Case Report
Volume 1 Issue 3 - 2015
Chronic Suppurative Osteomyelitis of Maxilla: A Case Report
Soheyl Sheikh, Shambulingappa Pallagatti, Deepak Gupta, Amit Aggarwal, Ravinder Singh and Renu Sharma*
Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, India
*Corresponding Author: Renu Sharma, Department of Oral Medicine and Radiology, MM College of Dental Sciences and Research, Mullana, Ambala, Haryana, India.
Received: February 21, 2015; Published: March 28, 2015
Citation: Renu Sharma., et al. “Chronic Suppurative Osteomyelitis of Maxilla: A Case Report”. EC Dental Science 1.3 (2015): 126-131.
Osteomyelitis of the jaws is inadequately treated true bony infection of the complex craniofacial anatomy and associated craniofacial skeletal. It is one of the most difficult infections to treat. It is a well documented fact that most of the cases of Maxillofacial Osteomyelitis occur in the mandibular region as compared to the maxilla. This case report highlights chronic osteomyelitis of the maxilla, with bony destruction and sequestra involving whole of the maxillary ridge. The clinical relevance with emphasis on radiographic interpretation in such cases is highlighted.
Keywords: Osteomyelitis; Maxilla; Infection; Denuded bone
Osteomyelitis represents an inflammation of the medullary cavity, Haversian system and adjacent cortex of bone [1]. It was first described by the French surgeon, Edouard Chassaignac in 1852. But in 1764, John Hunter had coined the terms sequestra and involucrum for pockets of dead cortical bone with abscess and new bone formed in response to the sequestra respectively [2]. Osteomyelitis of maxilla was originally described by Rees in 1847. Osteomyelitis of the jaws was relatively common before the era of antibiotic therapy. Today osteomyelitis of facial bones is a rare condition. This case is presented since maxillary osteomyelitis is rare compared to mandibular osteomyelitis. This is because of the extensive blood supply & strut like structure of the bone of the maxilla which makes it less prone to chronic infection [3].
Case Report
A 45 year old female reported to the Department of Oral Medicine & Radiology with a chief complaint of a non-healing area in the upper front jaw since the last 4 months. The history dated back to 4 months when the patient had undergone extraction done in the upper jaw because of pain and pus discharge in the teeth. She was also having nasal regurgitation since 4 months while consuming liquids. She also complained of foul smell from the oral cavity, non-blood stained nasal discharge along with the pain and discomfort upon chewing food. There was no significant medical history. But the patient was a chronic smoker since the last 30 years and had poor oral hygiene maintenance measures.
There were no significant findings upon general physical examination and extra oral examination of the patient. On intraoral examination, bilateral denuded bone was seen on the right and left maxillary alveolar ridge measuring 2x3 cm in size and extending from 12,13,14,15, 16 & crossing the midline involving 22 to 27 tooth region (Figure 1). There were also bilateral fistulous tracts about 0.5 cm x 0.5 cm present on the posterior aspect of the maxillary alveolar ridge, suggestive of oro-antral fistulae.
Figure 1: Intraoral denudation at the maxillary vestibular region with bilateral sinus openings.
Radiographic investigations were then carried out. Intra Oral Periapical and Panoramic Radiograph (Figure 2) revealed moth eaten appearance of the maxillary bone, involving the entire maxilla. Computed Tomography Scan (Figure 3,4) was also done, which showed moth eaten type of destruction of the maxilla in the anterior region involving the entire arch. There was also destruction of the antero-inferior wall bilaterally of the maxilla. There was also the expansion of the zygomatic arches bilaterally. Small hyper-dense bony fragments were seen in the medullary cavity suggestive of sequestrum. There was associated periosteal reaction with cortical thickening and full thickness defects in the cortex at places suggestive of cloacae.
Figure 2: Orthopentomograph revealing moth eaten appearance of the maxillary alveolar bone.

Figure 3: Coronal CT section revealing destruction of the maxillary alveolar bone in the anterior region involving the entire arch along with destruction of the antero-inferior wall of the maxillary sinus bilaterally.

Figure 4: Axial CT section reveals expansion of the zygomatic arches bilaterally with sequestration in the medullary cavity and associated periosteal reaction with cortical thickening.
Lab investigations were carried out and all the values were under normal range. Biopsy was then performed. Histopathologically there was hyperplasic epithelium with spongiosis. The connective tissue stroma contained irregular, thick interlacing bundles of collagen fibres and chronic infiltrative cells predominantly lymphocytes and plasma cells (Figure 5). There were also bony spicules containing osteocytes within the lacunae. The hard tissue specimen sequestra show bone devoid of osteocytes and this correlated well with the clinical findings. Thus a diagnosis as chronic suppurative osteomyelitis was confirmed.

Figure 5: Histopathology revealing hyperplasic epithelium with spongiosis. The connective tissue stroma contained irregular, thick interlacing bundles of collagen fibres and chronic infiltrative cells predominantly lymphocytes and plasma cells.
Our patient has crossed the non-invasive approach hence radical resection of the necrotic maxilla and the tissue was performed. Patient had undergone healing and no reoccurrence was there after six months. Administration of amoxiclav 600 mg and metronidazole 250 mg intravenously in every 12 hours were continued for one week postoperatively prior to the patient being discharged from the ward. The patient was reviewed regularly during periodic follow-up visits.
Osteomyelitis is an opportunistic infection that is usually a complication of some other condition rendering the host susceptible to disease. In tooth bearing bone, osteomyelitis is usually caused by polymicrobial odontogenic bacteria. The treatment of osteomyelitis varies from a range of simple non-invasive approach to more invasive radical treatment. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical [1].
In both acute and chronic forms, the mandible is most commonly involved, especially the posterior parts [3]. A study by Taher., et al. comprising of 88 cases of osteomyelitis of the mandible found trauma to be the most common predisposing cause for osteomyelitis, attributing it to the geo-political difficulties. Histopathological examination of the surgical specimens or granulation tissues can help in more accurate diagnosis of the predisposing factors such as malignancy, tuberculosis or other granulomatous conditions [4,5]. The treatment protocol consists of a combination of surgery and antimicrobial treatment.
In this present case, with the clinical features and history, chronic suppurative osteomyelitis of the maxilla was provisionally arrived at. But the dilemma was regarding the aetiology of osteomyelitis. The case presented here represents osteomyelitis following odontogenic infection. This is because necrotic bone, pus discharge and foul odour following dental extraction as present in this case are typical features of bacterial infection.
Various radiographic as well as imaging modalities aid in defining the exact extent of the osteomyelitic lesion. Radiographs may include an orthopentomograph as done in this case. Imaging modalities may include a CT scan or an MRI. In most of the cases CT scans are used to define the exact areas involved [5-7].
Chronic osteomyelitis is a very serious condition requiring immediate hospitalization followed by aggressive surgical and antibiotic therapy. In this disease, the blood supply to the infected area is usually severely compromised. At the time of surgery, culture material should be obtained so that appropriate antibiotics can be chosen for treatment of the infection. Most authors agree that antibiotics should be continued much longer than usual for odontogenic infections [7]. For chronic osteomyelitis, antibiotic treatment may be continued for up to 6 months. The treatment goal is directed to resolution of the infection while maximizing patient function. Celsius, in the 1st century AD, described scraping away or debridement of the dead bone until it bleeds. Only in the past 25 years has the treatment of chronic osteomyelitis progressed to include use of muscle flaps and vascularised bone grafts to manage large open defects. New management techniques such as antibiotic beads are used to manage dead space in staged reconstructions [8].
Osteomyelitis of the craniofacial skeleton is a complex problem requiring rapid and thorough diagnosis and treatment [9-11]. Failure to do so can result in a host of complications and consequences. The cause of this disease is multi-factorial and its presentation varies. Whatever the cause may be, complete resolution of the infection must be obtained to decrease the morbidity and mortality of the patient [10,11].
Literature has been flooded with articles highlighting the treatment of Osteomyelitis which ranges from simple non-invasive to surgical treatment [5,10-14]. Antibiotics are considered to be the treatment of choice in the initial stages. Antibiotics can also be placed in high concentration in direct contact with the bone manually or with an implantable pump [6]. As suggested in literature, the duration of the process, the formation of granulation tissue and the presence of sequestra in almost all cases make surgery mandatory with simultaneous antimicrobial therapy in the management of osteomyelitis. Our patient has crossed the non-invasive approach hence radical resection of the necrotic maxilla and the tissue was performed.
As this case is not medicine related osteonecrosis (MRONJ) of the jaw. There was no Current or previous treatment with anti-resorptive or anti-angiogenic agents. Moreover MRONJ is painful and difficult to treat. Osteonecrosis of the jaw has been recognized by dental and medical practitioners for many years and bisphosphonates as a contributory factor to this condition.
Similar cases must be differentiated from osteonecrosis. Osteonecrosis of the jaw could be viewed as an alteration of normal wound healing in which “delayed” epithelial closure of an opening in the oral mucosa leads to an infection and subsequent necrosis of the bone. Multiple factors, including the patient's immunocompetence and the use of drugs (bisphosphonates, steroids) which impair wound closure may contribute to the pathogenesis.
Osteomyelitis of the maxilla is rare in the modern antibiotic era. However it should still be suspected especially in a patient with diabetes and associated focus of infection such as carious teeth. Adult Osteomyelitis remains one of the most difficult-to-treat infectious diseases, with considerable morbidity and costs to the health care system. Although osteomyelitis involving the alveolar process of maxilla is common due to dental causes, osteomyelitis involving the entire maxilla is very rare and must be supported by advanced maxillofacial imaging modalities like CT scan for treatment.
  1. Shamanna K., et al. “Osteomyelitis of maxilla: a rare case”. Journal of Public Health and Medical Research 2.1 (2014): 50-52.
  2. Pincus DJ., et al. “Osteomyelitis of the craniofacial skeleton”. Seminars In Plastic Surgery23.2 (2009): 73-79.
  3. Singh M., et al. “Chronic suppurative osteomyeliis of maxilla mimicking actninimycotic osteomyelitis: a rare case report”. National Journal of Maxillofacial Surgery 1.2 (2010): 153-156.
  4. Sheikh S., et al. “Tuberculous osteomyelitis of mandibular condyle: a diagnostic dilemma”. Dentomaxillofacial Radiology 41.2 (2012): 169-174.
  5. Gupta D., et al. “Osteomyelitis of the mandible mimicking fibrous dysplasia: A radiographic controversy”. Clinical Dentistry 7.3 (2013): 20-25.
  6. Suei Y., et al. “Diagnosis and classification of mandibular osteomyelitis”. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 100.2 (2005): 207-214.
  7. Baltensperger M and Eyrich G. “Osteomyelitis of the jaws” Chapter 2: Definition and Classification. Springer book on Osteomyelitis of the Jaws. 
  8. Prasad KC., et al. “Osteomyelitis in the head and neck”. ActaOto-Laryngologica 127.2 (2007):194-205.
  9. Nezafati S., et al. “Localized osteomyelitis of the mandible secondary to dental treatment: report of a case”. Journal of Dental Research, Dental Clinics, Dental Prospects 3.2 (2009): 67-69.
  10. Fogarty C., et al. “Invasive fungal infection of the maxilla following dental extractions in a patient with chronic obstructive pulmonary disease”. Journal (Canadian Dental Association) 72.2 (2006): 149-152.
  11. Yeoh SC., et al. “Chronic suppurative osteomyelitis of the mandible: case report”. Australian Dental Journal 50.3 (2005): 200-203.
  12. Rasmussen AQ., et al. “Non-infectious osteomyelitis of the mandible in a young woman: a case report”. Journal of Medical Case Reports 8 (2014): 44.
  13. Ali K., et al. “An unusual case of chronic suppurative osteomyelitis of the mandible”. Archives of Orofacial Sciences 7.1 (2012): 37-41.
  14. Shenoi R., et al. “Recurrent chronic suppurative osteomyelitis: review of literature and report of a case”. Indian Journal of Multidisciplinary Dentistry1.1 (2010): 29-32.
Copyright: © 2015 Renu Sharma., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PubMed Indexed Article

EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005

EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777

EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347

EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478

EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253

EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033

EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992

EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505

EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793

EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211

EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047

EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560

EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318

EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819

EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840

EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344

EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476

EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658

EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489

EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278

EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108

EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571

EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333

EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883

EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001

EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937

EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723

EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726

EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603

EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646

EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616

EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290

EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226

EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812

EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268

News and Events

November Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the November issue of respective journals and can be viewed in the current issue pages.

Submission Deadline for January Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the January issue of respective journals. Submissions are accepted on/before December 03, 2020.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to