X-ray signs of inflammatory diseases of the jaws

Inflammatory diseases of the jaws are most often observed in children aged 5-10 years and patients aged 20-40 years. The most common odontogenic osteomyelitis occurs predominantly in the lower jaw (up to 93% of all cases); in 35-55% of all patients with osteomyelitis, the jaws are affected.

Bone infection occurs from periapical foci in acute and exacerbation of chronic periodontitis, less often - from marginal areas in periodontitis and suppuration of radicular cysts. Osteomyelitis can also develop when the socket becomes infected after tooth extraction.

Depending on the state of the body's reactivity and the pathogenicity of the microflora, a small area of bone tissue within 3-4 teeth or large areas of bone - half of the jaw or the entire jaw (diffuse osteomyelitis) are involved in the inflammatory process.

Despite the fact that purulent melting begins already on the 3rd-4th day from the onset of the disease, the first radiographic signs of acute osteomyelitis appear only after 10-14 days. At the apex of the "guilty" tooth, a picture of chronic periodontitis is determined. The earliest (on the 2nd-3rd day) indirect radiographic signs may be thickening and deformation of the perimaxillary soft tissues, clearly visible on electroradiographs. The radiograph shows foci of rarefaction of bone tissue of a round or oval shape with uneven contours, merging with each other in some areas, and unassimilated linear periostitis.

After spontaneous separation of pus, the subacute period of osteomyelitis begins, characterized by an increase in the destructive process. The duration of this period is 10-12 days, in diffuse osteomyelitis - up to 3 weeks. Bone necrosis is caused by a disruption of its blood supply due to vascular thrombosis and exposure to toxic substances. Granulation tissue formed from the non-osteogenic stroma of the bone marrow is involved in the rejection of necrotic areas of the bone - the formation of sequesters. After rejection, the sequester is located in the cavity of the abscess. On the radiograph, the sequester looks like a denser shadow, sometimes with uneven, "eaten away" contours, against the background of a rarefaction focus. Timely detection of sequesters is an important diagnostic task, the solution of which determines the indications for surgery and the success of osteomyelitis treatment, since the presence of sequesters interferes with healing. The operation - sequestrectomy - is performed with complete rejection of the sequester.

The duration of chronic osteomyelitis is from 1 month to several years, during which demarcation (separation) of necrotic bone areas, rejection of sequesters, and formation of fistulas continue. In young patients, rejection of spongy sequesters located in the alveolar region occurs after 3-4 weeks, and cortical sequesters after 6-7 weeks. Deformation of the jaw increases due to assimilation of periosteal layers.

Detection of sequesters on radiographs is sometimes quite a difficult task. Recognition is simplified by the formation of a demarcation ridge of granulation tissue around the sequester, defined as a band of enlightenment around a more intense shadow of the sequester. Detection of an additional shadow extending beyond the jaw into soft tissues, a change in the position of the suspicious area on repeated identical radiographs undoubtedly indicate the presence of a sequester.

In osteomyelitis of the socket of an extracted tooth, the process begins with fragmentation of the cortical endplate, then destruction of the interradicular septum occurs, the size of the socket increases, and cortical sequesters are visible.

If perimaxillary abscesses and phlegmons are not opened in a timely manner, contact osteomyelitis occurs with the formation of cortical sequesters. After sequestration, significant bone defects remain.

Pronounced destructive changes and the formation of large sequesters may lead to the development of a pathological fracture. In case of incorrect and untimely treatment, especially in elderly patients with reduced reparative processes, a pseudoarthrosis with pathological mobility may form. In the elderly, atypically occurring chronic osteomyelitis with a predominance of a productive reaction (hyperplastic, hyperostotic) is often observed, affecting mainly the lower jaw. The radiograph shows assimilated periosteal layers with thickening of the cortex, foci of pronounced osteosclerosis, obliteration of bone marrow spaces. Sequesters do not form, fistulous tracts appear.

Traumatic osteomyelitis as a complication of jaw fractures develops in 3-25% of cases. The frequency of its occurrence is affected by the severity of the injury, the presence of an open fracture, the timing of seeking medical help and insufficient immobilization of jaw fragments. Long-term soft tissue edema in the fracture area makes it difficult to timely detect the onset of suppuration of the bone wound.

The first radiographic signs of traumatic osteomyelitis: increasing spotty osteoporosis, blurring and unevenness of the marginal sections of fragments, an increase in the width of the fracture line, displacement of fragments due to disruption of the formation of connective tissue callus, are noted 8-10 days after the onset of clinical symptoms of the disease.

In case of necrosis of small fragments and marginal sections of bone fragments, sequesters are shown on radiographs as denser shadows. On repeated radiographs, fragments change little, a delicate shadow may appear along the contour due to endosteal bone formation. The shadow of sequesters becomes more intense within 2-3 weeks. Necrosis of a fragment is also indicated by its displacement during the analysis of identical repeated radiographs. Small sequesters and fragments can be absorbed within 2-3 months. Due to the peculiarities of blood supply, even small fragments in the middle zone of the face retain their viability.

Sclerotic changes in traumatic osteomyelitis are rare. Periosteal reaction in the form of linear exfoliated periostitis is visible only along the lower edge of the body and along the posterior edge of the mandibular branch.

In osteomyelitis, not the entire surface of the fragments may be affected, but only limited areas (wire suture area, alveolar margin area). In chronic course of the process, healing of the fracture occurs in other areas with the formation of bone callus. In these cases, sometimes only X-ray examination allows us to suspect the presence of a complication.

When the mucous membrane of the maxillary sinus is involved in the process, the course of osteomyelitis is complicated by odontogenic sinusitis. The inflammatory process is localized mainly in the tissues around the root of the "causative" tooth, while only the mucous membrane of the lower parts of the sinus is affected. In these cases, X-ray examination plays a major role in recognizing the disease. General chin-nasal radiographs in most cases do not resolve diagnostic difficulties. Sometimes, when X-raying in a vertical position, a horizontal fluid level is visible if the outflow from the sinus is not impaired. Panoramic lateral radiographs and tomograms, as well as zonograms in the frontal-nasal projection, are more informative. The images show uneven thickening of the entire mucous membrane or only in the area of the lower wall.

The introduction of a radiopaque substance into the sinus (sinusography) does not provide the necessary information about the condition of the mucous membrane.

Osteomyelitis of the jaws in children. In children, osteomyelitis occurs in the area of primary molars and first permanent molars on the upper and lower jaws. Peculiarities of the anatomical structure of bones with their insufficient mineralization determine the diffuse course of the inflammatory process in children. On radiographs in the acute period in the first days of the disease, despite the pronounced clinical picture, only foci of bone tissue destruction in the bifurcation zone of primary molars are detected (a picture of chronic granulating periodontitis). Already at the end of the 1st week, foci of bone tissue rarefaction, linear periosteal layers and soft tissue shadow may appear.

In chronic osteomyelitis, the rudiments of permanent teeth are also subject to sequestration, the image of the closing cortical plate of the follicle disappears, the formation of the tooth is disrupted; in the later stages, the contours of the rudiment become unclear and it shifts.

In the hyperplastic form of osteomyelitis, there is a deformation of the jaw due to pronounced periosteal layers. In order to get an idea of the state of the spongy substance, it is necessary to conduct tomography, which allows identifying areas of rarefaction of bone tissue that do not contain sequesters. Difficulties arise in the differential diagnosis of the disease with tumors, in particular with osteogenic sarcoma, which can sometimes be overcome only through histological examination. It should be noted that, unlike osteogenic sarcomas, periosteal layers in osteomyelitis are linear.

Hematogenous osteomyelitis occurs in newborns and in early childhood as a complication of pyoderma, pemphigus, umbilical sepsis, pneumonia, maternal mastitis, meningitis, and mediastinitis. In hematogenous osteomyelitis, active bone growth zones are affected: on the lower jaw - the condylar process with a tendency to involve the joint in the pathological process, on the upper jaw - the edge of the orbit, the alveolar process, and the area of tooth rudiments. On the 6th-7th day from the onset of the disease, an X-ray reveals an indistinct, blurred bone pattern. Round and oval rarefaction foci merge in some areas. Hematogenous osteomyelitis is characterized by the involvement of significant sections of the bone in the process. Spongy and cortical sequesters become visible on the 3rd-4th week. The detection of periosteal deposits along the outer surface, posterior edge and parallel to the base of the jaw indicate a chronic course of the disease.

Radiation damage to the jaws. The widespread use of radiation therapy in the treatment of malignant tumors of the maxillofacial region and large radiation loads on the upper and lower jaws during a radical course of radiation therapy determine the relatively high frequency of their radiation damage.

The first clinical symptom of developing osteomyelitis is pain. Later, osteoporosis, areas of destruction, spongy and cortical sequesters appear, and pathological fractures may occur. Radiation osteomyelitis is characterized by a long torpid course, with sequestration occurring only after 3-4 months. A characteristic feature of the radiographic picture is the absence of a periosteum reaction.

Irradiation of growth zones in childhood and adolescence causes growth cessation in the corresponding areas.