will often present with complaints of a dull and deep pain, swelling and erythema of overlying tissues, paresthesia of the IAN, trismus, lymphadenopathy, fistula, fever, and malaise [38, 39]. In patients with chronic osteomyelitis, signs of acute infection such as fever are often not present; however, fistulas, both intra‐ and extraorally, are more common. Radiographs typically demonstrate a “moth‐eaten” appearance or the presence of radio‐opaque bony sequestra. CT scanning can assist in the demarcation of lesion extent, although it should be noted that 30–50% demineralization of bone is necessary before radiographic changes [38] (Figure 2.9). In chronic osteomyelitis, there may be radiopacity due to an osteitis‐type reaction and proliferation of bone. Laboratory workup will demonstrate a leukocytosis in acute forms, and elevated erythrocyte sedimentation rate (ESR) and C‐reactive protein (CRP) levels. Further laboratory evaluation of ESR and CRP levels during treatment can assist in assessment of resolution of the disease process. Culture specimens will often yield bacteria traditionally responsible for odontogenic infections, such as Bacteroides, Peptostreptococcus, Fusobacterium, and Streptococcus species. Occasionally, less common odontogenic bacteria are present, including Lactobacillus, Eubacterium, Klebsiella, Acinetobacter, and Pseudomonas aeruginosa . Osteomyelitis of the jaws is different from osteomyelitis of other bones in that staphylococci are usually not the predominant bacteria [38].
The treatment of osteomyelitis involves both surgical and medical management. Treatment of comorbid systemic diseases must be considered along with medical consultation, when appropriate. Empirical systemic antibiotics should be administered while awaiting final culture and sensitivity results. Penicillin/metronidazole or clindamycin are excellent first‐line choices for empirical antibiotics. In chronic cases, sequestrectomy, decortication, and saucerization may be necessary to debride the involved bone to vital, bleeding bone margins to assist in healing acceleration. Removal of the bony cortex with attachment of the periosteum directly on the marrow space assists in blood flow and revascularization. After aggressive bone debridement, bone fixation and stabilization may be needed to prevent a pathological mandible fracture or stabilize an existing fracture. External fixation, rigid internal fixation, or intermaxillary fixation may be used with various fixation schemes, with the specific type dependent upon surgeon preference and degree of success of surgical debridement [38, 39] (Figure 2.10a–i). Other methods of treatment have been proposed, such as local antibiotic administration, with both resorbable and nonresorbable carriers (antibiotic‐impregnated beads) and hyperbaric oxygen (HBO) (controversial). Poly(methyl methacrylate) beads impregnated with gentamicin have been used in orthopedic surgery; however, results can be disappointing due to inadequate local release and subinhibitory antibiotic levels. Also, a second surgery is necessary to remove the beads. HBO has not been demonstrated to have a significant effect on outcome based on the limited available literature [40, 41]. Esterhai et al. studied the use of HBO in 28 patients with chronic refractory osteomyelitis, and this controlled trial concluded that HBO had no effect on length of hospitalization, rate of wound repair, or recurrence of infection [40].
Fig. 2.9. 3D reconstruction of right mandibular osteomyelitis demonstrating a “moth‐eaten” appearance to the bone.
Instrument Breakage/Foreign Body Displacement
Etiology: excessive force, inappropriate instrument use
Management: immediate or delayed removal of foreign body, monitoring
The complexity of instruments utilized by the surgeon during third molar surgery can vary significantly based upon individual training, experience, and preferences. Nearly every surgeon has a preferred instrument for each situation, and, in many instances, the reliability and resiliency of those instruments may be taken for granted.
The structural failure of an instrument can lead to complications associated with foreign body displacement into the maxillary sinus, infratemporal fossa, sublingual space, airway, gastrointestinal tract, etc. One well‐documented, and avoidable, complication is local anesthetic needle breakage, usually occurring during an IAN block. In most instances, the clinician has bent the needle at the hub in order to allow for an easier approach to the medial aspect of the ascending ramus and mandibular foramen to ensure an adequate local anesthetic injection [42].
When instrument breakage does occur, the key is to locate the fractured portion of the instrument and assure that it is not violating, or could potentially violate, any surrounding critical structures (e.g., nerves, blood vessels). Once the location is ascertained, the surgeon should decide between two options: (i) leave the fractured piece in place and monitor for any migration or (ii) decide upon removal of the fractured instrument immediately or in a delayed fashion after fibrosis occurs.
Once the decision has been made to remove the retained foreign body, the safest method that will allow adequate access should be utilized. This often requires general anesthesia in an operating room setting. Since the fractured pieces are almost always small in size, the use of fluoroscopic or navigational guidance is often used. Blind exploration for a broken needle in the infratemporal fossa, or elsewhere, is not advised. On rare occasions, the assistance of either the neurosurgical or interventional neuroradiology teams may be required if potential vascular injury could occur during retrieval of the fracture instrument or needle [43] (Figure 2.11a–c) (Algorithm 2.6).
Fig. 2.10. (a) Panoramic image of biopsy proven left mandibular osteomyelitis demonstrating osteosclerosis, reactive periostitis, and “moth‐eaten” appearance to the bone. (b) Intraoperative appearance of the left mandible with reactive bone and advanced disease. (c) Following resection of the involved left mandible and reconstruction bone plate placement. (d) Surgical resection specimen with negative margins. (e) Postoperative panorex demonstrating a large continuity defect. (f) Secondary reconstruction with iliac crest three months after initial surgery and following completion of six weeks of IV antibiotics. (g) Iliac crest graft compressed and packed into syringes for delivery to the defect site. (h) Six months following secondary reconstruction demonstrating excellent graft take and restoration of continuity of the mandible.
Fig. 2.11. (a) Sagittal view CT demonstrating displacement of a 25‐gauge needle during posterior superior alveolar block with migration through foramen ovale and into the middle cranial fossa causing pain and intermittent facial numbness. Patient required a right pterional craniotomy for retrieval. (b) Coronal view of needle displacement through foramen ovale. (c) Axial view of needle displacement through foramen ovale.
Algorithm 2.6. Fractured Instrument/Foreign Body
CONCLUSIONS
Despite the fact that there are many possible risks and