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02-19

CT Evaluation Of Mandibular Osteomyelitis

KB TAORI, R SOLANKE, SM MAHAJAN, V RANGANKAR, T SAINI

Abstract

Mandibular osteomyelitis often is associated with involvement of the soft tissues. The purpose of this study
was to clarify the relationship between CT patterns and the presence of inflammation in soft tissues. 30 cases
diagnosed with osteomyelitis of the mandible were evaluated with CT scans. CT patterns of osteomyelitis
were classified into four types: lytic, sclerotic, mixed & sequestrum patterns. Location extent of the lesion
and change of the cortical plate were evaluated.
The data demonstrate a close interaction between cortical plate disruption and muscle inflammation.
The extent of inflammation including soft tissue involvement was better appreciated with CT in osteomyelitis

Ind J Radiol Imag 2005 15:4:447-451

Key words : - Computed tomography, Osteomyelitis, Mandible.

INTRODUCTION: to define the precise location and extent. The spread of

Osteomyelitis is an inflammatory condition of bone that
the medullary cavity and the adjacent cortex. It occurs
more frequently in mandible than in the maxilla [1],
although most cases of osteomyelitis of the jaws result
from dental origins, other sources of infection are possible
[2]. The significance of radiological evaluation is twofold:
to differentiate osteomyelitis from other conditions that
show similar signs & symptoms and to check the progress
of the disease and its response to treatment. [3]
infection can be defined on CT scan according to the
appearance of fascial spaces.
In the evaluation of osteomyelitis, both bone trabecular
patterns and the extent of the soft tissue inflammation
should be assessed. The purpose of this study is to clarify
the relationship between CT patterns and the presence
of inflammation in the soft tissues.

Fig 1: Division of BLOCKS of mandible [ A - Anterior, P- Pre

Molar, M- Molar, R- Ramus, C- Coronoid Process/ Condyle]

Ariji et al [4] reported the role of CT in the mandibular

osteomyelitis. CT revealed the exact location and extent
of infection ads well as the relationship between soft tissue
and bony lesions. They concluded that CT provides useful
additional information about mandibular osteomyelitis.

The role of CT in the diagnosis of maxillofacial infection is 2a

From the Govt. Medical College; Nagpur.

Request for Reprints: DR. KISHOR TAORI, M.D. (Radiodiagnosis), Prof. and Head , Dept. of Radio-diagnosis, Govt. Medical
College, Nagpur - 440 003

Received 31 January 2005; Accepted 8 August 2005

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448 KB Taori et al IJRI, 15:4, November 2005

2b

Fig 3 : Bilateral lamellar type of periosteal reaction.

MATERIAL & METHODS:

Total of 30 cases of mandibular osteomyelitis were

evaluated with CT scan over period of 24 months from
August 2002 to November 2004 in the department of
Radiodiagnosis Government Medical College & Hospital,
Nagpur (M.S.).

Diagnosis of osteomyelitis was on the presence of signs,

symptoms and radiological findings, which was again
2c confirmed by FNAC. The included 22 male (73.66%)and
8 female (26.33%) was ranged in age from 5 to70 yrs.

Contiguous axial scan 4mm thick were taken with the

use of MDCT scanner (Siemens Somatom, volume
Access Germany)

CT patterns of osteomyelitis were evaluated at the initial

CT examinations and classified into four types: lytic,
sclerotic, mixed & sequestrum patterns, according to the
amount of bony sclerosis in osteomyelitis and the
presence of sequestrum. Lesion location extent and
cortical plate involvement were evaluated.

The spread of infection and soft tissue involvement of the

lesion was evaluated by lateral asymmetry of the shape
and density of the various fascial spaces and tissues
2d
using soft tissue window.

Evaluation of the lesion extent and cortical plate

Fig 2: Examples of each CT pattern of mandibular
osteomyelitis. involvement was done with bone window CT sections.
2a: Localized Lytic type. Evaluation of the extent of the lesion was based on the
2b: Diffuse Lytic type. number of segments of the mandible involved. (Fig)
2c: Mixed Type
2d: Sequestrum type.
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IJRI, 15:4, November 2005 CT Evaluation of Mandibular Osteomyelitis 449

Table No.1
Patterns of osteomyelitis
Patterns of osteomyelitis No. of Pts. Percentage
Lytic 21 70%
Sclerotic - -
Mixed 5 16.66%
Sequestrum 4 13.33%
Total 30 100%

Table 1 shows the distribution of patterns of

osteomyelitis. The most common CT patterns in our study
was lytic type (70%) followed by mixed type (16%) and
sequestrum patterns. no case of purely sclerotic pattern
was found in our study

Table No.2
Extent of the lesion
Extent of lesion Lytic Mixed Sclerotic Sequestrum
Localized 15 1 - 3
Diffuse 6 4 - 1
Total 21 5 - 4

Table 2 shows the distribution of extent of lesions. Most

lesions with a lytic or sequestrum pattern were relatively
localized, whereas the majority of the mixed pattern was
diffuse.

Table No. 3
Block-wise Disease laterality of cases
BLOCKS No. of Pts. Total
A 2 2
P RT 6 13
LT 7
M RT 14 23
LT 9
R RT - 5
LT 5
C RT - 2
LT 2

Table 3 shows the block-wise laterality of lesions. The

Fig 4: Disruption of cortical plate
4a: Buccal aspect cortical plate disruption
4b: Lingual aspect cortical plate disruption
RESULTS:
Total 30 cases ranged in age from 5 to 70 yrs including
22 male (73.66%) and 8 female (26.33%) were evaluated.
The most common age group involved was 21 - 30 yrs (7
cases 23.33%) followed by 31 - 40 yrs (6 cases 20%).
most common block involved in our study was molar
followed by premolar.
Table4 shows the incidence of periosteal reaction. The
periosteal reaction was seen in 10 (%) of the 21 lytic
pattern cases, the incidence of which was significantly
higher than in mixed pattern (2 / 5; --%).
Table 5 shows the incidence of cortical plate disruption.
Disruption of cortical plate was seen 17 patients out of
30 amongst which 5 cases showed bilateral cortical break.
12 out of 21 cases of lytic pattern showed cortical break
with 4 cases showing bilateral cortical break, the
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450 KB Taori et al IJRI, 15:4, November 2005

Table no.4
Incidence of periosteal reactions
Lytic Mixed Sclerotic Sequestrum Total
Buccal plate 8 2 - 2 10
Lingual plate 5 1 - - 6
Bilateral reaction 3 1 - - 4
Total No of cases 21 5 - 4 30

Table No. 5
Incidence of cortical plate disruption
Lytic Mixed Sclerotic Sequestrum Total
Buccal plate 10 2 - 2 14
Lingual plate 6 1 - 1 8
Bilateral disruption 4 1 - 5
Total No of cases 21 5 - 4 30

Table No .6
Extent of soft tissue involvement
Soft tissue extent Lytic Mixed Sclerotic Sequestrum
Confined to one space 6 2 - 3
Confined to more than one space 15 3 - 1
No. Of cases 21 5 4

disruption was seen in two cases each of the mixed type
and sequestrum type, out of which one case of mixed
pattern had bilateral break. The incidence of cortical plate
disruption was seen more frequently in buccal cortex than
the lingual
Table 6 shows the extent of soft tissue involvement. More
number of cases showed involvement of more than one
soft tissue space (19/30, 63.33%) involvement than
involvement of only one space (11/30,36.66%).
DISCUSSION:

Osteomyelitis results from either from the direct extension

of pulpal infection without the formation of a granuloma
or from the acute exacerbation of a periapical lesion .it
may also occur following penetrating trauma or various
surgical procedures. Extension of the infection into
adjacent soft tissue and fascial spaces is common, and
often the presenting the clinical symptom for which the
CT study may be ordered. Trans cortical extension of
the inflammatory process can result in cortical destruction,
fistulization and periosteal reaction, all these changes
can be evaluated very well by CT [5]

Appropriate evaluation of radiographic types of

osteomyelitis is necessary for treatment planning.
Kazunori Yoshiura [6] classified mandibular osteomyelitis
into four basic patterns, as lytic, sclerotic, mixed and
sequestrum pattern .our study also comprise of the same
classification of osteomyelitis patterns. Periosteal
reaction and cortical plate disruption were also common
findings in our study.

Ariji et al [4] reported that all infection of the masticator

Fig 5 : Soft tissue involvement of more than one fascial spaces were accompanied by trismus and were
spaces. associated with swelling of the masseter muscle.

IJRI, 15:4, November 2005
Kazunori Yoshiura [6] speculated mixed pattern
osteomyelitis with cortical plate abnormalities may initiate
masticator space inflammation. In our study the
involvement of more than one Space was more frequently
seen than that of the one Space.
A periosteal reaction and cortical plate disruption were
observed in the buccal plate more often than ion the lingual
plate. This finding is probably related to inflammation of
the masseter muscle or submandibular space as
hypothesized by the Kazunori Yoshiura.[6] The masseter
and medial pterygoid muscles attached to the lateral and
medial surfaces of the mandibular ramus respectively.
The termination areas of the masseter muscle on the
lateral surface by comparison is wider than that of medial
pterygoid muscle on the medial surface, hence,
mandibular inflammation could affect the masseter muscle
proportionately more than the medial pterygoid muscle.
Adekeye and Cornah [7] have reported the incidence of
blood supply in maxillary osteomyelitis. When the
masseter muscle is involved in mandibular inflammation,
disturbance of blood supply to the mandibular ramus and
its periosteum may occur. This could leads to surface
bone resorption and induced disruption of the cortical
plate.
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CT Evaluation of Mandibular Osteomyelitis 451
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