A 30-year-old male patient presented to the clinic in August 2023 complaining of pain in the left mandibular angle region. He reported that his symptoms started in January 2023 following extractions of the lower left first and second molars, which failed to heal properly, resulting in pain, inflammation, and purulent discharge. He underwent multiple antibiotic treatments. He mentioned a diagnosis of Pycnodysostosis syndrome made 5 years ago, along with a history of multiple fractures in the upper and lower extremities.
During the physical examination, it was observed that the patient was oriented, cooperative, and exhibited characteristic features of Pycnodysostosis syndrome: a small face, proptosis, blue sclera, prominent nose, frontal and occipital protuberances, obtuse mandibular angle, as well as anteroposterior and transverse bimaxillary hypoplasia. Intraorally, severe dental crowding, anterior and posterior crossbite, and an ulcer were identified in the posterior region of the left hemimandible with bone segment exposure and purulent secretion, along with painful points upon palpation. The patient presented a video of a computed axial tomography performed in February 2023, revealing a loss of the lingual bone table in the region of the lower left second molar, as well as the presence of hyperdense and hypodense images suggestive of bone sequestration measuring approximately 1 cm in diameter.
A tomography scan was requested to assess the progress, but the patient did not attend the scheduled appointment. He returned in October 2023 reporting increased pain and halitosis. Consequently, a cone beam tomography was performed, revealing the absence of lingual cortex in the region of the lower left first molar, with mixed areas and the presence of a hypodense area without continuity with the adjacent bone, suggestive of bone sequestration Fig. 1. Additionally, a discontinuity was observed at the level of the first cervical vertebra, with diastasis. This was compared with the previous video, in which no alterations at the vertebral level were noted, leading to a diagnosis of a type 3 fracture according to Gehweiler Fig. 2.
The patient was questioned about any recent history of trauma, and he reported experiencing a "cracking" noise when flexing his neck while bending over 15 days prior, followed by pain for three days thereafter. Consequently, he sought treatment from a sobador, who performed massages, and his symptoms decreased after the fifth day. At the time of consultation, the patient was awake, oriented, and walking without any symptoms. He was referred to the spine surgery service for evaluation, where the diagnosis was confirmed. They recommended immobilization with a Philadelphia-type rigid collar for 8 weeks, without any other specific indications.
The patient reported increased pain in the region of the bone sequestration and difficulty eating food after the collar was placed. Consequently, he consulted with the spine surgery service, and it was decided to initiate osteomyelitis management. The procedure was performed with the patient in the Fowler position and wearing the collar. Under local anesthesia using a truncal technique of the left inferior dental nerve, a sequestrectomy was performed, and a culture was taken. Lavage with 200 ml of 0.9% saline solution was carried out, followed by debridement. Antibiotic therapy was initiated with amoxicillin 875 mg plus clavulanic acid 125 mg every 12 hours for 5 days. Additionally, rinses with 0.12% chlorhexidine for one minute, three times a day for 15 days were prescribed. The culture did not identify any specific bacteria, and the antibiogram showed no bacterial resistance. Therefore, antibiotic therapy was continued for 4 weeks. The microscopic biopsy result revealed several fragments of bone tissue with separate trabeculae having irregular edges, lacunae devoid of osteocytes, as well as several areas of mature bone tissue surrounded by basophilic material compatible with bacterial colonies. Moreover, the presence of extravasated erythrocytes and inflammatory cells confirmed the diagnosis of osteomyelitis.
The patient showed adequate progress, reporting the disappearance of pain in the osteomyelitis region, absence of purulent secretion, and proper healing of soft tissues. At 10 weeks, a cone beam tomography was requested to evaluate the osteomyelitis and atlas fracture. No changes in displacement and repair were observed in the atlas (Fig. 3). In the region of the lower left first molar, bone defects in healing process were observed, with a slightly irregular contour and increased surrounding bone density. In the area of the lower left second molar, loss of the lingual bone table was observed, with a defined bone defect and sclerotic contour; however, no relevant changes were noted. The images suggest an initial bone repair process, with no free bone fragments. At the tenth week, it was recommended to continue using the collar for an additional 2 weeks; however, the patient decided to remove it. Despite being asymptomatic, he resumed his daily activities and attended regular check-ups for 4 months, showing satisfactory progress in his osteomyelitis and no cervical discomfort, leading a normal life.