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WELCOME TO 19th TRIPLE “O” MEET

DEPARTMENT OF ORAL AND MAXILLOFACIAL

SURGERY

DEPARTMENT OF ORAL AND MAXILLOFACIAL

PATHOLOGY AND MICROBIOLOGY

DEPARTMENT OF ORAL MEDICINE DIAGNOSIS

AND RADIOLOGY

BORN: September 3, 1924

BORN- December 11,1843, 

Born - March 27, 1845,

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TRIPLE O PRESENTATION

DR. ASIF IQBAL2ND year MDS

DEPARTMENT OF ORAL AND MAXILLOFACIAL PATHOLOGY.

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Date Type of Biopsy Provisional Diagnosis

24/4/2013 Excisional Tuberculous osteomyelitis

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Macroscopic Pathology:

HARD TISSUES

SOFT TISSUES

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OSTEOMYELITIS

The word “osteomyelitis” originates from the ancient Greek words

• osteon (bone) and • muelinos (marrow)• Itis-Inflammation• By meaning osteomyelitis is an inflammation

of the bone and bone marrow.

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Events Of Tubercular Osteomyelitis

1. Inflammation of bone and bone marrow

2. Ischemia

3. Necrosis

4. Resorption of bone

5. Sequestrum formation

6. Involucrum formation

7. Cause - Tuberculosis

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1.INFLAMMATION

• Components of inflammation1. RBC’s2. WBC’s3. Blood vessels4. Macrophage

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INFLAMMATION OF BONE AND BONE MARROW

Bone marrow

Bone

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INFLAMMATION OF BONE AND BONE MARROW

INFLAMMATION

BONE

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INFLAMMATION

INFLAMMATORY CELLS UNDER HIGHER MAGNIFICATION

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2.SEQUESTRUM

• It is a devitalized avascular segment of bone, surrounded by pus/infected granulation tissue

• Its outer surface is usually jagged/irregular due to erosive process by proteolytic enzymes in granulation tissue.

1210x

Sequestrum (dead bone) formationBONY TRABECULAE

WITHOUT OSTEOCYTES AND

OSTEOBLASTS

INFLAMMATION

INFLAMMATION

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SEQUESTRUM(HIGHER MAGNIFICATION)TRABECULAE WITHOUT CELLS(OSTEOBLAST AND OSTEOCYTES)

ABSENCE OF OSTEOCYTES

ABSENCE OF OSTEOBLASTS

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SEQUESTRUM UNDERGOING RESORPTION(IRREGULAR MARGIN)

40x

IRREGULAR MARGIN OF BONY TRABUCULAE

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TUBERCULOSIS

Characterized by granuloma formation

Accumulation of- 1. Activated macrophages(EPITHELOID CELLS) 2. Lymphocytes, 3. Giant cells (LANGHANS GAINT CELLS)4. and Fibroblasts.

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Role of Granuloma in Tuberculosis

GRANULOMA FORMATION

Provides a local environment for interaction of cells of the immune system.

Prevents dissemination of the mycobacteria

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MYCOBACTERIUM TUBERCULOSIS

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MYCOBACTERIUM TUBERCULOSIS being killed by macrophage(Scanning electron microscopy)

MYCOBACTERIUM TUBERCULOSIS

EPITHELIOID CELLS(MACROPHAGE)

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Granuloma formation

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TUBERCULOSIS. GRANULOMA FORMATION

4x

Ciliated pseudo stratified columnar epithelium

GRANULOMA

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TUBERCULAR GRANULOMA (HIGHER MAGNIFICATION)

10x

GRANULOMA

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40x

EPITHELIOID CELLS

EPITHELIOID CELLS

LANGHANS GIANT CELLS

LANGHANS GIANT CELLS

LYMPHOCYTES

TUBERCULAR GRANULOMA (HIGHER MAGNIFICATION)

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LANGHANS GIANT CELL(Horse shoe shape arrangement of nuclei)

EPITHELIOID CELLS

LANGHANS GIANT CELLS

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40x

EPITHELIOID CELLS

LANGHANS GIANT CELLS

LYMPHOCYTES

TUBERCULAR GRANULOMA (HIGHER MAGNIFICATION)

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NECROSIS

NECROSIS

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INVOLUCRUM (New Bone Formation)

It is derived from the word “volvere” i.e. to wrap. It is the result of reactive new bone formation by periosteal reaction, in an attempt to wall off the infection by forming a thick tense wall.

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NEW BONE FORMATION(INVOLUCRUM)

periosteum

New bone

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NEW BONE FORMATION(INVOLUCRUM)

periosteum

New bone

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PSEUDOSTRATIFIED EPITHELIUM

PSEUDOSTRATIFIED EPITHELIUM(RESPIRATORY EPITHELIUM)

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PSEUDOSTRATIFIED EPITHELIUM

(HIGHER MAGNIFICATION)

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DIAGNOSIS

• Features are suggestive of tuberculous osteomyelitis.

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Total cases of osteomyelitis - 20.

Total cases of Oral tuberculosis - 3.

Out of these three cases:-

1. Lower anterior gingiva.

2. Lymph node.

3. Maxilla.

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HISTORY OF OSTEOMYELITIS

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WHY OSTEOMYELITIS IS GENERALLY SEEN IN MANDIBLE?

• The mandible has a relatively poor blood supply, which deteriorates with age.

• The cortical plates are thick.

• The blood supply to mandible is primarily via the inferior alveolar artery and secondarily via the periosteum. Any compromise to this supply is a critical factor in development of OM in the mandible.

REFERENCE: Chapotel S. Tuberculose mandibularie. Rev Odent 1930;51:444-445

Thomas KH. Oral Pathology. In: Kimpton H, editor. A textbook of oral pathology. 3rded. Philadelphia: WB Saunders Company; 1950:891-895.

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WHY MAXILLA IS AFFECTED IN TUBERCULOUS OSTEOMYELITIS?

• Maxilla is more vascular than Mandible.• Therefore haematogenous spread is generally

to the maxilla.

Reference : Gupta KB, Manchanda M, Yadav SPS, Mittal A. Tubercular osteomyelitis of mandible. Indian J Tuberc. 2005;52:147–50

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CONCLUSION

Our case is unique :-

1. SITE-MAXILLA2. ETIOLOGY-TUBERCULOSIS3. YOUNGER AGE

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REFERENCE

• Gupta KB, Manchanda M, Yadav SPS, Mittal A. Tubercular osteomyelitis of mandible. Indian J Tuberc. 2005;52:147–50

• Chapotel S. Tuberculose mandibularie. Rev Odent 1930;51:444-445

• Thomas KH. Oral Pathology. In: Kimpton H, editor. A textbook of oral pathology. 3rded. Philadelphia: WB Saunders Company; 1950:891-895.

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SOME FAMOUS PERSONALITY WHO DIED OF TUBERCULOSIS BECAUSE OF UNAVAILABILITY

OF TREATMENT AT THEIR TIME

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