African Journal of Paediatric Surgery About APSON | PAPSA  
Home About us Editorial Board Current issue Search Archives Ahead Of Print Subscribe Instructions Submission Contact Login 
Users Online: 393Print this page  Email this page Bookmark this page Small font size Default font size Increase font size 
 
 


 
CASE REPORT Table of Contents   
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 111-113
Surgical management of garre's osteomyelitis in an 8-year-old child


1 Department of Oral and Maxillofacial Surgery, A.J Institute of Dental Sciences, Mangalore, RGUHS (Rajiv Gandhi University of Health Sciences), Mangalore, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Goa Government Dental College and Hospital, Mangalore, Karnataka, India
3 Consultant Oral Pathologist, Goa Government Dental College and Hospital, Mangalore, Karnataka, India
4 Postgraduate, Goa Government Dental College and Hospital, Mangalore, Karnataka, India
5 Consultant Periodontist, KMC Hospitals, Mangalore, Karnataka, India
6 Department of Orthodontics, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Click here for correspondence address and email

Date of Submission17-May-2020
Date of Decision24-Jun-2020
Date of Acceptance13-Jul-2020
Date of Web Publication18-Feb-2021
 

   Abstract 


Chronic non-suppurative osteomyelitis, also known as Garre's osteomyelitis is a well-described pathologic entity in dental literature. We present here a case report of a unilateral hard bony swelling of the lower jaw associated with infection. Radiograph revealed the pathognomic feature of 'onion skin' appearance. Surgical recontouring of the lower jaw was performed since there was no evidence of bone remodelling after removal of the infected tooth.

Keywords: Child, Garre's osteomyelitis, surgical management

How to cite this article:
Nidhin Philip LM, Akkara F, Khwaja T, Narayan T, Kamath AG, Jose NP. Surgical management of garre's osteomyelitis in an 8-year-old child. Afr J Paediatr Surg 2021;18:111-3

How to cite this URL:
Nidhin Philip LM, Akkara F, Khwaja T, Narayan T, Kamath AG, Jose NP. Surgical management of garre's osteomyelitis in an 8-year-old child. Afr J Paediatr Surg [serial online] 2021 [cited 2021 Jun 15];18:111-3. Available from: https://www.afrjpaedsurg.org/text.asp?2021/18/2/111/309687



   Introduction Top


'Osteomyelitis' is defined as the inflammation of the bone and its marrow contents. Cierny et al.[1] have classified osteomyelitis as suppurative and non-suppurative. Garre's osteomyelitis, a type of chronic non-suppurative osteomyelitis, was named after Carl Garré in 1893. It presents as a focal gross thickening of the periosteum with peripheral reactive bone. Persistent low-grade infection in children and young adults in the presence of high osteoblastic activity triggers the periosteum to lay down new bone.[2]

Garre's osteomyelitis is seen in the mandible, especially its lower and lateral borders, more commonly than in the maxilla. This predilection is due to the fact that maxilla has a rich vascular supply and thin cortical plates while the blood supply to the mandible is only limited to the inferior alveolar artery. Most commonly Garre's osteomyelitis presents as facial asymmetry on the lower part of face owing to a solitary swelling with normal to inflamed overlying skin. On palpation, the swelling is bony hard and non-tender.[3] The causative factors associated with this lesion are grossly carious tooth, periodontal defects, persistent infection and trauma. Intraoral periapical radiograph is helpful in cases of deep carious lesions in relation to the bony mass. Orthopantomograph (OPG) reveals a periosteal thickening of the inferior border of the mandible due to increase in osteoblastic activity resulting in an 'onion skin' appearance.


   Case Report Top


An 8-year-old male patient reported to our institution with a chief complaint of facial asymmetry in the lower portion of his face for 5 months. The swelling was initially pea sized and gradually increased to its final dimensions. The patient gave a history of extraction of grossly carious lower right deciduous molar with no reduction in the size of the swelling. On extraoral examination, facial asymmetry with a solitary localised oval-shaped swelling measuring 20 mm × 20 mm was seen on the right side of the face near the body of mandible [Figure 1]. On palpation, the swelling was noted to be well defined, hard in consistency, non-tender, non-pulsatile and non-fluctuant. Localised ipsilateral submandibular lymphadenopathy was also evident. Intraorally, obliteration of the lower buccal vestibule on the right side was noted [Figure 2]. OPG revealed 'onion skin' appearance at the inferior border of the mandibular body suggestive of a periosteal reaction [Figure 3].
Figure 1: (a) Pre-operative clinical photographs showing facial asymmetry on the right side of the mandible as seen in front (a) and worm's (b) view

Click here to view
Figure 2: Clinical photograph showing mild obliteration of the lower buccal vestibule on the right side

Click here to view
Figure 3: Orthopantomograph reveals deposition of bone in the outer cortex of the inferior aspect of the mandible on the right side

Click here to view


Based on the clinical and radiographic findings, the lesion was diagnosed as Garre's osteomyelitis and surgical recontouring under general anaesthesia was planned [Figure 4]. Extraoral approach was used to expose the lesion, and the excess bony mass was excised using surgical bur and handpiece. The excised bone fragments [Figure 5] were subjected to histopathological examination which revealed trabeculae of bone with osteoblastic rimming and reversal lines together with a chronic inflammatory infiltrate. The microscopic picture confirmed the diagnosis of Garre's osteomyelitis. The patient was followed up 3 months post-surgery with no recurrence of the lesion [Figure 6].
Figure 4: Intraoperative picture showing submandibular incision to expose the lesion (a) and recontoured bone (b)

Click here to view
Figure 5: Resected bone chips

Click here to view
Figure 6: Post-operative clinical photograph at 3 months reveals gross improvement in facial symmetry as seen in frontal (a) and worm's (b) view

Click here to view



   Discussion Top


Garre's osteomyelitis is a lesion with a large amount of periosteal reaction. Its development depends on the interplay of chronic infection, activity of the osteoblastic cells in the periosteum, virulence of the infectious agents and the host resistance. This lesion is seen exclusively in children or young adults by virtue of a periosteum that is capable of vigorous osteoblastic activity. Owing to similar radiographic findings of 'onion skin' appearance, osteogenic sarcoma, infantile cortical hyperostosis, fibrous dysplasia and Ewing's sarcoma could be considered as differential diagnoses.[4] Management varies from conservative to surgical approach including endodontic therapy, extraction of tooth and recontouring of bone. The latest treatment modality for Garre's osteomyelitis involves resection of bone followed by transport distraction osteogenesis.[5] Remodelling of the mandible occurs after resolution of the infection, but occasionally, it remains static necessitating surgical recontouring procedures.


   Conclusion Top


Garre's osteomyelitis is associated with low-grade infection usually arising from an infected tooth that results in stimulation of bone formation. Elimination of the source of infection is important to restore the impaired balance between the virulent bacteria and the oral flora. In the present case, no resolution of the bony mass was noted for 6 months despite removal of the infected tooth. Hence, surgical recontouring of bone was carried out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 2003;414:7-24.  Back to cited text no. 1
    
2.
Topazian, RG. Osteomyelitis of the jaws. In: Topazian RG, Goldberg MH, editors. Oral and Maxillofacial Infections. 3rd ed.. Philadelphia: Saunders; 1994. p. 251-88.  Back to cited text no. 2
    
3.
Schwartz S, Pham H. Garre's osteomyelitis: A case report. Pediatr Dent 1981;3:283-6.  Back to cited text no. 3
    
4.
Chang YC, Shieh YS, Lee SP, Hsia YJ, Lin CK, Nieh S, et al. Chronic osteomyelitis with proliferative periostitis in the lower jaw. J Dent Sci 2015;10:450-5.  Back to cited text no. 4
    
5.
Nikomarov D, Zaidman M, Katzman A, Keren Y, Eidelman M. New treatment option for sclerosing osteomyelitis of Garré. J Pediatr Orthop B 2013;22:577-82.  Back to cited text no. 5
    

Top
Correspondence Address:
Dr. Lida Mary Nidhin Philip
Department of Oral and Maxillofacial Surgery, AJ Institute of Dental Sciences, Mangalore, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajps.AJPS_66_20

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed734    
    Printed24    
    Emailed0    
    PDF Downloaded3    
    Comments [Add]    

Recommend this journal