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Condylar loss due to infantile osteomyelitis
CONDYLAR LOSS DUE TO INFANTILE OSTEOMYELITIS DAVID J. KENNEDY, D.D.S., SYRAC~TSE,N. Y. N M A Y 27, ]955, a 26-year-old man was r e f e r r e d for t r e a t m e n t of a swelling of the left mandible of three d a y s ' duration. There was m o d e r a t e swelling of the left cheek and also of the mucobuecal fold of the molar area.
O
The p a t i e n t p r e s e n t e d an e x t r e m e l y obvious facial d e f o r m i t y which app a r e n t l y h a d its source in the left r a m u s and was reflected in the occlusion. The mandible exhibited considerable regression in comparison to the maxilla and a large c o n c a v i t y was present in the superior r a m u s region (Fig. 1). Deviation of the mandible to the ]eft side was extensive (Fig. 2). The p a t i e n t was able to attain an a n t e r i o r opening of 45 ram., and the mandible shifted even f a r t h e r to the left side during the opening movement. The m a n d i b u l a r incisors i m p i n g e d upon the palate and a distance of 15 mm. was m e a s u r e d between the incisive edges of the m a x i l l a r y and m a n d i b u l a r incisors. Oral hygiene was poor a n d n u m e r o u s teeth were missing. The p a t i e n t claimed t h a t he h a d no m a s t i e a t o r y difficulties, and a review of his diet: seemed to substantiate this surprising elaim. The m a n d i b u l a r left first m o l a r w~ts tender to percussion. An intraora] r o c n t g e n o g r a m disch)sed an apical area ~)f r a r e f a c t i o n on the mesial root of this tooth. The crown of an i m p a c t e d third m o l a r was noted in the film and a resorptive process was a p p a r e n t in the ])one around the crown, p a r t i c u l a r l y on the distal side of the second molar. A lateral j a w r o e n t g e n o g r a m (Fig. :I) was t a k e n of the left mandible to obt~dn ~ more s a t i s f a c t o r y view of the une r u p t e d tooth. This flint indicated their there was no bone in the c o n d y l a r re~ion. On questioning the patient, it was discovered t h a t the facb,1 a s y m m e t r y had been present all his life. A t 5 months of a~'e he developed a "strep" infection of the rig'ht toe. This was opened for drainage. Subsequently, a swelling of the left cheek appeared, which was also incised. A 1/2 inch scar could be seen about 1~ inch a n t e r i o r to the lower p a r t of the left ear. A t a l a t e r date, an
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CONDYLAR
Fig.
profile v i e w i l l u s t r a t i n g t h e c o n c a v i t y in t h e s u p e r i o r the mandible.
1.--Left
LOSS
DUE
TO INFANTILE
Fig'. 2 . - - F u l l f a c e v i e w s h o w s f a c i a l a s y m m e t r y
29
OSTEOMYELITIS
ramus
and
retrusion
of
a n d d e v i a t i o n of m a n d i b l e to t h e left.
Fig. 3 . - - L e f t l a t e r a l j a w r o e n t g e n o g r a m . Note loss of t h e c o n d y l e a n d t h e a c c e n t u a t e d i n d e n t a t i o n a t l o w e r b o r d e r of m a n d i b l e .
30
KENXE])Y
o . s . , o. M., ~ o. l'.
J:muat). 19:,7
Treatment.--The patient was given penicillin intramuscularly. Nit~'ous oxide and oxygen anesthesia was used, and an incision and drainage proeedm'c was performed in the nmeobueeal fold of the left mandibular molar area. The first and second molar teeth were extracted. Normal response to therapy was
Fig'. 4 . - - V i e w o f r i g h t a n d l e f t t e m p o r o m a n d i b u l a r j o i n t areas tion. Note sclerotic appearance at the site of the r
with mandible in closed f o s s a o n t h e left.
posi-
apparent the next day, and the rubber drain was removed. Arrangements were made to have tcmporomandibular joint vocntgenograms taken. The roentgenologist's report %1lows.
"Radiographic examination of the temporomandibular joints shows that tile right temporomandibular joint is entirely normal in appearance. It is noted that the condyle of the left side of the mandible is missing (Fig. 4). This was undoubtedly destroyed at the time of this patient's previous osteomyelitis. There is also some deformity of the angle of the mandible on the left, undoubtedly dne to destruction by the former osteomyelitis. I cannot identify anything that might suggest the presence of active osteomyelitis at this time. "Conclusion:
The entire condyle of the left side of the mandible is missing. This is undoubtedly the result of the old osteomyelitis. There is no evidence of active osteomyelitis at this time." Two weeks later, the unerupted mandibular left third molar was removed under local anesthesia and the patient was advised to obtain restorations for his numerous missing teeth.
Discussion A patient was seen for routine treatment. The resulting examination led to the discovery that the left condyle was missing. The possibility that
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31
this case may represent congenital agenesis of the condyle cannot be completely ruled out. The medical history strongly suggests that the patient had suffered a blood-borne osteomyelitic infection during infancy. Thoma 1 believes the etiology of infantile osteomyelitis to be infection, tie states that hcmatogenous involvement is not unusual and often results in multiple ostcomyelitis from a skin injury, infection of the middle car, mastoid, or tonsils, or typhoid fever or pneumonia. Wilensky 2 claims that Staphylococcus aureus is the most common organism. SelP feels that streptococcus or pneumococcus septicemia causes metastatic infection through hematogenous channels. After weighing the evidence in this case, it seems logical to conclude that the loss of the condyle was due to hematogenous spread of an osteomyelitic infection which originated in the patient's toe. References 1. Thoma, K u r t H.: Oral Pathology, ed. 3, St. Louis, 1948, The C. V. l~Iosby Company, p. 859. 2. Wilensky, A. O.: Osteomyelitis of the Jaws in Nurslings and Infants, Ann. Surg. 95: 33, 1932. 3, Self, Edward B.: Acute Hematogenous Osteomyelitis, Pediatrics 1: 617, 1948.
O
The p a t i e n t p r e s e n t e d an e x t r e m e l y obvious facial d e f o r m i t y which app a r e n t l y h a d its source in the left r a m u s and was reflected in the occlusion. The mandible exhibited considerable regression in comparison to the maxilla and a large c o n c a v i t y was present in the superior r a m u s region (Fig. 1). Deviation of the mandible to the ]eft side was extensive (Fig. 2). The p a t i e n t was able to attain an a n t e r i o r opening of 45 ram., and the mandible shifted even f a r t h e r to the left side during the opening movement. The m a n d i b u l a r incisors i m p i n g e d upon the palate and a distance of 15 mm. was m e a s u r e d between the incisive edges of the m a x i l l a r y and m a n d i b u l a r incisors. Oral hygiene was poor a n d n u m e r o u s teeth were missing. The p a t i e n t claimed t h a t he h a d no m a s t i e a t o r y difficulties, and a review of his diet: seemed to substantiate this surprising elaim. The m a n d i b u l a r left first m o l a r w~ts tender to percussion. An intraora] r o c n t g e n o g r a m disch)sed an apical area ~)f r a r e f a c t i o n on the mesial root of this tooth. The crown of an i m p a c t e d third m o l a r was noted in the film and a resorptive process was a p p a r e n t in the ])one around the crown, p a r t i c u l a r l y on the distal side of the second molar. A lateral j a w r o e n t g e n o g r a m (Fig. :I) was t a k e n of the left mandible to obt~dn ~ more s a t i s f a c t o r y view of the une r u p t e d tooth. This flint indicated their there was no bone in the c o n d y l a r re~ion. On questioning the patient, it was discovered t h a t the facb,1 a s y m m e t r y had been present all his life. A t 5 months of a~'e he developed a "strep" infection of the rig'ht toe. This was opened for drainage. Subsequently, a swelling of the left cheek appeared, which was also incised. A 1/2 inch scar could be seen about 1~ inch a n t e r i o r to the lower p a r t of the left ear. A t a l a t e r date, an
Volume t0 Number l
CONDYLAR
Fig.
profile v i e w i l l u s t r a t i n g t h e c o n c a v i t y in t h e s u p e r i o r the mandible.
1.--Left
LOSS
DUE
TO INFANTILE
Fig'. 2 . - - F u l l f a c e v i e w s h o w s f a c i a l a s y m m e t r y
29
OSTEOMYELITIS
ramus
and
retrusion
of
a n d d e v i a t i o n of m a n d i b l e to t h e left.
Fig. 3 . - - L e f t l a t e r a l j a w r o e n t g e n o g r a m . Note loss of t h e c o n d y l e a n d t h e a c c e n t u a t e d i n d e n t a t i o n a t l o w e r b o r d e r of m a n d i b l e .
30
KENXE])Y
o . s . , o. M., ~ o. l'.
J:muat). 19:,7
Treatment.--The patient was given penicillin intramuscularly. Nit~'ous oxide and oxygen anesthesia was used, and an incision and drainage proeedm'c was performed in the nmeobueeal fold of the left mandibular molar area. The first and second molar teeth were extracted. Normal response to therapy was
Fig'. 4 . - - V i e w o f r i g h t a n d l e f t t e m p o r o m a n d i b u l a r j o i n t areas tion. Note sclerotic appearance at the site of the r
with mandible in closed f o s s a o n t h e left.
posi-
apparent the next day, and the rubber drain was removed. Arrangements were made to have tcmporomandibular joint vocntgenograms taken. The roentgenologist's report %1lows.
"Radiographic examination of the temporomandibular joints shows that tile right temporomandibular joint is entirely normal in appearance. It is noted that the condyle of the left side of the mandible is missing (Fig. 4). This was undoubtedly destroyed at the time of this patient's previous osteomyelitis. There is also some deformity of the angle of the mandible on the left, undoubtedly dne to destruction by the former osteomyelitis. I cannot identify anything that might suggest the presence of active osteomyelitis at this time. "Conclusion:
The entire condyle of the left side of the mandible is missing. This is undoubtedly the result of the old osteomyelitis. There is no evidence of active osteomyelitis at this time." Two weeks later, the unerupted mandibular left third molar was removed under local anesthesia and the patient was advised to obtain restorations for his numerous missing teeth.
Discussion A patient was seen for routine treatment. The resulting examination led to the discovery that the left condyle was missing. The possibility that
Volume I0 Number I
CONDYLAR LOSS DUE TO I N F A N T I L E O S T E O M Y E L I T I S
31
this case may represent congenital agenesis of the condyle cannot be completely ruled out. The medical history strongly suggests that the patient had suffered a blood-borne osteomyelitic infection during infancy. Thoma 1 believes the etiology of infantile osteomyelitis to be infection, tie states that hcmatogenous involvement is not unusual and often results in multiple ostcomyelitis from a skin injury, infection of the middle car, mastoid, or tonsils, or typhoid fever or pneumonia. Wilensky 2 claims that Staphylococcus aureus is the most common organism. SelP feels that streptococcus or pneumococcus septicemia causes metastatic infection through hematogenous channels. After weighing the evidence in this case, it seems logical to conclude that the loss of the condyle was due to hematogenous spread of an osteomyelitic infection which originated in the patient's toe. References 1. Thoma, K u r t H.: Oral Pathology, ed. 3, St. Louis, 1948, The C. V. l~Iosby Company, p. 859. 2. Wilensky, A. O.: Osteomyelitis of the Jaws in Nurslings and Infants, Ann. Surg. 95: 33, 1932. 3, Self, Edward B.: Acute Hematogenous Osteomyelitis, Pediatrics 1: 617, 1948.