Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2014; 59: 372374

doi: 10.1111/adj.12186

Osteomyelitis of the condyle secondary to pericoronitis of

a third molar: a case and literature review
R Wang,* Y Cai, YF Zhao, JH Zhao
*The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedical
Engineering of Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan, China.

ABSTRACT
In this study, we report a very unusual case of a patient with osteomyelitis of the condyle secondary to pericoronitis of
an impacted third molar. The patient was treated by removal of the impacted third molar, opening of the drainage, com-
bined with systemic application of antibiotics for two weeks. This treatment option did not lead to any functional
defects or facial asymmetry. The patient fully recovered and the disease did not recur.
Keywords: Condyle, impacted third molar, osteomyelitis, pericoronitis.
(Accepted for publication 16 October 2013.)

(including periapical periodontitis, pericoronitis,

INTRODUCTION
Impacted third molars are associated with risks of
many disorders and complications,1 including pericor-
onitis, caries, resorption and periodontal problems.
Serious complications, such as the development of
cysts and tumours, severe inflammatory responses,
bone fractures, and osteomyelitis of the mandible,
require hospitalization for treatment.2
Among these complications, osteomyelitis of the
mandible very rarely occurs.3 In this study, we report
the case of a patient with osteomyelitis of the condyle
secondary to pericoronitis of an impacted third molar.
To the best of our knowledge, this case is only the
second case which has been reported with osteomyeli-
tis of the condyle caused by the impacted third molar
(Table 1).
REVIEW OF OSTEOMYELITIS IN THE MANDIBLE
Osteomyelitis is an inflammatory condition of the
bone and bone marrow. In the oral and maxillofacial
region it almost exclusively affects the mandible.
Although mandibular osteomyelitis is sometimes
attributed to bisphosphonate therapy (bisphosphonate
related osteonecrosis) or radiotherapy (osteoradione-
crosis), bacterial infection of odontogenic origin
Authors contributed equally to this work.
372
extraction wounds and infected fracture) can be iden-
tified in most cases. Such cases are diagnosed as sec-
ondary osteomyelitis. Cases in which no apparent
aetiological factor can be found are classified as pri-
mary osteomyelitis.
In developed countries, the prevalence of mandibular
osteomyelitis has decreased significantly in recent dec-
ades. This change can be attributed to increased avail-
ability of antibiotics and improvements in oral and
dental health standards. However, its incidence in
developing countries is still relatively high because of
limited oral health knowledge, poor oral hygiene and
affordability problems.4 An effective treatment method
for mandibular osteomyelitis is a combination of anti-
microbial therapy and surgery consisting of incision
and drainage, or sequestrectomy. In addition, use of
adjunctive treatment options, such as hyperbaric oxy-
gen, can produce good short-term clinical effects.
CASE PRESENTATION
A 37-year-old male patient was referred to our
department with complaints of severe limitation of
mouth opening and swelling and pain in the left facial
and temporal regions for three days. Prior to these
symptoms, the patient had been suffering from pain
around the left lower region of the third molar for
two weeks. Physical examination revealed extensive
2014 Australian Dental Association
 Osteomyelitis of the condyle

Table 1. Osteomyelitis of the mandible secondary to pericoronitis of the third molar

Author (year) Age/Gender Origin Extension Therapy
15
Thoma 28/F upper left third molar condyle tooth extraction and condylectomy
Reck3 16/M lower left third molar coronoid process tooth extraction and coronoidectomy
Tong16 12/M lower left third molar angle region tooth extraction and curettage
Mohammed-Ali17 22/F lower left third molar mandibular ramus tooth extraction and drainage of the left
submasseteric space
Mohammed-Ali17 21/F lower right third molar mandibular ramus tooth extraction and extensive decortication
Lambade13 35/F ectopic third molar in condyle condyle tooth extraction and curettage
Present case 37/M lower left third molar condyle tooth extraction and drainage

swelling in the left facial and temporal regions, palpa-
ble fluctuation on the frontal tragus and temple
region, and limited mouth opening of less than 1 cm.
Intraoral examination showed impaction of perma-
nent tooth 38, with gingival swelling and pus fluxing
from the gingival sulcus of the impacted third molar.
The patients medical history revealed no presumable
cause and the patient had no history of drinking alco-
hol or smoking. A computed tomography scan of the
patients head showed a lytic lesion in the left ramus
of the mandible. The lesion resembled a tunnel from
the impacted third molar to the condyle and had
destroyed the outer cortical plates of the condyle
(Figs. 1 and 2).
Based on test results and a history of pain around
the left lower region of the third molar, the patient
was diagnosed with infection of the buccal, temporal,
pterygomandibular and masseteric spaces followed by
Fig. 1 A panoramic radiograph showed a lytic lesion of the left ramus
of the patients mandible. The lesion resembled a tunnel from the
impacted third molar to the condyle.
osteomyelitis of the condyle secondary to pericoronitis
of an impacted third molar. As per the patients
request, the treatment plan included extraction of the
third molar, removal of the buccal alveolar bone of
the third molar, drainage from the buccal cavity of
the third molar, and incision and drainage of the
preauricular area. The patient was discharged with a
prescription for intravenous injections of clindamycin
and metronidazole. He fully recovered after 14 days
and did not report pain or swelling on the left side of
the face in telephone follow-ups.
DISCUSSION
Prophylactic removal of impacted third molars, which
is the extraction of the asymptomatic impacted third
molars, remains highly controversial.5 Generally, any
recommendation for prophylactic removal of third
molars should consider ongoing symptoms or pathol-
ogy, future complications and morbidity associated
with retention of the third molars, and possible
increased risks of extraction at an older age.5,6 Several
studies7,8 have provided strong evidence to support the
retention of asymptomatic mandibular third molars,
showing that extraction of impacted lower third molars
is associated with mandibular fractures and increased
risk of injury to the lingual and inferior alveolar nerve.
In addition to some common complications (peri-
odontal disease, odontogenic infections, systemic
inflammation and anterior incisor crowding), impacted
third molars are also associated with serious complica-

Fig. 2 A computed tomography scan and three-dimensional reconstruction of the left hemi-mandible revealed the lesion deteriorated the outer cortical
plates of the condyle.
2014 Australian Dental Association 373
R Wang et al.
tions such as mandibular fractures and development of
cysts and tumours.6 Previous studies have reported that
asymptomatic and radiographically pathology-free
retained third molars have the potential for cystic (or
neoplastic) transformation over the lifespan of a
patient.6 About 25% to 59% of all patients with
retained third molars suffer from this condition.6,9,10
Moreover, extensive evidence6,11,12 shows that removal
of impacted third molars reduces the incidence of man-
dibular angle fractures, which is said to be caused by a
decrease in the cross-sectional area of bone at the angle
with a retained third molar and a greater susceptibility
to mandibular angle fractures. Additionally, the pre-
existing periodontal disease around the distal of the sec-
ond molar generally improves with extraction of the
third molars,6 and extractions done at an older age can
lead to more serious complications. Thus, prophylactic
extraction of mandibular third molars in early adult-
hood merits serious consideration. In this study, devel-
opment of osteomyelitis of the condyle was the first
observed complication secondary to an impacted third
molar. Therefore, extraction of the third molar should
be performed as early as possible even in the absence of
symptoms.
Surgical management of osteomyelitis of the con-
dyle aims to relieve symptoms and minimize morbid-
ity without affecting the functional efficiency of the
mandibular condyle.13 It is well-known that decortica-
tion and removal of necrotic tissue, and surgical resec-
tion of the condyle are the two possible methods for
managing osteomyelitis of the condyle.14 However, in
the present case, decortication and removal of necro-
tic tissue could have caused the pathological fracture
of the condyle, while surgical resection of the condyle
would not cure osteomyelitis of the ascending ramus
of the left mandible. Considering the clinical findings
and the patients request, removal of the aetiological
factor and combined therapy of drainage opening and
systemic administration of antibiotics was deemed the
best treatment option. Importantly, this treatment
method resulted in a favourable outcome with mini-
mal detrimental effects.
ACKNOWLEDGEMENTS
This study was supported by grants 81200772 and
81102054 from the National Natural Science Founda-
tion of China and 121064 from Wuhan University to
Rong Wang.
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Address for correspondence:
Professor Ji-Hong Zhao
Department of Oral and Maxillofacial Surgery
School and Hospital of Stomatology
Wuhan University
237 LuoYu Road
Wuhan 430079
China
Email: jhzhao988@aliyun.com
2014 Australian Dental Association