Decortication in treatment of osteomyelitis of the mandible

Oral

SURGERY

Oral

MEDICINE

ANDorai

PATHOLOGY

VOLUME

29

NUMBER

5

MAY,

1970

Operative oral surgery

Decortication in treatment of osteomyelitis of the mandible E. H$rting-Hansen,

D.D.S., Dr. odojlt., * Ziirich,

Xwitmdand

DEPARTMENT OF ORAL AND RIBXILLO-FACI~~L SURGERY ( HE.~D : HITGO 1,. OBWEGESER, M.D., D.M.D.), UNIVERSITY DENTAL SVHOOL, UNIVERSITY OF ZtiRICH

E

arly in the antibiotic era most serious cases of acute osteomyelitis WPW cured. Before penicillin was introduced, patients occasionally died of osteomyelitis of the mandible, but since the advent of the antibiotics such deaths have been rare 2:.27,34 For the successful t.reatment of acute osteomyelitis with antibiot.ics, it is essential that treatment be initiated as soon as possible after the onset of s.vmptomsl*, 13,16,*A *C 31 Furthermore, the etiologic agents should be attacked wit.h an antibiotic to which they are sensitive. In 1954 Trueta and Morgan3” reported that in eighty-two cases of osteomyelitis of long bones in which 8taphylococ~cu.s nureus was the causative agent, these staphylococci were relatively resistant, t,o penicillin in only three cases. Harris I3 found that 35 per cent of sixty-four batterial cultures taken from osteomyelitic foci of long bones mere resistant to penicillin. This alarming increase in the development of resistant, strains was further strcsed by Green!“’ who found 55 pc’r (dent of thirty-one cultures of Presented in part at the Oesterreichische ZahnLrztetnk~ngr, Graz, Austria. St~ptow~b+!r, 1968. *Assistant, Department of Oral and Maxilla-Facial Surgery, University of Ziiricth. t’resent address: Dental Department, University Hospital, Rlegdamsvej, Copenhagen, Ikwnnrk. 641

642

H.&Ming-Hamen

Oral Surg. May, 1970

staphylococci to be insensitive to penicillin. Similar figures for osteomyelitis of the jawbones were reported by Grasser,g Stiebitz,30 and Christensen.’ The surgical treatment of osteomyelitis may be divided into four categories: 1. Drilling of burr holes into the marrow cavity. This is most often applied in combination with antibiotic therapy in the early treatment of acute osteomyelitis of the long bones.13’ 35 2. Removal of sequestra after complete x-ray demarcation later in the course of the disease. This was recommended by several authors in the treatment of osteomyelitis of the mandible.15J 23,37 3. Radical surgical treatment and decortication. 4. Resection of the affected areas with immediate or later reeonstruction.20 The decortication procedure involves removal of the entire cortical plate of the outer side covering the diseased area. The removal should be extended 1 to 2 cm. beyond where the bony edges are bleeding normally. Sequestra and granulation tissues are removed at the same time. This operative procedure was suggested by OrP for the treatment of chronic osteomyelitis of long bones. The decorticated area was kept open and packed with petrolatum gauze. Miltner and WolfeI applied this principle in treating suppurative osteomyelitis of the mandible and reported good results in eight cases. In the preantibiotic years they recommended that the decortication be performed no’ earlier than 3 weeks after appearance of the first symptoms, because of the possible risk of spreading the infection. In 1944 and 1945 Mowlemls~ I9 suggested primary closure of the skin wound after the decortication. At the time of operation, tubes for penicillin instillation were inserted and penicillin was administered for 3 to 10 days. This procedure was used with great success in forty-five cases. Although in most cases the decortication was performed 10 weeks after the first symptoms appeared, Mowlem recommended that the operation be carried out as early as possible. Similar results were reported by Wass.36 ObwegesePO reported good results with decortication in nine cases. In eight of these the decortication was performed as an intraoral procedure with primary closure of the mucosa; healing was uneventful. Later Becker,3 Allwright,l and Zisser38a38 performed the decortication via the intraoral route; they, too, reported good results. In the United States saucerization, with the use of a tube for instillation of an antibiotic, has been recommended by Thoma.32 Most authors agree that the best treatment for acute osteomyelitis is early antibiotic therapy, with high doses given over a sufficiently long time. However, the incidence of subacute and chronic osteomyelitis of the jawbones is increasing,2T 3r 34 and conservative therapy in such cases is protracted and unsuccessful. For this reason, it seemed worthwhile to present the results of a long-term observation of cases of osteomyelitis of the mandible which had been treated by decortication. MATERIAL

AND

METHODS

The material consisted of twenty-eight patients, seventeen men and eleven women, in whom osteomyelitis of the mandible was treated by decortication (Table I). All patients were referred from elsewhere, and the earliest referral

Volume Number

Table

29 5

I. Distribution

Deco&cation

according to type of osteomyelitis, 10

Diagnosis

in t,reatment of osteomyelitis

to 30 yrs.

Men

Women

age, and sex

&e 31 to 60 yrs.

61 to 80 yrs.

Men

Xen

Women

643

Totals Women

,Nen

KotB I Women / sexes

Acute/subacute osteomyelitis Secondary chronic. osteomyelitis Primary chronic osteomyelitis

was 3 weeks after onset of the disease. The paCents \vere t,reated during the period from 1958 to 1967 in the Department of Oral and MaxilloLFacial Surgery, Dental Institute, University of Ziirich. The short-term results in nine of thesc cases were reported by Obwegese?O in 1960. Terminology

Acute/subacute osteomyelitis. Patients in t,his group had one or more of the classic symptoms and signs of acute osteomyelitis of the jaws. These symptoms-swelling, pronounced pain, increased body tempcraturc, increased mobility 01 the teet,h in the involved area, absce.sses and drainage of pus, and disturbecl sensibility in the region of the mental nerve-had been present before decort,ication. Antibiotic treatment prior to decortication had been unsuccessful ill bringing the disease under control Radiographically, only minor changes were present; these were slight osteoporosis or a beginning radiolucency with demar cation of sequestra (Fig. 1). There were seven patients in this group (Table I). Xecondary chronic osteomyelitis. Prior treatment, usually with antibiotics, had abated the symptoms of acute osteomyelitis in this group of patients. Acute to subacute exacerbations were later noted, and further treatment with antibiotics or conservative surgical treatment (removal of sequestra) was not successful; the osteomyelitis of the mandible persisted. Fistulae, drainage of pus, soft-tissue swelling, tenderness of the affected bone, and neurologic symptonis in the mental region were often present at the time of decortication. Radiographically, various-sized areas of the mandible had been destroyed; scquestra surrounded by irregular radiolucencies were characteristic (Fig. 5). This ,group comprised fifteen patients. Primary chronic osteomyelitis. The onset of disease in this group was irksidious; often there was only slight pain, which disappeared without treatment but later recurred. A slow increase in size of the ma.ndihle was noted, and occasionally a sequestrum was found, without actual drainage of pus. Often tile symptoms had existed for several years before the patients had been referred for treatment. Radiographically, a “cotton wool” appearance, similar to that seen in osteitis deformans (Paget’s disease of bone), was seen. Radiopaque areas interspersed with small radiolucent zones and often a periosteal reaction with for-

644

Hjgrting-Hansen

Fig.

May, 1970 Oral Burg.

2

Fig. 1. Acute osteomyelitis in a 46.year-old man. The osteomyelitis developed removal of the third molar. Note the irregular radiolucency in the angle area. Fig. 8. Same patient as in Fig. 1, immediately after decortication. The cortical was removed from the region of the first molar nearly to tbc semilunar notch.

Fig. 3. Cortical

plate removed from patient

shown in Figs. 1 and 2.

after plate

Volume Number

Fig.

Decortication,

29 5

4. Same

patient

as in Figs.

in frentme~zf

1 to 3. Radiographic

appearance

645

of osteomyelitis

7 years

aj iter

dc rcorti.

cal tion.

E

E

6

Fig. 5. Secondary chronic osteomyelitis in a 29-year-old woman. The osteomy ,elitis develed aft ,er extraction of the second premolar, and symptoms had been present fol . more : than month is. Note the sequestra and t,he irregular radiolueent areas along t,he 12ase 0 f the ma tndibk Fig. 6. Same patient as in Fig. 5, immediately after decortication from the catnine I.egion t0 the a, WIle area. The third molar was projecting into osteomyelitic foci and was rem07 red.

lip

Map, Eli0 Oral Rurg.

after

Fig. 7. Same pat,ient decortication.

Fig.

as in Figs. 5 and 6. Complete

regeneration

of the mandible

Fig.

8

Figs. 8 and 3. Extensive changes of the mandible chronic osteomyelitis of several years’ duration.

in a ‘i3-year-old

3 years

9 woman

with

primary

mation of dense sclerotic bone were seen (Figs. 8 and 9). This group consisted of six patients (Table I). Age

of patients

The material was divided into three groups on the 31 to 60, and 61 to 80 years (Table I). Most of the subacute and secondary chronic osteomyelitis were 31 to the six patients with primary chronic osteomyelitis were (Table I). lime

of decortication

and

operative

basis of age: 10 to patients with acute 60 years of age. Five more than 60 years

30, to of old

procedure

No decortication was performed less than 3 weeks after the onset of symptoms. In patients with acute or subacute osteomyelitis decortication was performed

F1:q. 20. Same patient as in Figs. 5 and 9, 3 years after decortication. The bony structuw is nearly normal, and a biopsy specimen from the right side shomed no signs of persistirlcl ost,eomyelitis.

Table

II. Time lapse between onset of symptoms and tlccortication Acute/subnr~~te osteomye7iti,s

rSe~ondn~y,/chronic osteomyelitis

3 7 .> L’ 1

7 -

3 to 8 weeks 9 to 26 weeks l/i to 2 years 2 to 4 years More than 4 years

is

7

Primccry/chro7lic ostromyeEiti,s

1 1 4 ci

within the first 8 weeks after the onset of the disease. In eight of the remaining patients from the two other groups the operation was first performed more than 2 years after the onset of the disease; in one patient the symptoms and signs had persisted for 1.5 years (Table II). The operations were performed under general anesthesia. In twenty-seven cases the operation was performed as an intraoral procedure with primary closure of the soft-tissue wound. Teeth located in the ostcomyelitically diseased bone were removed at, the same time; otherwise, they were left, and excochleation in the apical areas of these teet,h was performed very carefully. When soft-tissue dehiscence occurred, irrigation with antibiotics for local LEE (Nebacetin), was indicated until the wound had closed ; this varied from a few days to one week. When possible, the entire cortical pla.te covering the pathologic area was removed in one piece (Fig. 3). (Careful suturing and the use of a pressure bandage helped prevent cavity forma.tion between the softtissue flap and the denuded bone. In every case but one, the buccal cortical plate was removed. Although the lingual cortical plate showed ostromyelitic perfora-. tions in many instances, it was not operated upon. Antibiotic

treatment

prior

to

decortication

and

postoperatively

In nineteen patients, antibiotic treatment had brcn started elsewhere before we performed the decortication. In no case in this group was antibiotic treatment

648

Oral Surg. May, 1970

Hjprting-Hansefa

curative. After the decortication, antibiotics were given to twenty-four four patients received no antibiotics postoperatively. Bacterial

patients;

cultures

Bacteriologic Neurologic

culture

symptoms

and sensitivity

in the region

tests were carried out in fifteen cases.

of the mental

nerve

The degree of sensibility in the region of the mental nerve was recorded before decortication. This was checked immediately after the operation and during the follow-up examinations (Table IV). location

The material was divided according to the anatomic area: Two to four teeth, five to eight or body and ramus (Fig. 11). In four of the osteomyelitis, large parts of the body and even involved. Relation

of tooth

extraction

to onset

osteomyelitic extension into an teeth, body of mandible, ramus, six cases with primary chronic the ramus of the mandible were

of disease

On the basis of anamnestic information and referral notes, attempts were made to correlate the dental disease or dental extraction with the onset of disease (Table III). Histologic

examination

In twenty-six cases the removed bone was submitted for histologic examination which, in each case, confirmed the clinical and radiographic diagnosis. An analysis of the histopathologic findings will be published separately. Table

III. Origin of osteomyelitis Acute/ szlbaoute

Origin Dental Probably dental Probably hematogenous Other causea

Table

IV. Sensibility

Secondary

chronk

7 -

12 1 1 1

?

15

Primary chronic -

Total 19 2

i -

Y

s

of the mental region before decortication,

ii

immediately Secomlary

Acute/subaowte Before Sensibility normal Hypoesthesia Hyper- or paresthesia Anesthesia Sensations by change of weather No information

1 1 3 2

Follow-up

after

exam.

T 5 ;

h-0:

osteomyelitis

osteomyelitis

Immediately

aftc

Immediate Before

after

2

8 3

;”

: 4

i

8

3

2

Decortication in treatment

Volume 29 Number 5

of osteomyelitis

649

RESULTS

In the follow-up, twenty-two of the twenty-eight patients reported for examination. The other six patients had died of other diseasesor had moved away from Switzerland. Twenty of the twenty-two patients were followed for 2 years or more after the decortication; in nine easesthe observation period was 5 yea.rs or more. The results of the decortication are tabulatrd in Table 1’. Primar\~ healing of the soft-tissue wound and complete regeneration of the affected boric. without late symptoms or signs of a persisting osteom.velitis, were found ill five of the six controlled casesof acute/subacute osteomyelitis and in nine of tht: ten casesof secondary chronic osteomyelitis (Figs. 4 and 7). Ko patient. in thcsc groups showed persistence of disease and, according to the charts, the rcsnlts were similar in the six cases in which a follow-up examination was impossible. In the primary chronic osteomyelitis group, one patient, demonstrated a primary cure (Fig. 10). In three cases,one to three acute t,o subacute exacerbat,ions ww seen; removal of superficial sequestra. and further antibiotic t reat,mcnt. WPW required before healing occurred. A similar condition was observed in two patients with acute/subacute and secondary chronic osteomyelitis. The osteomy+ litis persisted in the remaining two patients in the group with primary chronic osteomyelitis. In no case wa.s a pathologic fracture encountered in yel:ltion ro the decortication. Operative

findings

Acute/subacute type. The cortical bone occasionally demonstrated small perforations; otherwise, it appeared normal and the rigidity was that of normal bone. The cortical plate could be chiseled off in one piece. The spongy bone and its marrow spaces were replaced by inflammatory tissue with pus. After escochleation perforations and osteomyelitic foci were often seen in the lingual cortical bone. Secondary chronic type. Here greater perforations of the cortical bone were often present. The periosteum was occasionally more adherent to the bony SLIPface than normal because of sear tissue. The cortical bone was often softer t.hnn normal bone, but in most casesit was possible to remove the cortical plate in one piece. A reactive periosteal new bone formation was noted in some cases. After removal of the cortical bone, a cavity containing abscessformations and partially

nd at follow-up examination Total

PG?tIfZry chronic osteomyelitis FOllO‘W-Up

exam.

Before

Immediately after

5 4

2 1 2

1 5

f

1

-

Follow-up exam.

1 3 1 1 1

Before

Immediately after

11 5

4 3

6

18 3

s

-Follow-up exam.

6 9 4 2 7 1

650

ISj@-ting-I;Tansen

Oral Surg. May, 1970

Table V. Clinical and radiographic findings at follow-up examination of twentytwo casesof osteomyelitis of the mandible treated by decortica.tion Acute/ subacute Complete healing contour

with normal

of osteomyelitic

chronic type

Primary

5

9

1

15

1

1

3

5

2

2

Total

bone

One to three exacerbations after decortication, then complete healing Persistence

Secondary chronic type

infection

filled with granulation tissue was found. Sequestra were often seen. Perforations of the lingual cortical bone occurred also in the secondary chronic type of osteomyelitis. Primary chronic type, Reactive new bone formation on the surface of the cortical bone was a characteristic finding after elevation of the periosteum. The surface of the cortical bone was rough. Removal of the cortical plate was very difficult because of sclerosis of the spongy bone. After removal, no cavity formation was found; on the contrary, the marrow spaces were nearly obliterated by a dense sclerotic bone. Occasionally, small cavities filled with granulation tissue were encountered. Antibiotic

treatment

Only one of the four patients who had not had postoperative antibiotic treatment reported for follow-up. In this one case the immediate postoperative healing was primary, and at the follow-up examination 3+$ years after the decortication the radiographic picture was normal and there were no symptoms or signs of a persisting osteomyelitis. In the remaining three patients, the postoperative healing was uneventful and had remained so through the last followup examination. Bacterial

cultures

In three of the fifteen cases, the bacteriologic examination showed a mixed flora; in the remaining twelve cases,a single type of bacterium was demonstrated. Staphylococci were present in nine cases,five of which were resistant to penicillin; hemolytic streptococci were found in four cases, and all were sensitive to penicillin. Further enterococcus and colibacteria were found. Where resistance to penicillin was found, tetracycline or Streptomycin was given for 4 to 6 days as postoperative antibiotic therapy. Neurologic

symptoms

in the region

of the

mental

nerve

At the first examination eleven patients were found to have sensory alteration over the distribution of the mental nerve; this ranged from a slight hypoesthesia to anesthesia. This finding was most pronounced in the acute/subacute osteomyelitis group (Table IV). In six patients no information was available; in

Volume

29

Numlocr

5

acute/subacute secondary chronic primary chronic number of

2-4 teeth or 5-8 teeth angle of the jaw Pig. 11. Location

of osteomyelitis

Entire body of mandible

according

to involwd

Ramus

Ramus and body

jaw segment.

eleven, sensibility was normal. At the follow-up examination fifteen of the twenty-two patients followed had normal to slightly reduecd sensibility. The degree of hyposensibility was so modest that most of the patients were not awarc of a change. Two patients had permanent anesthesia. Because of severe mental retardation and a nearly complete aphasia, r&able information could not be gathered in one case. Seven patients complained of a slight itching sensation when the weather changed. Immediately postoperatively eighteen pat.ients had a complete anesthesia of the region of the mental nerve, but this was transitory; in two of these patients comp1et.canesthesia was still present at the follow-u11 examination. location

Fig. 11 shows the specific location of the osteomyelitis. Large areas of tlm body of the mandible, as well as the ramus, were affected in four of t.he sis patients with primary chronic osteomyelitis. In the other osteomyelitis groups the number of cases in the two location categories (limited area versus extensive area) was nearly the same. Relation

of tooth

extraction

to onset

of disease

In fifteen patients t.he extraction of teeth could be correlated with the onset of the disease; fourte.en of these were patients with acute/subacute or secondary chronic osteomyelitis. Molars had been extracted in nine patients, premolars in three patients, and incisors in three patients. Erysipelas was the cause in one case in the secondary chronic osteomyelitis group; in the Same group a bee sting in the chin region caused an infection of the soft tissues, which was followed by osteomyelitis. Three patients with primary chronic osteomyelitis were edentulous. One had one tooth left at the onset of disease and this was extracted as it was presumably the cause of the disease. The remaining two patients in the: primary chronic osteomyelitis group were dentulous, but in these two patients

652

Hjprrting-Hansen

Oral Burg. May, 1970

as well as the three edentulous patients in the same group no relation between dental pathosis and osteomyelitis could be established. DISCUSSION

On the basis of extensive studies, Brosch4-6 described the histopathologic picture of osteomyelitis of the mandible. He found that, as the infection progressed, the spongy bone and its marrow spaces were converted to a continuing “marrow cavity” of the mandible. This means that when an osteomyelitis of the mandible is established, the pathologic/anatomic picture of the mandible is similar to the findings of osteomyelitis in a long bone. The arteries of the mandible are end-arteries.ll The vascular thrombosis caused by infection occurs very early in the course of the disease,36making the possibility of curing osteomyelitis of the mandible with antibiotics rather dubious, unless the antibiotic treatment is instituted within the first 48 to 72 hours after the onset of symptoms. Hunsuckl’ found that, although the vascularity of the periosteum is abundant, the actual number of vascular communications between the periosteum and the vessels of the marrow space is limited. If the vascular supply to the mandible in human beings is similar to that of rhesus monkeys, does this mean that the cortical bone receives its major blood supply from the marrow spaces?In cases of osteomyelitis, it is to be expected that most of the cortical bone will eventually become necrotic. The pathologico-anatomic rationale for performing a decortication is thus well established. ObwegeserzOwas the first to perform this operation via an intraoral approach and to close the soft tissues primarily. Earlier it had been performed via an extraoral incision, either with packing17 or with primary closure. 181I913F The extraoral approach, irrespective of the method used, resulted in scarring. This can be completely avoided by the intraoral incision. The present findings corroborate the short-term observations of Obwegese?Oand the reports of Becker3 and Zisser.38 In the present study, decortication yielded a very high percentage of healing in patients with acute/subacute or secondary chronic osteomyelitis. It should be pointed out that in the acute/subacute group the decortication was never performed less than 3 weeks after the first signs of disease. If proper antibiotic treatment is instituted sufficiently early in the course of osteomyelitis (2 to 3 days after onset), this is the treatment of choice for the acute type, and it has a high rate of success. If the optimum time has been missed, however, the bacteria will probably become resistant to the antibiotics. There is also an indication for carrying out a decortication in the acute/ subacute stage. The well-known protracted course of conservatively treated cases of the secondary chronic type establishes, in view of the present findings, an absolute indication for decortication. This is in agreement with the findings of Kinnman and Lee,15who used saucerization, removal of sequestra, and modeling of the borders of the osteomyelitic foci in combination with a 6-week period of treatment with antibiotics. The nature of the primary chronic osteomyelitis is still obscure. Most authors are of the opinion that a very conservative attitude should be taken in its treatment.24-26It is interesting to note the result of decortication in these patients.

Volume 29 Number 6

Decortication

in treatment

of osteomzjelitis

653

Although a continuous “marrow cavity” was not found in primary chronic osteomyelitis, the cortical bone was removed anyway. This established contact between the periosteum and the soft tissues and their ample blood supply, so that the natural body defense could combat the infection. The decortication, as performetl in the present study, entails only a slight operative risk, and since four out. 01’ six patients were cured (with an observation period of more than 2 years) ? i I is recommended that decortication be performed in cases of primary chronic osteomyelit.is, where the disease has had a protracted course and has resulted in disability of the patient. Similarly, this has beeu reported by Rowe and IIes10p~“’ in the treatment of periostitis and osteomyelitis of the mandible in children. Resistance to penicillin was found in five of nine cases in which staphvlococc*i had been cultured. This agrees with the findings of Stiebitz’“, 30and Christensell.’ The results of the bacteriologic cultures in the present study should bc vicw~~~i with reservation, however, because these patients n-ere not originally treat<4 for their disease in our department. All had been treated clsewhcrc ~(1 then IV ferred; thus, nineteen patients had received treatrucnt with antibiotics. nil11 unsatisfactory results. The equally good results of decortication in the four patients to whom no postoperative antibiotic treatment was administered are noteworthy. It is thought that actual removal of the cortical plat,e with the establishment. oi’ contact to the soft tissues is the main reason for the good results. The ultra-short postoperative treatment with antibiotics (‘5 to 7 days) might be unnecessa.ry, blrt larger comparative studies will have to be carried ollt in ordcbr to ;~nswc~~this question. Anesthesia or hypoesthesia in the region of the mental nerve is one oC the classic symptoms of acute osteomyelitis. One would expect that radical surgi(:al intervention could further damage the mental nerve; if so, the surgery might ])e contraindicated when the actual anatomic area of the mental foramen was illvalved. However, only two patients showed a permanent anesthesia, although anesthesia occurred in eighteen patients immediately after decortication. The locations of the osteomyelitis in the present material correspond with those of earlier reports. A change toward more localized osteomycli& foci, as reported by Trauner,33 was not observed in the present study. In most of the cases in this series the osteomyelitis was of dental origill: in fifteen pa.tients the onset of the disease was directly related to a tooth cxtracCon. This corresponds with the a.ceepted concept of the etiology of osteomyelitis of the jaws. In five of the six cases of primary chronic osteomyelitis, no rc*Iation to de.ntal disorder could be established; these we’re probably hematogcnons, although this was not proved. CONCLUSION “Suspect early-treat immediately-and you will then fail to confirm later,” wrote Ficklings with respect to antibiotic treatment of acute osteomyelitis of the jaws. Generally one has to agree with this point of view, but the steadily increasing number of patients with secondary chronic osteomyelitis shows I ha,t the conservative treatment is not always sufficient. On the basis of the prescntcltl

Oral

May,

Surg. 1970

findings, one feels justified in recommending radical decortication via the intraoraJ route with immediate closure of soft-t.issue wounds, as suggested by Obwegeser,*O as a very effective surgical procedure in the treatment of acute/subacute and secondary chronic osteomyelitis of t,he mandible in adults. Further, when a protracted course is encountered in cases of primary chronic osteomyelitis, decortication should also be considered as a method of treatment. SUMMARY The results of a study of twenty-eight patients wit.h osteomyelitis of the mandible, in whom decortication had been performed, are reported. The decortication via the oral route was performed from 3 weeks to several years after onset of the disease. Twenty patients were examined more than 2 years after the decortication, and in all patients with acute/subacute or secondary chronic osteomyelitis complete healing was encountered. In four of the six patients with primary chronic osteomyelitis, the decortication arrested the symptoms of the disease. The findings are discustsed, and decortica,tion is strongly recommended as a means of treating osteomyelitis of the jaws. The author wishes mitting him to utilize during its preparation.

to express his deep appreciation to Professor H. Obwegeserfor perthis

material

for

the study

and for

his continuing

encouragement

REFERENCES

Osteomyelitis of the Jaws. In Husted, E., and Hj$rting1. Allwright, W. C.: Tropical Forlag, pp. 228-232. Hansen, E. : Oral Surgery, Copenhagen, 1967, Ejnar Munksgaards iiber die Zunahme dcr Kieferosteomyelitis und Aenderungen 2. Becker, R.: Beobachtungen ihres Krankheitsbildes, Deutsch. ZahnLrztl. Z. 14: 1373, 1959. 3. Becker, R.: Therapeutische Konsequenzen aus der Aenderung des Krankheitsverlaufs der Osteomyelitis, Forts&r. Kiefer- Gesichtschir. 9: 15i, 1964. Grundlage der Symptome bei Kieferosteomyelitis, 4. Brosch, F. : Die histopathologisehe Deutsch. ZahnLrztl. Z. 9: 827, 983. 1954. kntlastunr des osteomvelitischen Kiefers mBelich und 5. Rrosch. F.: 1st die onerative zweckmlssig, Deutsch. &hn%rztl. Z. 13: &6, 1958. U Kiefers, Fortschr. Kiefer6. Brosch, F.: Zur Entstehune: des Bildes des osteomyelitis&en Gesichtschir. 9: 153, 1964. of the Mandible, Med. J. Aust. 51: 393, 1964. 7. Christensen, G. : Osteomyelitis B. W.: The Present Status of Treatment for Osteomyelitis. 1% Husted, E., and 8. Fickling, Hjgrting-Hansen, E., Oral Surgery, Copenhagen, 1967, Ejnar Munksgaards Forlag, p. 249. der Kieferosteomyelitis, Deutsch. Zah&rztl. Z. 15: 9. Grasser, H.-H. : iiber den Riickgang 518, 1960. in Treatment of Acute Osteomyelitis. Brit. Med. J. 2: 414, 1967. 10. Green. J. H.: Cloxacillin (Necrosis) of the Jaws-Its ’ Pathology and Treitment, G. T.: Osteomyelitis 11. Hankky, Rrit. Dent. J. 65: 549, 1938. 12. Harris. N. H.: Some Problems in the Diagnosis and Treatment of Acute Osteomyelitis, _ I J. Bone joint Surg., 42B: 535, 1960. Brit. Med. J. 13. Harris, N. H.: Place of Surgery in Early Stages of Acute Osteomyelitis, 2: 1440, 1962. Analyzing the Microcirculatory Architecture 14. Hunsuck, E. E.: A Method of Quantitatively of the Mandible: Preliminary Report, J. Oral Surg. 26: 449, 1968. of the Mandible, ORAL Sum. 15. Kinnman, J. E. G., and Lee, H. S.: Chronic Osteomyelitis 25: 6-11, 1968. 16. Koenig, M. G., and Rogers, D. E.: Current Status of Therapy in Acute Osteomyelitis, .T. A. M. A. 180: 1115. 1962. Osteomyelitis of the Mandible, 17. Miltner, L. J., and Wblfe, J. J.: Treatment of Suppurative Surg. Gynec. Obstet. 59: 226, 1934. in Mandibular Infection, Brit. Med. J. 1: 517, 1944. 18. Mowlem, R.: Surgery and Penicillin of the Jaw, Proc. Roy. Sot. Med. 38: 452, 1944-45. 19. Mowlem, R. : Osteomyelitis Vorgehen bei der Osteomyelitis mandibulae, Oest. 20. Obwegeser, H. : Aktives chirurgisches Z. Stomat. 57: 216, 1960.

21. Orr, 22.

23. 24. 25.

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