Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 372–374 doi: 10.1111/adj.12186
Osteomyelitis of the condyle secondary to pericoronitis of a third molar: a case and literature review R Wang,*‡ Y Cai,†‡ YF Zhao,† JH Zhao† *The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedical Engineering of Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China. †Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
ABSTRACT In this study, we report a very unusual case of a patient with osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. The patient was treated by removal of the impacted third molar, opening of the drainage, combined with systemic application of antibiotics for two weeks. This treatment option did not lead to any functional defects or facial asymmetry. The patient fully recovered and the disease did not recur. Keywords: Condyle, impacted third molar, osteomyelitis, pericoronitis. (Accepted for publication 16 October 2013.)
INTRODUCTION Impacted third molars are associated with risks of many disorders and complications,1 including pericoronitis, caries, resorption and periodontal problems. Serious complications, such as the development of cysts and tumours, severe inflammatory responses, bone fractures, and osteomyelitis of the mandible, require hospitalization for treatment.2 Among these complications, osteomyelitis of the mandible very rarely occurs.3 In this study, we report the case of a patient with osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. To the best of our knowledge, this case is only the second case which has been reported with osteomyelitis of the condyle caused by the impacted third molar (Table 1). REVIEW OF OSTEOMYELITIS IN THE MANDIBLE Osteomyelitis is an inflammatory condition of the bone and bone marrow. In the oral and maxillofacial region it almost exclusively affects the mandible. Although mandibular osteomyelitis is sometimes attributed to bisphosphonate therapy (bisphosphonate related osteonecrosis) or radiotherapy (osteoradionecrosis), bacterial infection of odontogenic origin ‡Authors contributed equally to this work. 372
(including periapical periodontitis, pericoronitis, extraction wounds and infected fracture) can be identified in most cases. Such cases are diagnosed as secondary osteomyelitis. Cases in which no apparent aetiological factor can be found are classified as primary osteomyelitis. In developed countries, the prevalence of mandibular osteomyelitis has decreased significantly in recent decades. This change can be attributed to increased availability of antibiotics and improvements in oral and dental health standards. However, its incidence in developing countries is still relatively high because of limited oral health knowledge, poor oral hygiene and affordability problems.4 An effective treatment method for mandibular osteomyelitis is a combination of antimicrobial therapy and surgery consisting of incision and drainage, or sequestrectomy. In addition, use of adjunctive treatment options, such as hyperbaric oxygen, can produce good short-term clinical effects. CASE PRESENTATION A 37-year-old male patient was referred to our department with complaints of severe limitation of mouth opening and swelling and pain in the left facial and temporal regions for three days. Prior to these symptoms, the patient had been suffering from pain around the left lower region of the third molar for two weeks. Physical examination revealed extensive © 2014 Australian Dental Association
Osteomyelitis of the condyle Table 1. Osteomyelitis of the mandible secondary to pericoronitis of the third molar Author (year) 15
Age/Gender
Origin
Extension
Therapy tooth extraction and condylectomy tooth extraction and coronoidectomy tooth extraction and curettage tooth extraction and drainage of the left submasseteric space tooth extraction and extensive decortication tooth extraction and curettage tooth extraction and drainage
Thoma Reck3 Tong16 Mohammed-Ali17
28/F 16/M 12/M 22/F
upper left third molar lower left third molar lower left third molar lower left third molar
condyle coronoid process angle region mandibular ramus
Mohammed-Ali17 Lambade13 Present case
21/F 35/F 37/M
lower right third molar ectopic third molar in condyle lower left third molar
mandibular ramus condyle condyle
swelling in the left facial and temporal regions, palpable fluctuation on the frontal tragus and temple region, and limited mouth opening of less than 1 cm. Intraoral examination showed impaction of permanent tooth 38, with gingival swelling and pus fluxing from the gingival sulcus of the impacted third molar. The patient’s medical history revealed no presumable cause and the patient had no history of drinking alcohol or smoking. A computed tomography scan of the patient’s head showed a lytic lesion in the left ramus of the mandible. The lesion resembled a tunnel from the impacted third molar to the condyle and had destroyed the outer cortical plates of the condyle (Figs. 1 and 2). Based on test results and a history of pain around the left lower region of the third molar, the patient was diagnosed with infection of the buccal, temporal, pterygomandibular and masseteric spaces followed by
Fig. 1 A panoramic radiograph showed a lytic lesion of the left ramus of the patient’s mandible. The lesion resembled a tunnel from the impacted third molar to the condyle.
osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. As per the patient’s request, the treatment plan included extraction of the third molar, removal of the buccal alveolar bone of the third molar, drainage from the buccal cavity of the third molar, and incision and drainage of the preauricular area. The patient was discharged with a prescription for intravenous injections of clindamycin and metronidazole. He fully recovered after 14 days and did not report pain or swelling on the left side of the face in telephone follow-ups. DISCUSSION Prophylactic removal of impacted third molars, which is the extraction of the asymptomatic impacted third molars, remains highly controversial.5 Generally, any recommendation for prophylactic removal of third molars should consider ongoing symptoms or pathology, future complications and morbidity associated with retention of the third molars, and possible increased risks of extraction at an older age.5,6 Several studies7,8 have provided strong evidence to support the retention of asymptomatic mandibular third molars, showing that extraction of impacted lower third molars is associated with mandibular fractures and increased risk of injury to the lingual and inferior alveolar nerve. In addition to some common complications (periodontal disease, odontogenic infections, systemic inflammation and anterior incisor crowding), impacted third molars are also associated with serious complica-
Fig. 2 A computed tomography scan and three-dimensional reconstruction of the left hemi-mandible revealed the lesion deteriorated the outer cortical plates of the condyle. © 2014 Australian Dental Association
373
R Wang et al. tions such as mandibular fractures and development of cysts and tumours.6 Previous studies have reported that asymptomatic and radiographically pathology-free retained third molars have the potential for cystic (or neoplastic) transformation over the lifespan of a patient.6 About 25% to 59% of all patients with retained third molars suffer from this condition.6,9,10 Moreover, extensive evidence6,11,12 shows that removal of impacted third molars reduces the incidence of mandibular angle fractures, which is said to be caused by a decrease in the cross-sectional area of bone at the angle with a retained third molar and a greater susceptibility to mandibular angle fractures. Additionally, the preexisting periodontal disease around the distal of the second molar generally improves with extraction of the third molars,6 and extractions done at an older age can lead to more serious complications. Thus, prophylactic extraction of mandibular third molars in early adulthood merits serious consideration. In this study, development of osteomyelitis of the condyle was the first observed complication secondary to an impacted third molar. Therefore, extraction of the third molar should be performed as early as possible even in the absence of symptoms. Surgical management of osteomyelitis of the condyle aims to relieve symptoms and minimize morbidity without affecting the functional efficiency of the mandibular condyle.13 It is well-known that decortication and removal of necrotic tissue, and surgical resection of the condyle are the two possible methods for managing osteomyelitis of the condyle.14 However, in the present case, decortication and removal of necrotic tissue could have caused the pathological fracture of the condyle, while surgical resection of the condyle would not cure osteomyelitis of the ascending ramus of the left mandible. Considering the clinical findings and the patient’s request, removal of the aetiological factor and combined therapy of drainage opening and systemic administration of antibiotics was deemed the best treatment option. Importantly, this treatment method resulted in a favourable outcome with minimal detrimental effects.
2. Kunkel M, Kleis W, Morbach T, Wagner W. Severe third molar complications including death–lessons from 100 cases requiring hospitalization. J Oral Maxillofac Surg 2007;65:1700–1706. 3. Reck SF, Fielding AF, Hess DS. Osteomyelitis of the coronoid process secondary to chronic mandibular third molar pericoronitis. J Oral Maxillofac Surg 1991;49:89–90. 4. Chen L, Li T, Jing W, et al. Risk factors of recurrence and lifethreatening complications for patients hospitalized with chronic suppurative osteomyelitis of the jaw. BMC Infect Dis 2013;13:313. 5. Kunkel M, Morbach T, Kleis W, Wagner W. Third molar complications requiring hospitalization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:300–306. 6. Bagheri SC, Khan HA. Extraction versus nonextraction management of third molars. Oral Maxillofac Surg Clin North Am 2007;19:15–21, v. 7. Zhu SJ, Choi BH, Kim HJ, et al. Relationship between the presence of unerupted mandibular third molars and fractures of the mandibular condyle. Int J Oral Maxillofac Surg 2005;34:382–385. 8. Iida S, Nomura K, Okura M, Kogo M. Influence of the incompletely erupted lower third molar on mandibular angle and condylar fractures. J Trauma 2004;57:613–617. 9. Adelsperger J, Campbell JH, Coates DB, Summerlin DJ, Tomich CE. Early soft tissue pathosis associated with impacted third molars without pericoronal radiolucency. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:402–406. 10. Glosser JW, Campbell JH. Pathologic change in soft tissues associated with radiographically ‘normal’ third molar impactions. Br J Oral Maxillofac Surg 1999;37:259–260. 11. Iida S, Hassfeld S, Reuther T, Nomura K, Muhling J. Relationship between the risk of mandibular angle fractures and the status of incompletely erupted mandibular third molars. J Craniomaxillofac Surg 2005;33:158–163. 12. Hanson BP, Cummings P, Rivara FP, John MT. The association of third molars with mandibular angle fractures: a meta-analysis. J Can Dent Assoc 2004;70:39–43. 13. Lambade P, Lambade D, Dolas RS, Virani N. Ectopic mandibular third molar leading to osteomyelitis of condyle: a case report with literature review. Oral Maxillofac Surg 2013;17: 127–130. 14. Zemann W, Feichtinger M, Pau M, Karcher H. Primary osteomyelitis of the mandibular condyle–a rare case. Oral Maxillofac Surg 2011;15:109–111. 15. Thoma KH. Oral Surgery. 4th edn. St Louis: Mosby, 1983: 603–671. 16. Tong AC, Ng IO, Yeung KM. Osteomyelitis with proliferative periostitis: an unusual case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e14–19. 17. Mohammed-Ali RI, Collyer J, Garg M. Osteomyelitis of the mandible secondary to pericoronitis of an impacted third molar. Dent Update 2010;37:106–108.
ACKNOWLEDGEMENTS This study was supported by grants 81200772 and 81102054 from the National Natural Science Foundation of China and 121064 from Wuhan University to Rong Wang. REFERENCES 1. Adeyemo WL. Do pathologies associated with impacted lower third molars justify prophylactic removal? A critical review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:448–452.
374
Address for correspondence: Professor Ji-Hong Zhao Department of Oral and Maxillofacial Surgery School and Hospital of Stomatology Wuhan University 237 LuoYu Road Wuhan 430079 China Email: [email protected] © 2014 Australian Dental Association
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 372–374 doi: 10.1111/adj.12186
Osteomyelitis of the condyle secondary to pericoronitis of a third molar: a case and literature review R Wang,*‡ Y Cai,†‡ YF Zhao,† JH Zhao† *The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedical Engineering of Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China. †Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
ABSTRACT In this study, we report a very unusual case of a patient with osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. The patient was treated by removal of the impacted third molar, opening of the drainage, combined with systemic application of antibiotics for two weeks. This treatment option did not lead to any functional defects or facial asymmetry. The patient fully recovered and the disease did not recur. Keywords: Condyle, impacted third molar, osteomyelitis, pericoronitis. (Accepted for publication 16 October 2013.)
INTRODUCTION Impacted third molars are associated with risks of many disorders and complications,1 including pericoronitis, caries, resorption and periodontal problems. Serious complications, such as the development of cysts and tumours, severe inflammatory responses, bone fractures, and osteomyelitis of the mandible, require hospitalization for treatment.2 Among these complications, osteomyelitis of the mandible very rarely occurs.3 In this study, we report the case of a patient with osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. To the best of our knowledge, this case is only the second case which has been reported with osteomyelitis of the condyle caused by the impacted third molar (Table 1). REVIEW OF OSTEOMYELITIS IN THE MANDIBLE Osteomyelitis is an inflammatory condition of the bone and bone marrow. In the oral and maxillofacial region it almost exclusively affects the mandible. Although mandibular osteomyelitis is sometimes attributed to bisphosphonate therapy (bisphosphonate related osteonecrosis) or radiotherapy (osteoradionecrosis), bacterial infection of odontogenic origin ‡Authors contributed equally to this work. 372
(including periapical periodontitis, pericoronitis, extraction wounds and infected fracture) can be identified in most cases. Such cases are diagnosed as secondary osteomyelitis. Cases in which no apparent aetiological factor can be found are classified as primary osteomyelitis. In developed countries, the prevalence of mandibular osteomyelitis has decreased significantly in recent decades. This change can be attributed to increased availability of antibiotics and improvements in oral and dental health standards. However, its incidence in developing countries is still relatively high because of limited oral health knowledge, poor oral hygiene and affordability problems.4 An effective treatment method for mandibular osteomyelitis is a combination of antimicrobial therapy and surgery consisting of incision and drainage, or sequestrectomy. In addition, use of adjunctive treatment options, such as hyperbaric oxygen, can produce good short-term clinical effects. CASE PRESENTATION A 37-year-old male patient was referred to our department with complaints of severe limitation of mouth opening and swelling and pain in the left facial and temporal regions for three days. Prior to these symptoms, the patient had been suffering from pain around the left lower region of the third molar for two weeks. Physical examination revealed extensive © 2014 Australian Dental Association
Osteomyelitis of the condyle Table 1. Osteomyelitis of the mandible secondary to pericoronitis of the third molar Author (year) 15
Age/Gender
Origin
Extension
Therapy tooth extraction and condylectomy tooth extraction and coronoidectomy tooth extraction and curettage tooth extraction and drainage of the left submasseteric space tooth extraction and extensive decortication tooth extraction and curettage tooth extraction and drainage
Thoma Reck3 Tong16 Mohammed-Ali17
28/F 16/M 12/M 22/F
upper left third molar lower left third molar lower left third molar lower left third molar
condyle coronoid process angle region mandibular ramus
Mohammed-Ali17 Lambade13 Present case
21/F 35/F 37/M
lower right third molar ectopic third molar in condyle lower left third molar
mandibular ramus condyle condyle
swelling in the left facial and temporal regions, palpable fluctuation on the frontal tragus and temple region, and limited mouth opening of less than 1 cm. Intraoral examination showed impaction of permanent tooth 38, with gingival swelling and pus fluxing from the gingival sulcus of the impacted third molar. The patient’s medical history revealed no presumable cause and the patient had no history of drinking alcohol or smoking. A computed tomography scan of the patient’s head showed a lytic lesion in the left ramus of the mandible. The lesion resembled a tunnel from the impacted third molar to the condyle and had destroyed the outer cortical plates of the condyle (Figs. 1 and 2). Based on test results and a history of pain around the left lower region of the third molar, the patient was diagnosed with infection of the buccal, temporal, pterygomandibular and masseteric spaces followed by
Fig. 1 A panoramic radiograph showed a lytic lesion of the left ramus of the patient’s mandible. The lesion resembled a tunnel from the impacted third molar to the condyle.
osteomyelitis of the condyle secondary to pericoronitis of an impacted third molar. As per the patient’s request, the treatment plan included extraction of the third molar, removal of the buccal alveolar bone of the third molar, drainage from the buccal cavity of the third molar, and incision and drainage of the preauricular area. The patient was discharged with a prescription for intravenous injections of clindamycin and metronidazole. He fully recovered after 14 days and did not report pain or swelling on the left side of the face in telephone follow-ups. DISCUSSION Prophylactic removal of impacted third molars, which is the extraction of the asymptomatic impacted third molars, remains highly controversial.5 Generally, any recommendation for prophylactic removal of third molars should consider ongoing symptoms or pathology, future complications and morbidity associated with retention of the third molars, and possible increased risks of extraction at an older age.5,6 Several studies7,8 have provided strong evidence to support the retention of asymptomatic mandibular third molars, showing that extraction of impacted lower third molars is associated with mandibular fractures and increased risk of injury to the lingual and inferior alveolar nerve. In addition to some common complications (periodontal disease, odontogenic infections, systemic inflammation and anterior incisor crowding), impacted third molars are also associated with serious complica-
Fig. 2 A computed tomography scan and three-dimensional reconstruction of the left hemi-mandible revealed the lesion deteriorated the outer cortical plates of the condyle. © 2014 Australian Dental Association
373
R Wang et al. tions such as mandibular fractures and development of cysts and tumours.6 Previous studies have reported that asymptomatic and radiographically pathology-free retained third molars have the potential for cystic (or neoplastic) transformation over the lifespan of a patient.6 About 25% to 59% of all patients with retained third molars suffer from this condition.6,9,10 Moreover, extensive evidence6,11,12 shows that removal of impacted third molars reduces the incidence of mandibular angle fractures, which is said to be caused by a decrease in the cross-sectional area of bone at the angle with a retained third molar and a greater susceptibility to mandibular angle fractures. Additionally, the preexisting periodontal disease around the distal of the second molar generally improves with extraction of the third molars,6 and extractions done at an older age can lead to more serious complications. Thus, prophylactic extraction of mandibular third molars in early adulthood merits serious consideration. In this study, development of osteomyelitis of the condyle was the first observed complication secondary to an impacted third molar. Therefore, extraction of the third molar should be performed as early as possible even in the absence of symptoms. Surgical management of osteomyelitis of the condyle aims to relieve symptoms and minimize morbidity without affecting the functional efficiency of the mandibular condyle.13 It is well-known that decortication and removal of necrotic tissue, and surgical resection of the condyle are the two possible methods for managing osteomyelitis of the condyle.14 However, in the present case, decortication and removal of necrotic tissue could have caused the pathological fracture of the condyle, while surgical resection of the condyle would not cure osteomyelitis of the ascending ramus of the left mandible. Considering the clinical findings and the patient’s request, removal of the aetiological factor and combined therapy of drainage opening and systemic administration of antibiotics was deemed the best treatment option. Importantly, this treatment method resulted in a favourable outcome with minimal detrimental effects.
2. Kunkel M, Kleis W, Morbach T, Wagner W. Severe third molar complications including death–lessons from 100 cases requiring hospitalization. J Oral Maxillofac Surg 2007;65:1700–1706. 3. Reck SF, Fielding AF, Hess DS. Osteomyelitis of the coronoid process secondary to chronic mandibular third molar pericoronitis. J Oral Maxillofac Surg 1991;49:89–90. 4. Chen L, Li T, Jing W, et al. Risk factors of recurrence and lifethreatening complications for patients hospitalized with chronic suppurative osteomyelitis of the jaw. BMC Infect Dis 2013;13:313. 5. Kunkel M, Morbach T, Kleis W, Wagner W. Third molar complications requiring hospitalization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:300–306. 6. Bagheri SC, Khan HA. Extraction versus nonextraction management of third molars. Oral Maxillofac Surg Clin North Am 2007;19:15–21, v. 7. Zhu SJ, Choi BH, Kim HJ, et al. Relationship between the presence of unerupted mandibular third molars and fractures of the mandibular condyle. Int J Oral Maxillofac Surg 2005;34:382–385. 8. Iida S, Nomura K, Okura M, Kogo M. Influence of the incompletely erupted lower third molar on mandibular angle and condylar fractures. J Trauma 2004;57:613–617. 9. Adelsperger J, Campbell JH, Coates DB, Summerlin DJ, Tomich CE. Early soft tissue pathosis associated with impacted third molars without pericoronal radiolucency. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:402–406. 10. Glosser JW, Campbell JH. Pathologic change in soft tissues associated with radiographically ‘normal’ third molar impactions. Br J Oral Maxillofac Surg 1999;37:259–260. 11. Iida S, Hassfeld S, Reuther T, Nomura K, Muhling J. Relationship between the risk of mandibular angle fractures and the status of incompletely erupted mandibular third molars. J Craniomaxillofac Surg 2005;33:158–163. 12. Hanson BP, Cummings P, Rivara FP, John MT. The association of third molars with mandibular angle fractures: a meta-analysis. J Can Dent Assoc 2004;70:39–43. 13. Lambade P, Lambade D, Dolas RS, Virani N. Ectopic mandibular third molar leading to osteomyelitis of condyle: a case report with literature review. Oral Maxillofac Surg 2013;17: 127–130. 14. Zemann W, Feichtinger M, Pau M, Karcher H. Primary osteomyelitis of the mandibular condyle–a rare case. Oral Maxillofac Surg 2011;15:109–111. 15. Thoma KH. Oral Surgery. 4th edn. St Louis: Mosby, 1983: 603–671. 16. Tong AC, Ng IO, Yeung KM. Osteomyelitis with proliferative periostitis: an unusual case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e14–19. 17. Mohammed-Ali RI, Collyer J, Garg M. Osteomyelitis of the mandible secondary to pericoronitis of an impacted third molar. Dent Update 2010;37:106–108.
ACKNOWLEDGEMENTS This study was supported by grants 81200772 and 81102054 from the National Natural Science Foundation of China and 121064 from Wuhan University to Rong Wang. REFERENCES 1. Adeyemo WL. Do pathologies associated with impacted lower third molars justify prophylactic removal? A critical review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:448–452.
374
Address for correspondence: Professor Ji-Hong Zhao Department of Oral and Maxillofacial Surgery School and Hospital of Stomatology Wuhan University 237 LuoYu Road Wuhan 430079 China Email: [email protected] © 2014 Australian Dental Association
