateral to the inferior border of the mandible hard mass extending from the second premolar to the producing facial asymmetry, which brought the pa- second molar along the lower border of the right side tient to seek treatment rather than the pain. of the mandible. The right lower first molar was — The regression of the lesion with subsequent bone cariously involved. The child had not sought treat- remodeling occurred within the same six to eight ment for that lesion, but for the painful carious left month period as seen in the literature.469" molar. She had no temperature elevation. Periapical Because this case was associated with obvious den- radiographs showed caries on the lower first molars tal causes and exhibited typical clinical and ra- extending into the pulp chambers. The panoramic diographic features of le Garre's osteomyelitis, it was view revealed a smooth regular apposition of bone ex- not deemed necessary to perform any bone biopsies. tending along the lower border of the right mandible However, in atypical cases with a negative history of and exhibiting a definite cortical outline (Figures 2 deep carious lesions, chronic abscesses, or trauma to and 3). An occlusal radiograph showed an enlargement the area, bone biopsies are recommended in order to of bone, extending 1.5 cm buccally to the first lower rule out several disease entities. These include the right molar and stretching the periosteum. A clinical following: diagnosis of le Garre's osteomyelitis was made. 1. Infantile Cortical Hyperostosis or Caffey's disease, Both lower first molars were extracted. No other which is a syndrome of unknown etiology arising dur- therapy was instituted, except for follow-ups. The ing the first six months of life and affecting mostly the Figures 2 and 3. Lateral and Panoramic radiographs reveal- ing the mass. 284 GARRE'S OSTEOMYELITIS: Schwartz and Pham mandible with the manifestation of a peripheral bony tumor. This disease runs a benign course and subsides without treatment in several months.12 2. Ewing's sarcoma, a rare malignant neoplasm occur- ring predominantly in children, which produces a bony tumor showing layers of new subperiosteal bone on radiographs when affecting the mandible. Radical surgery coupled with radiotherapy is recommended, but the prognosis is very poor.12 3. Osteogenic sarcoma, which mostly affects males between 10 and 25 years of age, and produces facial asymmetry when the mandible is involved. The scler- osing form exhibits the typical sun-rays appearance of osteosarcoma on X-Rays. Although radical surgery is the recommended treatment, this highly malignant disease carries a poor prognosis.12 Figure 4. Panorex taken in 1978 showing absence of mass 4. Cherubism, a familial disease showing a slow, pain- and normal symmetry. less, symmetric swelling of the jaws which regresses as the patient approaches puberty.12 maintenance of the chronic inflammation sites seen in 5. Histiocytosis X. Oral manifestations of the disease, microscopic examinations. The young host cannot en- if present, may include loss of alveolar bone, local tirely dispose of those byproducts, but can stimulate pain, swelling and tenderness of the jaw. McKelvy et new bone formation in an attempt to encapsulate the al.13 describe a patient, diagnosed and treated for lesion. "osteomyelitis and sinus tract with a proliferative Because in many cases, there is no complaint of a reaction in the buccal vestibule." After a few weeks of "tooth ache," many physicians are inclined to perform unsuccessful treatment, past medical history and a bone biopsies (through an extraoral approach) with- biopsy were taken and the final diagnosis of Histiocy- out even thinking about a possible dental etiological tosis was made. factor. We feel, therefore, that patients presenting A review of the literature has shown that this sup- with any maxillofacial tumefaction, with or without posedly rare form of bone infection is becoming more oral symptoms, should be sent to a dentist for an and more common. Two reasons could account for this evaluation. growing incidence: 1. As a result of the increase of health and living standards, people are responding in a "anabolic rather Acknowledgment than catabolic manner." The authors wish to thank Dr.
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