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FIBRO OSSEOUS
LESIONS OF THE JAWS
Clinco-Radiographic Diagnosis and Differential
Diagnosis
INDIAN DENTAL ACADEMY
Leader in...
Introduction
• Fibro-osseous lesions are one of the most
confusing area of pathology
DEFINITION
• Fibro –osseous lesions a...
• Because of histologic similarities among
these diverse group of lesions , that
includes developmental , reactive or
dysp...
• The histologic diagnosis of FOLs in most is
relatively uncomplicated
• However the main challenge lies in the sub
classi...
• The literature is confounding and contrary
in regard to nomenclature , classification ,
diagnosis , and management of th...
WHO Classification --1971
6www.indiandentalacademy.com
Waldron classification - 1985
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WHO Classification -- 1992
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Classification
A) Fibro-osseous lesion of
medullary bone origin
1) Fibrous Dysplasia
2) Cherubism
3) Juvenile ossifying
fi...
Modified from Waldron CA
A) Fibrous Dysplasia
B) Reactive ( Dysplastic) lesions arising in the
tooth bearing area – predom...
• A number of other disease processes
demonstrate clinical , radiographic and
microscopic features that bear
resemblance t...
• The disease processes that may be included in
the differential diagnosis of a BFLOs are
• Paget’s disease , Osteosarcoma...
• From the clinical standpoint , BFOLs may
be associated with significant cosmetic
and functional disturbances , or they m...
• Radiographically ,BFOLs may manifest as
• Solitary , multifocal ,or multiquadrant
disease
• They may have a radiolucent ...
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FIBROUS DYSPLASIA
• First described: Von Recklinghausen in
1891
• Termed by : Lichtenstein in 1938
• Commonly known as foc...
ETIOLOGY
• Appears to be developmental disturbance of bone
• Gene mutation (GNAS 1)
• Mutation during early embryonic stag...
Based on number of Bones involved
Monostotic Polyostotic
Fibrous Dysplasia involving large
number of Bones
Pigmented Lesio...
• Monostotic fibrous dysplasia is much more
common than polyostotic form
• Overall 25% of all FDs and 35% patients
with Ma...
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• Maxilla is involved more often than the
mandible
• The term craniofacial FD is often used to
describe the maxillary lesi...
• Although multiple bones are affected ,the
contiguous distribution of the lesion
preclude the classification of craniofac...
Clinical features
• FD usually arises within the first or second decayed of
life
• Monostotic FD generally exhibit equal g...
• Craniofacial lesions may cause anosmia (loss of
smell sensation) , deafness and blindness
• Active growth of FD typicall...
Maxilla  Zygoma
Sphenoid
Occiput
Craniofacial
dysplasia
28
Craniofacial fibrous dysplasia could be
used when there is ext...
Polyostotic fibrous dysplasia -Jaffe-
Lichtenstein syndrome, McCune – Albright
syndrome
-• Uncommon FD involves two or mor...
• Unilateral cutaneous pigmentation with
irregular margin, resembling a map of the
coastline of Maine. .The lesions are of...
• Patients with polyostotic disease are often
younger at the time of diagnosis than those with
monostotic fibrous dysplasi...
Radiographic Features
• Varies with the stage of development and
amount of bony matrix within the lesion
• Early lesions m...
• As the lesion matures dysplastic bone
trabeculae increase in number and size
• The abnormal trabaculae usually are
short...
• Within the lesion , the replacement of fibrous tissue by
trabeculae of approximately equal in size continues to
the poin...
• Alternatively fibrous dysplasia may demonstrate
areas of whorled , amorphous , chalky calcified
material that are fairly...
• The lamina dura surrounding the teeth in the
affected area may be completely effaced
• Classic FD has a ground –glass or...
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• FD of mandible may be unique in displacing the
inferior alveolar canal superiorly , whereas
almost all other BFOLs devel...
• May expands into the antrum by displacing
its cortical boundary and subsequently
occupying part or most of the maxillary...
• CT and MRI scan may be useful for establishing
the full extent of the lesion and for assessing the
degree of bony expans...
• Although rare ,malignant transformation of
FD has been reported in patients with
craniognathic disease.
• Most malignant...
Shepherd crook deformity
Lateral bowing of
proximal part of thigh
Widening of hip
region
Hockey stick
deformity
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• Fibrous dysplasia in
posterior maxilla ,
with an ill-defined anterior
Margin that blends into
normal bone pattern
in the...
In early stage internal
Structure has very little
bone and therefore is
radiolucent .
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• A granular or ground
glass or orange peel
pattern
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• A Very dense amorphous pattern
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• A cotton wool pattern ( almost circular
radiopaque regions)
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Thumb print appearance-
Mand- vertical depth increased
inferior border appear as ribbon
like cortex
In some cases- cortex-...
Mature radiopaque Lesion
• Orange peel- due to bone of
increased density
• Normal structure is replaced
by stippled appear...
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• A coronal CT scan using bone algorithm –
lesion has caused the lateral wall of the
maxilla to expand into maxillary antr...
• A coronal CT scan –
has lesion displaced
Inferior alvolar canal in
superior direction.
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Smoky mottled appearance
• As lesion matures,
dysplastic bony
trabeculae increased
in size & no. and
appear like smoky
mot...
Differential diagnosis
1.Cemento ossifying
fibroma (PDL origin)
• Round in shape
• Jaw expansion caused by
COF is usually ...
2.Chronic osteomyelitis
• In its R/L – R/O can mimic the
motted appearance of fibrous
dysplasia.
• When purulent drainage ...
3.Paget’s disease
• May involve the single bone
but usually affect the several
bones of the skeleton
• Multiple lesions ar...
Osteosarcoma
May demonstrate striking similarity to FD and
manifest as an expanding lesion with borders
that blend with su...
5.Oseoblastic Metastatic Carcinoma
• Pattern as monotonus as that of the mottled type of
fibrous dysplasia.
• Older age gr...
6.Lymphomas of bone
(Rare)
• (may be seen as poorly
defined rarefactious,
perhaps with a few septa
of bone left intact, wh...
7.Chondrosarcoma
• (uncommon malignant
tumour of the jaw)
• Affects an older age
group (30-60yrs)
• Produce pain.
• R/L –R...
Lab. Investigation
• In 50% of cases- serum alkaline phosphatase
level – elevated
• Pituitary follicle stimulating hormone...
Treatment
medical surgical
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Medical
• Bisphosphonates ( BPNs)
• Includes: etidronate, pamidronate,
alendronate, risedronate,
zoledronate, ibandronate
...
Treatment
Surgical
Based on Size of Lesion Based on Age
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Reactive (dysplastic) lesions
of PDL origin
• Robinson in 1956 observed that some
fibro-osseous lesions didn’t meet the
cr...
• Because these lesions have a distinct
predilection for females , it also has been
suggested that osseous dysplasia may
r...
• Since osseous dysplasias develop only in
the tooth bearing region , it is theorized
that this unique group of lesions is...
Classification
Based on clinical and radiographic appearance
Nonhereditary
• Periapical COD
• Focal COD
• Florid COD
Hered...
Periapical cemental dysplasia
• Formerly K/A Cementoma .Also called
as Periapical fibrous dysplasia , periapical
al osteof...
Clinical Features
• Distinct predilection for black females and
develops almost exclusively after 30 yrs
• Also may be see...
Radiographic Features
• Usually found in intimate association with
mandibular anterior teeth
• In occasional cases it may ...
Radiographic Features
• Depending on the maturity of the lesion.
• Serial radiograph have demonstrated
initially as multip...
• May be irregularly shaped or may have an
overall round or oval shape centered
below the apex of the tooth and rarely
ove...
• Some time root resorption
• occasionally hypercementosis
• larger lesions may cause expansion of the
jaw
• lesion always...
• In most cases , the characeristic clinlcal and
radiographic features of periapical osseous dysplasia
usually preclude th...
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Focal cemento osseous dysplasia
• Most common fibro osseous lesion
• Focal cemento-osseous dysplasia exhibits single site ...
Clinical features
• Like POD- focal osseous dysplasia is
more common in females
• More common in blacks and most lesions
a...
• The lesion is seen in close association of
teeth or in areas where a tooth has been
extracted previously
• In contrast ,...
Radiographic features
Irregular shaped,well
demarcated < 2cms
Lesion -- either completely
radiolucent , Mixed
radiolucent-...
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TREATMENT
• Asymptomatic discovered on routine
radiological examination
- NO TREATMENT REQUIRED
• If Symtomatic ( Bone enl...
Florid Osseous Dysplasia
• FLOD is a widespread form of PCD and is
a clinical and radiographic diagnosis in which at
least...
Clinical features
• Like the other two forms of osseous
dysplasias ,FLOD is also common in black
females during 4th or 5th...
• Unlike patients with PCD and FOD patients
with FLOD may have limited bony
expansion , especially of mandible
• Lesions r...
Radiographic features
• The disease is limited exclusively to the tooth
bearing areas of the jaws
• Usually bilaterally sy...
Radiograph often shows numerous , irregularly
shaped , radiolucent , radiopaque or mixed
lesion
Radiopaque legions can var...
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TREATMENT
• Asymptomatic discovered on routine
radiological examination
- NO TREATMENT REQUIRED
• superimposed osteomyliti...
Familial Gigantiform
Cementoma
• Is an autosomal dominant disorder with variable
expressivity .
• A number of affected fam...
Fibro Osseous Neoplasms
• Cementifying Fibroma
• Ossifying Fibroma
• Juvenile Ossifying Fibroma
97www.indiandentalacademy....
Cemento-ossifying fibroma
(Ossifying fibroma and cementifying
fibroma)
• Are considered to be true benign fibro-osseous
ne...
• Consists of highly cellular , fibrous tissue that contains
varying amounts of abnormal bone or cementum.
• When histolog...
Clinical features
• Occurs more commonly in females may occur at
any age but have peak incidence during the 3rd
and 4th de...
• Although OFs may manifest as small
asymptomatic lesions ,most are slow growing ,
expanding lesions that are often more t...
• Pain and paraesthesia are rarely
associated with OFs
• These lesions occur most commonly in a
solitary fashion , althoug...
Radiographic features
• Location- exclusively in the facial bones
• Mandible- typicaly inferior to the premolars and
molar...
Cementifying fibroma
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Homogenous ,radiopaque internal structure and radiolucent band at the periphery
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• Internal structure- mixed radiolucent-
radioopaque density
- Almost radiolucent with just a hint of calcified
material ....
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Wispy trabecular pattern
Fibrous dysplasia granular like
patttern
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A flocculent pattern with larger tufts of bone formation
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• Effects on surrounding structure –
- Displacement of teeth or of the inferior
alveolar canal and expansion of the outer
...
Juvenile ossifying fibroma
Very aggressive form of COF
Two varients
-A trabecular varient (TJOF)
- A psammomatoid varient(...
• Approximately 75% of PJOFs develop in
orbit ,paranasal sinuses,and calvaria,
whereas only about 25% of all cases
involve...
Differential Diagnosis
COF
1.Boundaries are better
defined
2.Displace teeth from a
specific Point or epicentre.
3. Resorpt...
Juvenile ossifying
fibroma
1. More convex shape as it
extends to maxillary
antrum
2. Concentric growth of
tumor
3.T/t- Res...
COF
1. -
2. -
3. Behaves in a more
tumor like
fashion with the
displacement
of teeth.
Periapical Cemental
Dysplasia
1.Mult...
Management
• Surgical enucleation / Resection
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PAGET’S DISEASE
(OSTEITIS DEFORMANS)
• First described in England by Sir James
Paget in 1876
• Etiology : unknown
: Inflam...
Introduction
• Condition of abnormal resorption and
apposition of osseous tissue in one or
more bones.
• involve many bone...
• Rare endemic disease affecting 3% of the
European population over the age 40yrs
• Men are affected 1.5 times than women
...
CLINICAL FEATURES
• Later middle and old age ( incidence of about 3.5%
of individuals over 40 years of age)
• Males are af...
• Affected bone is thickened, enlarged and
commonly deformed,
• Results in : bowing of the legs with a waddling
gait
{ sim...
Involvement of Jaw
• Maxilla
• Osteoblastic activity create
expansion and progressive
enlargement of maxilla.
• Alveolar r...
• Dentures may be tight or may fit poorly in
dentulous patients.
•
• In extreme cases, the alteration results in
a lionlik...
• Nasal obstruction, enlarged turbinates,
obliterated sinuses and deviated septum may
develop secondary to maxillary invol...
Lab findings
.
• levels of serum alkaline phosphatase during
osteoblastic phases of the disease upto 250
bodansky unit
•...
Radiographic features
A] Location:
• Paget’s disease occurs most often in the pelvis, femur,
skull and vertebrae and infre...
A) The initial stage is osteolytic and fibroblastic causing
a generalized radiolucency.
B) The intermediate stage is osteo...
Paget’s Disease with multiple radiopaque masses that have cotton wool appearance
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Trabeculae :
• altered in number and shape,
• may be long and may align themselves in a horizontal
linear pattern ( common...
Paget’s Disease with an altered trabecular pattern
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Effects on surrounding structures
• Paget’s disease always enlarges an
affected bone to affected bone .
• Prominent pageto...
Paget’s Disease involving skull, maxilla and mandible
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Paget's disease. Axial CT image demonstrates
marked thickening of the bony structures, presenting mixed
densities as scler...
Paget’s disease
Almost bilateral
• Characteristically involve the
complete jaw bone.
• Simultaneously affects the
several ...
Aneurysmal bone cyst
• Exact etiology- unknown
• Reactive bone lesion
• May develop in association with a number
of other ...
• Females ,below 30 yrs
• An ABC in the jaw usually manifests as a
rapid bony swelling( buccal or labial)
• Pain ( occasio...
ABC in the angle of mandible with illdefined septa in the internal structure
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CGCG – Bluish purple mass present on the anterior alveolar ridge
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Panoramic radiograph showing a large , expansile radiolucent lesion
in the anterior mandible
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Pedro Infante Cossío, Rafael Martínez
de Fuentes, Andrés Carranza Carranza,
Daniel Torres Lagares, José Luis
Gutiérrez Pér...
Cherubism
• Formerly was known as familial fibrous
dysplasia
• It is now clear that cherubism is not a
subtype of BFOL , l...
• Usually occurs : 2and 5 yrs of age but may
develop as early as 1 year of age
• Patients typically have painless , bilate...
• The resultant enlargement produce the
cherub -like expression by tilting the
eyeballs superiorly.
• Typically progresses...
Clinical Features
• Facial appearance 
Plump cheeked little
angels (Cherubs)
• “ Eyes Upturned to
Heaven”
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• An intraoral examination may reveal
multiple missing teeth
• Radiographically , the lesion usually manifest as
a bilater...
Cherubism with multiple lesions in maxilla and mandible
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Osteoblastoma and osteoid
osteoma
• Osteoblastoma and osteoid osteoma are
solitary benign neoplasms that may
clinically , ...
• However osteoblastoma may have a different
clinical potential because of the propensity for
recurrence ,locally aggressi...
• The radiographic appearance of osteoblastoma
often is characterized by a well-
circumscribedlytic lesion more than 2 cms...
• Osteoid osteoma typically manifests as a small
(less than 2 cm), well-circumscribed , radiolucent
nidus , with or withou...
Benign Cementoblastoma
• Uncommon ,Slow growing , mesenchymal
neoplasms composed principally of
cementum
• Most cases aris...
Clinical features
• Tumor is a solitary lesion that is slow growing
but displace teeth
• Tooth is vital and painful.
• May...
Radiographic features
• Radiographically the tumor manifests as a well-
circumscribed mass surrounded by a radiolucent
hal...
Large ,bulbous,radiopaque mass associated
with the apical portion of mandibular first molar.
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Central giant cell granuloma
• CGCG is a giant cell lesion that commonly
develop within the jaw bones
• Often demonstrate ...
• Occurs over the wide age range , however the
majority of cases develop before the 30 yrs of
age
• A CGCG occurring in pa...
• Occasional CGCG may be aggressive resulting
in local destruction , pain and/or paraesthesia
• Appear as a solitary , uni...
Giant cell lesion in
Hyperparathyroidism
• Found in patients with primary,secondary
or tertiary hyperparathyroidism.
• Mul...
Granular bone pattern and a brown tumor related to the apical region of molars.
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Bone loss with loss of lamina dura and granular texture of the bone.
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Thank You
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fibroosseous lesions of the jaws/ dental implant courses

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fibroosseous lesions of the jaws/ dental implant courses

  1. 1. FIBRO OSSEOUS LESIONS OF THE JAWS Clinco-Radiographic Diagnosis and Differential Diagnosis INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
  2. 2. Introduction • Fibro-osseous lesions are one of the most confusing area of pathology DEFINITION • Fibro –osseous lesions are characterized by replacement of normal bone by collagenous , fibrous connective tissue with an admixture of mineralized product including osteoid , mature bone and in some lesions cementum –like material www.indiandentalacademy.com
  3. 3. • Because of histologic similarities among these diverse group of lesions , that includes developmental , reactive or dysplastic diseases and neoplasms ,the identification of the majority of FOLs is made upon clinical and radiological features www.indiandentalacademy.com
  4. 4. • The histologic diagnosis of FOLs in most is relatively uncomplicated • However the main challenge lies in the sub classification of FOLs , And here the clinical and radiographic features plays an important role * • And this is not merely an academic exercise because the management of BFOLs varies depending on the actual disease process www.indiandentalacademy.com
  5. 5. • The literature is confounding and contrary in regard to nomenclature , classification , diagnosis , and management of these lesions • With the advent of newer diagnostic technologies and our understanding , there is constant evolution in knowledge and so also in classification with inclusion and exclusion of some or the other lesions www.indiandentalacademy.com
  6. 6. WHO Classification --1971 6www.indiandentalacademy.com
  7. 7. Waldron classification - 1985 7www.indiandentalacademy.com
  8. 8. WHO Classification -- 1992 8www.indiandentalacademy.com
  9. 9. Classification A) Fibro-osseous lesion of medullary bone origin 1) Fibrous Dysplasia 2) Cherubism 3) Juvenile ossifying fibroma 4) Giant cell tumor 5) Aneurysmal Bone Cyst 6) Jaw lesions in Hyperparathyroidism 7) Paget’s Disease B) Fibro-osseous lesion of Periodontal origin 1) Periapical Cemental Dysplasia 2) Florid osseous Dysplasia 3) Cemento – ossifying fibroma 4) Cementifying fibroma 5) Ossifying fibroma www.indiandentalacademy.com
  10. 10. Modified from Waldron CA A) Fibrous Dysplasia B) Reactive ( Dysplastic) lesions arising in the tooth bearing area – predominantly PDL origin 1) Periapical Cemento – osseous Dysplasia 2) Focal Cemento – osseous Dysplasia 3) Florid Cemento – osseous Dysplasia C) Fibro – osseous neoplasm 1) Cementifying fibroma 2) Ossifying fibroma 3) Cemento – ossifying fibromawww.indiandentalacademy.com
  11. 11. • A number of other disease processes demonstrate clinical , radiographic and microscopic features that bear resemblance to those encountered in recognized fibro- osseous conditions • However , it must be noted that these lesions donot completely fulfill the histologic criteria for BFLOs as defined by Waldron www.indiandentalacademy.com
  12. 12. • The disease processes that may be included in the differential diagnosis of a BFLOs are • Paget’s disease , Osteosarcoma, Osteoblastoma and Osteoid oseoma , Cementoblastoma ,Central odontogenic fibroma, Renal osteodystrophy , Central giant cell granuloma , Brown tumor of hyperparathyroidism , Aneurysmal bone cyst, Cherubism www.indiandentalacademy.com
  13. 13. • From the clinical standpoint , BFOLs may be associated with significant cosmetic and functional disturbances , or they may be completely asymptomatic , localised lesions that are identified only on routine radiographs www.indiandentalacademy.com
  14. 14. • Radiographically ,BFOLs may manifest as • Solitary , multifocal ,or multiquadrant disease • They may have a radiolucent , mixed radiolucent – radiopaque , predominantly radiopaque , or ground glass appearance • They may be ill or well defined • They may or may not be associated with the root apices of teethwww.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com
  17. 17. www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19. FIBROUS DYSPLASIA • First described: Von Recklinghausen in 1891 • Termed by : Lichtenstein in 1938 • Commonly known as focal osteoid fibrosa 19www.indiandentalacademy.com
  20. 20. ETIOLOGY • Appears to be developmental disturbance of bone • Gene mutation (GNAS 1) • Mutation during early embryonic stages-affects osteoblast, melanocytes, and endocrine cells- Albright syndrome • Mutation during later stage –before birth –affect progeny of cells-multiple bones involvement-polyostotic FD • Mutation at postnatal period-localized defect manifest as monostotic form • Many consider it as a hamartomatous condition www.indiandentalacademy.com
  21. 21. Based on number of Bones involved Monostotic Polyostotic Fibrous Dysplasia involving large number of Bones Pigmented Lesions of Skin (Café au lait spots) Fibrous Dysplasia involving nearly All Bones of Skeleton Pigmented Lesions of Skin (Café au lait spots) Endocrine Disturbance JAFFE Type ALBRIGHT Syn 21www.indiandentalacademy.com
  22. 22. • Monostotic fibrous dysplasia is much more common than polyostotic form • Overall 25% of all FDs and 35% patients with Macune-Albright syndrome (MAS) exhibit mandibular or maxillary involvement . • Mandibular lesions may be monostotic www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. • Maxilla is involved more often than the mandible • The term craniofacial FD is often used to describe the maxillary lesions because often the adjacent bones such as the maxillary sinus, zygoma, nasal, sphenoid ,temporal ,orbital, frontal and occipital bones are also involved www.indiandentalacademy.com
  25. 25. • Although multiple bones are affected ,the contiguous distribution of the lesion preclude the classification of craniofacial FD as polyostotic disease • However , regardless of the number of bones affected , FD is almost always a unilateral disease , and lesions rarely cross midline • www.indiandentalacademy.com
  26. 26. Clinical features • FD usually arises within the first or second decayed of life • Monostotic FD generally exhibit equal gender distribution and polyostotic form tends to occur more commonly in females • Manifesting clinically as slowly growing painless swelling of the affected bone • In rare cases the expansion may be more rapid or begin to accelerate after the period of slow growth www.indiandentalacademy.com
  27. 27. • Craniofacial lesions may cause anosmia (loss of smell sensation) , deafness and blindness • Active growth of FD typically slows or ceases around the time of puberty or after the skeletal maturation ,however ,sporadic periods of regrowth may occur in adulthood www.indiandentalacademy.com
  28. 28. Maxilla  Zygoma Sphenoid Occiput Craniofacial dysplasia 28 Craniofacial fibrous dysplasia could be used when there is extensive involvement of facial bones and bones of the skull www.indiandentalacademy.com
  29. 29. Polyostotic fibrous dysplasia -Jaffe- Lichtenstein syndrome, McCune – Albright syndrome -• Uncommon FD involves two or more bones • When seen with café au lait pigmentation , the condition is termed Jaffe-Lichtenstein syndrome. • The triad of polyostotic fibrous dysplasia , café au lait pigmentation and multiple endocrinopathies( sexual precocity, pituitary adenoma or hyperthyroidism ) is known as the McCune – Albright syndrome. www.indiandentalacademy.com
  30. 30. • Unilateral cutaneous pigmentation with irregular margin, resembling a map of the coastline of Maine. .The lesions are often ipsilateral to the polyostotic FD • These pigmented lesions may be congenital, and pigmented oral mucosal macules also may be present www.indiandentalacademy.com
  31. 31. • Patients with polyostotic disease are often younger at the time of diagnosis than those with monostotic fibrous dysplasia • Although the skull and jaws may be affected with resultant asymmetry ,the clinical picture in patients with polyostotic FD is usually dominated by symptoms in the long bone lesions • Pathologic fracture with resulting pain and deformity is frequently noted ( hockey stick deformity) www.indiandentalacademy.com
  32. 32. Radiographic Features • Varies with the stage of development and amount of bony matrix within the lesion • Early lesions may appear and radiolucent with relatively well defined borders whereas later lesions may appear largely sclerotic and illdefined. • When lesion is small, no effect on surrounding structures. • Large lesion may cause expansion with maintenance of a thinned outer cortex. www.indiandentalacademy.com
  33. 33. • As the lesion matures dysplastic bone trabeculae increase in number and size • The abnormal trabaculae usually are shorter ,thinner , and irregularly shaped and more numerous than normal trabuculae causing a smoky , mottled radiopacity www.indiandentalacademy.com
  34. 34. • Within the lesion , the replacement of fibrous tissue by trabeculae of approximately equal in size continues to the point that the radiographic appearance may simulate granular appearance or GROUND GLASS or have an appearance resembling the small fragment of a shattered wind shield , a pattern resembling dense the surface of an orange ( peau d’ orange) , a wispy arrangement ( cotton wool arrangement ) • This type of appearance is most frequently seen in maxilla and is considered to be a radiographic sign of the disease • This is the most common radiographic appearance of FD www.indiandentalacademy.com
  35. 35. • Alternatively fibrous dysplasia may demonstrate areas of whorled , amorphous , chalky calcified material that are fairly well circumscribed • Other varieties of the lesions may be sclerotic cystlike or pagetoid ,showing areas of increased density and lucency such as seen in Paget’s disease • A distinctive characteristics is the organization of the abnormal trabuculae into a swirling pattern similar to a fingerprint. This appearace is pathognomonic of FDwww.indiandentalacademy.com
  36. 36. • The lamina dura surrounding the teeth in the affected area may be completely effaced • Classic FD has a ground –glass or orange –peel appearance , with poorly discernible borders that appear to blend in with the surrounding affected bone • These are important features that can be used to differentiate FD from ossifying fibroma which has well-cicumscribed and sharply defined borders www.indiandentalacademy.com
  37. 37. www.indiandentalacademy.com
  38. 38. • FD of mandible may be unique in displacing the inferior alveolar canal superiorly , whereas almost all other BFOLs develop above the inferior alveolar canal and may displace it downwords • FD can displace the teeth or interfere with normal erruption and rarely may cause root resorption • www.indiandentalacademy.com
  39. 39. • May expands into the antrum by displacing its cortical boundary and subsequently occupying part or most of the maxillary sinus and may appear obliterated in a Water’s view • A lateral skull view of craniofacial FD characteristically demonstrate increased radiodensity of the base of the skull involving the occiput, sella turcica, orbit, and frontal sinuswww.indiandentalacademy.com
  40. 40. • CT and MRI scan may be useful for establishing the full extent of the lesion and for assessing the degree of bony expansion.Also the bone scintigraphy may be useful for detecting early FD as well as for determining the extent of polyostotic disease www.indiandentalacademy.com
  41. 41. • Although rare ,malignant transformation of FD has been reported in patients with craniognathic disease. • Most malignant neoplasms develop in patients who previously have undergone radiation therapy to the affected area , however , de novo sarcomatous transformation has been identified www.indiandentalacademy.com
  42. 42. Shepherd crook deformity Lateral bowing of proximal part of thigh Widening of hip region Hockey stick deformity www.indiandentalacademy.com
  43. 43. • Fibrous dysplasia in posterior maxilla , with an ill-defined anterior Margin that blends into normal bone pattern in the region of the unerupted cuspid. www.indiandentalacademy.com
  44. 44. In early stage internal Structure has very little bone and therefore is radiolucent . www.indiandentalacademy.com
  45. 45. • A granular or ground glass or orange peel pattern 45www.indiandentalacademy.com
  46. 46. • A Very dense amorphous pattern www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48. • A cotton wool pattern ( almost circular radiopaque regions) 48www.indiandentalacademy.com
  49. 49. Thumb print appearance- Mand- vertical depth increased inferior border appear as ribbon like cortex In some cases- cortex- lost smooth curved downward projection of inferior margin. 49www.indiandentalacademy.com
  50. 50. Mature radiopaque Lesion • Orange peel- due to bone of increased density • Normal structure is replaced by stippled appearance resembles ring of orange www.indiandentalacademy.com
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  55. 55. • A coronal CT scan using bone algorithm – lesion has caused the lateral wall of the maxilla to expand into maxillary antrum. • The shape of lateral wall of sinus has maintained the zygomatic recess www.indiandentalacademy.com
  56. 56. • A coronal CT scan – has lesion displaced Inferior alvolar canal in superior direction. www.indiandentalacademy.com
  57. 57. Smoky mottled appearance • As lesion matures, dysplastic bony trabeculae increased in size & no. and appear like smoky mottled radiopacities • Dense structureless homogenous 57www.indiandentalacademy.com
  58. 58. Differential diagnosis 1.Cemento ossifying fibroma (PDL origin) • Round in shape • Jaw expansion caused by COF is usually nodular or dome shaped. • The COF has sharply defined radiographic feature • 70 % cases occur in the mandible. • Age : 7-58 yrs ( Avg- 26.4 yrs) • Root resorbtion may be seen Fibrous dysplasia • Rectangular in shape • In FD usually of the elongated fusiform type • The margin of FD are indistinct , blending imperceptibly with normal bone. • Maxilla predilection • < 20 yrs of age • Do not cause root resorbtion www.indiandentalacademy.com
  59. 59. 2.Chronic osteomyelitis • In its R/L – R/O can mimic the motted appearance of fibrous dysplasia. • When purulent drainage or denuded bone is present diagnosis must be chronic osteomyelitis. • Irregular cortices of bone at least at one point along the expanded region. • May result in enlargement of jaw but the additional bone is generated by the periosteum ;the new bone is laid down on the surface of the outer cortex. Close examination may reveal evidence of the original cortex within the expanded portion of the jaw. • Fibrous dysplasia • - • - • Expanded bone periphery , although thinned ,appears smoothly contoured and basically uniform. • Expands the internal aspect of the bone displacing and thining the outer cortex so that the remaining cortex maintains its position at the outer surface of the bone. www.indiandentalacademy.com
  60. 60. 3.Paget’s disease • May involve the single bone but usually affect the several bones of the skeleton • Multiple lesions are bilateral • age over 40 yrs favours Paget’s disease. • Males are more commonly affected than females • Whites more than blacks • Presence of extensive hypercementosis • Pain is usual symptom • Extremely high serum alkaline phosphatase levels and also urinary hydroxyproline level is elevated Fibrous dysplasia • Single lesion .of fibrous dysplasia even if it is large and involves almost all the jaw. • Multiple lesions are unilateral and may be associated with pigmentation • Usually below 20 yrs • Female predilection • No hypercementosis • No pain • IN contrast the serum biochemical profile with BFOLs remain unaffected www.indiandentalacademy.com
  61. 61. Osteosarcoma May demonstrate striking similarity to FD and manifest as an expanding lesion with borders that blend with surrounding bone and predominantly radiolucent or mixed RL-RO • However cortical thinning and local destruction may be seen along with one of the type of periosteal reactions, a feature not observed in FD. • Occasional patients may have pain or paraesthesia www.indiandentalacademy.com
  62. 62. 5.Oseoblastic Metastatic Carcinoma • Pattern as monotonus as that of the mottled type of fibrous dysplasia. • Older age group. www.indiandentalacademy.com
  63. 63. 6.Lymphomas of bone (Rare) • (may be seen as poorly defined rarefactious, perhaps with a few septa of bone left intact, which give a multilocular appearance.) • Exhibit osteoblastic activity and bone resorption and hence produce a mixed R/L – R/O appearance. • The pattern is more irregular and bizarre than that seen in the motted lesion of fibrous dysplasia. Fibrous dysplasia • - • Smooth,well countoured external bony borders are always maintained in fibrous dysplasia on clinical and radiographic appearance (never the case in extensive malignancies or osteomyelitis) www.indiandentalacademy.com
  64. 64. 7.Chondrosarcoma • (uncommon malignant tumour of the jaw) • Affects an older age group (30-60yrs) • Produce pain. • R/L –R/O image is completely disordered often invading the cortex. Fibrous dysplasia • - • Affects younger age group.(5-20yr) • Does not produce pain. • Typical rectangular, ordered radiographic appearance. www.indiandentalacademy.com
  65. 65. Lab. Investigation • In 50% of cases- serum alkaline phosphatase level – elevated • Pituitary follicle stimulating hormone – premature secretion • Basal metabolic rate -- Moderately elevated 65www.indiandentalacademy.com
  66. 66. Treatment medical surgical 66www.indiandentalacademy.com
  67. 67. Medical • Bisphosphonates ( BPNs) • Includes: etidronate, pamidronate, alendronate, risedronate, zoledronate, ibandronate • MOA: due to their high affinity to calcium, the BPNs enter the osteoclasts during resorptive state to cause; accelerated apoptosis, disruption of cytoskeleton, and internal inactivation of the osteoclasts 67www.indiandentalacademy.com
  68. 68. Treatment Surgical Based on Size of Lesion Based on Age 68www.indiandentalacademy.com
  69. 69. Reactive (dysplastic) lesions of PDL origin • Robinson in 1956 observed that some fibro-osseous lesions didn’t meet the criteria for fibrous dysplasia or ossifying fibroma and designated them as osseous dysplasia • Osseous dysplasias are the most common form of BFOLsof the jaw bones www.indiandentalacademy.com
  70. 70. • Because these lesions have a distinct predilection for females , it also has been suggested that osseous dysplasia may represent a dysplastic process related to a hormonal imbalance that influence bone remodeling 70www.indiandentalacademy.com
  71. 71. • Since osseous dysplasias develop only in the tooth bearing region , it is theorized that this unique group of lesions is derived from elements within the periodontal ligament space or is related to the unique presence of teeth and periodontium within the jaw bones • Similar lesions are yet to be found in any other bones apart from maxilla and mandible www.indiandentalacademy.com
  72. 72. Classification Based on clinical and radiographic appearance Nonhereditary • Periapical COD • Focal COD • Florid COD Hereditary • Familial gigantiform Cementoma 72www.indiandentalacademy.com
  73. 73. Periapical cemental dysplasia • Formerly K/A Cementoma .Also called as Periapical fibrous dysplasia , periapical al osteofibrosis • The lesion represent s a reactive rather than a neoplastic process • This lesion appears to be an unusual response of periapical bone and cementum to some local trauma or infection 73www.indiandentalacademy.com
  74. 74. Clinical Features • Distinct predilection for black females and develops almost exclusively after 30 yrs • Also may be seen in Asians • PCOD is almost always asymptomatic and nonexpanding and usually is discovered on routine dental radiograph www.indiandentalacademy.com
  75. 75. Radiographic Features • Usually found in intimate association with mandibular anterior teeth • In occasional cases it may be associated with single tooth , in which case it often is mistaken for inflammatory peri-apical disease • Vitality testing of the tooth should avoid any error in diagnosis , since PCOD affected teeth always remain vital www.indiandentalacademy.com
  76. 76. Radiographic Features • Depending on the maturity of the lesion. • Serial radiograph have demonstrated initially as multiple,circumscribed, noncorticated radiolucencies which may over time exhibit increasing radiopcity • Although each individual lesion exhibits little tendency to enlarge , often adjacent lesions coalesce to form a large , irregular shaped , mixed radilucent-radiopaque mass 76www.indiandentalacademy.com
  77. 77. • May be irregularly shaped or may have an overall round or oval shape centered below the apex of the tooth and rarely over the apex of the tooth. • Lamina dura is lost • Periodontal ligament space either less apparent or giving it a wider appearance 77www.indiandentalacademy.com
  78. 78. • Some time root resorption • occasionally hypercementosis • larger lesions may cause expansion of the jaw • lesion always bordered by a thin, intact outer cortex • may elevate the floor of the maxillary antrum 78www.indiandentalacademy.com
  79. 79. • In most cases , the characeristic clinlcal and radiographic features of periapical osseous dysplasia usually preclude the need for any surgical intervention • Although POD is a sporadic disorder, the classic radiographic features have been identified in multiple individuals of one family • No treatment required- Periodic radiographic follow up www.indiandentalacademy.com
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  81. 81. 81www.indiandentalacademy.com
  82. 82. Focal cemento osseous dysplasia • Most common fibro osseous lesion • Focal cemento-osseous dysplasia exhibits single site of involvement. • The concept of focal osseous dysplasia was not clarified until the mid-1990s. Before that time, most cases were misdiagnosed as a variant of ossifying fibroma • Recently given to PCOD – like lesions : occur in the premolar-molar region. 82www.indiandentalacademy.com
  83. 83. Clinical features • Like POD- focal osseous dysplasia is more common in females • More common in blacks and most lesions are recognized during IV th – V th decade • Small ,asymptomatic ,solitary well demarcated lesion • Commonly seen in Posterior Mandible site 83www.indiandentalacademy.com
  84. 84. • The lesion is seen in close association of teeth or in areas where a tooth has been extracted previously • In contrast , most OFs cause jaw expansion and are not intimately associated with teeth and FOD unlike OF exhibit little tendency to enlarge over time • Moreover OFs demonstrate no significant sex predilection • www.indiandentalacademy.com
  85. 85. Radiographic features Irregular shaped,well demarcated < 2cms Lesion -- either completely radiolucent , Mixed radiolucent- opaque or completely radiopaque with peripheral radiolucent border IN contrast OFS are usually larger in size and have well defined 85www.indiandentalacademy.com
  86. 86. www.indiandentalacademy.com
  87. 87. TREATMENT • Asymptomatic discovered on routine radiological examination - NO TREATMENT REQUIRED • If Symtomatic ( Bone enlargement ) • - CURRETAGE • Complications • Fused masses of acellular poorly vascular - sclerotic tissue – necrosis -- low grade infection- sequestration 87www.indiandentalacademy.com
  88. 88. Florid Osseous Dysplasia • FLOD is a widespread form of PCD and is a clinical and radiographic diagnosis in which at least 2 quadrants must be involved • Most common cause of pathologic generalized radiopacity of the jaws • Also Known as • Florid cementoosseous dyslpasia • Gigantiform cementoma • Familial multiple cementomas 88www.indiandentalacademy.com
  89. 89. Clinical features • Like the other two forms of osseous dysplasias ,FLOD is also common in black females during 4th or 5th decayed • Also reported in Asians • Most cases asymptomatic and detected on routine dental radiographs • However occasional patients may have dull , intermittent ,poorly localized pain especially in lesions that are infected secondarily 89www.indiandentalacademy.com
  90. 90. • Unlike patients with PCD and FOD patients with FLOD may have limited bony expansion , especially of mandible • Lesions restricted to the tooth bearing regions of the jaw bones • In many all 4 Quadrants of Mandible and Maxilla are involved www.indiandentalacademy.com
  91. 91. Radiographic features • The disease is limited exclusively to the tooth bearing areas of the jaws • Usually bilaterally symmetrical involving both jaws. • If present in one jaw- mandible is involved • Periphery- well defined with sclerotic border 91 www.indiandentalacademy.com
  92. 92. Radiograph often shows numerous , irregularly shaped , radiolucent , radiopaque or mixed lesion Radiopaque legions can vary from small oval and circular regions (cotton wool appearance) to large , irregular , amorphous areas of calcification Concommitant multiple traumatic bone cysts commonly develop in association with FLOD www.indiandentalacademy.com
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  95. 95. TREATMENT • Asymptomatic discovered on routine radiological examination - NO TREATMENT REQUIRED • superimposed osteomylitis should be treated by antibiotics, sequestrectomy,and excision of the sinus tract and the associated cementoosseous mass. 95www.indiandentalacademy.com
  96. 96. Familial Gigantiform Cementoma • Is an autosomal dominant disorder with variable expressivity . • A number of affected families have been identified • Radiographic appearance is similar to FLOD however there is no sex or racial predilection • Lesion often manifest at an early age and may cause substantial rapid bony expansion and facial assymmetry www.indiandentalacademy.com
  97. 97. Fibro Osseous Neoplasms • Cementifying Fibroma • Ossifying Fibroma • Juvenile Ossifying Fibroma 97www.indiandentalacademy.com
  98. 98. Cemento-ossifying fibroma (Ossifying fibroma and cementifying fibroma) • Are considered to be true benign fibro-osseous neoplasm that develops within the undifferentiated cells of periodontal ligament origin • A neoplastic etiology is supported by examples of lesions that achieve a large size , exhibit aggressive behavior , and produce significant osseous destruction • Other regard this lesion as an example of a localized dysplastic process in which bone metabolism is altered www.indiandentalacademy.com
  99. 99. • Consists of highly cellular , fibrous tissue that contains varying amounts of abnormal bone or cementum. • When histologic appearance of most of the calcified tissues was of irregular trabeculae of woven bone , the term – ossifying fibroma is used • When the predominant calcified component was cementum , the term – cementifying fibroma is used. www.indiandentalacademy.com
  100. 100. Clinical features • Occurs more commonly in females may occur at any age but have peak incidence during the 3rd and 4th decades • The majority of cases arise in the molar – premolar regions of the mandible • Unlike FODs, most OFs don’t show close association with the roots of teeth www.indiandentalacademy.com
  101. 101. • Although OFs may manifest as small asymptomatic lesions ,most are slow growing , expanding lesions that are often more than 3cms in diameter at the time of diagnosis • Occasionally tumor may behave aggressively ,reaching massive proportion and causing visible facial asymmetry • Displacement of teeth-early clinical features www.indiandentalacademy.com
  102. 102. • Pain and paraesthesia are rarely associated with OFs • These lesions occur most commonly in a solitary fashion , although rare instances of multiple synchronous lesions have been reported www.indiandentalacademy.com
  103. 103. Radiographic features • Location- exclusively in the facial bones • Mandible- typicaly inferior to the premolars and molars and superior to the inferior alveolar canal. • Maxilla- canine fossa and zygomatic arch. • OFs usually appear as unilocular lesion with sharply defined , smooth , corticated border , a feature that is used to differentiate Ofs from FDs www.indiandentalacademy.com
  104. 104. Cementifying fibroma www.indiandentalacademy.com
  105. 105. Homogenous ,radiopaque internal structure and radiolucent band at the periphery www.indiandentalacademy.com
  106. 106. • Internal structure- mixed radiolucent- radioopaque density - Almost radiolucent with just a hint of calcified material . - In the type –that contains mainly abnormal bone the pattern = fibrous dyspalsia or wispy ( similar to stretched tufts of cottons) or flocculent pattern (similar to large , heavy snow flecks) may be seen. - Cementum like material contain solid ,amorphous radioopacities (cementicles) = cemental dysplasia. www.indiandentalacademy.com
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  112. 112. Wispy trabecular pattern Fibrous dysplasia granular like patttern www.indiandentalacademy.com
  113. 113. A flocculent pattern with larger tufts of bone formation www.indiandentalacademy.com
  114. 114. • Effects on surrounding structure – - Displacement of teeth or of the inferior alveolar canal and expansion of the outer cortical plates of the bone (although displaced and thinned , remains intact.) - Occupy the entire maxillary sinus – expanding its walls outwards . - Lamina dura is missing - Resorption of teeth.www.indiandentalacademy.com
  115. 115. Juvenile ossifying fibroma Very aggressive form of COF Two varients -A trabecular varient (TJOF) - A psammomatoid varient(PJOF) PJOF is more common Both varients can occurs at any age, but most common during first 2 decades www.indiandentalacademy.com
  116. 116. • Approximately 75% of PJOFs develop in orbit ,paranasal sinuses,and calvaria, whereas only about 25% of all cases involve the maxilla or mandible • In contrast about 95 % of the cases of TJOF have developed within the jawbones , with maxillary lesions occurring more frequently • The radiographic is similar to COF www.indiandentalacademy.com
  117. 117. Differential Diagnosis COF 1.Boundaries are better defined 2.Displace teeth from a specific Point or epicentre. 3. Resorption of teeth may occur. FD 1.Boundaries usually blends in with Surrounding bone 2.Displace teeth. 3.Rarely resorbs teeth. www.indiandentalacademy.com
  118. 118. Juvenile ossifying fibroma 1. More convex shape as it extends to maxillary antrum 2. Concentric growth of tumor 3.T/t- Resection Fibrous Dysplasia 1. Usually displaces lateral wall of maxilla into Maxiallry antrum maintaining the outer shape of the wall 2.May change the bone around the teeth without moving them. 3.T/t- Observation www.indiandentalacademy.com
  119. 119. COF 1. - 2. - 3. Behaves in a more tumor like fashion with the displacement of teeth. Periapical Cemental Dysplasia 1.Multifocal 2.Presence of simple bone cyst. 3. Wide sclerotic border is a more characteristics of the slow growing cemental dysplasia. www.indiandentalacademy.com
  120. 120. Management • Surgical enucleation / Resection www.indiandentalacademy.com
  121. 121. PAGET’S DISEASE (OSTEITIS DEFORMANS) • First described in England by Sir James Paget in 1876 • Etiology : unknown : Inflammatory , genetic, endocrine factors www.indiandentalacademy.com
  122. 122. Introduction • Condition of abnormal resorption and apposition of osseous tissue in one or more bones. • involve many bones simultaneously but it is not a generalized skeletal disease. • Initiated by an intense wave of osteoclastic activity, with resorption of normal bone resulting in irregularly shaped resorption cavities. www.indiandentalacademy.com
  123. 123. • Rare endemic disease affecting 3% of the European population over the age 40yrs • Men are affected 1.5 times than women • Skull involvement as high as 70% had been reported • J. Tehranzadeh, Ying Fung, Michael Donohue, Arash Anavim and Henry W. Pribram. Computed tomography of Paget disease of the skull versus fibrous dysplasia; Skeletal Radiology (1998)27;664-672 www.indiandentalacademy.com
  124. 124. CLINICAL FEATURES • Later middle and old age ( incidence of about 3.5% of individuals over 40 years of age) • Males are affected more • Bone pain , which may be quite severe , • Pagetic bone often forms near joints and promotes osteoarthritic changes, with associated joint pain and mobility. • The lumbar vertebrae, pelvis, skull, tibia,humerus and femur : most commonly affected bones. www.indiandentalacademy.com
  125. 125. • Affected bone is thickened, enlarged and commonly deformed, • Results in : bowing of the legs with a waddling gait { simian ( monkeylike) stance} : curvature of the spine, : enlargement of the skull ( leads to progressive increase in the circumference of the head) Formina are often constricted ,consequently pressure is induced on the structures that pass through the foramen : causing neurologic signs such as deafness and diminishing vision. www.indiandentalacademy.com
  126. 126. Involvement of Jaw • Maxilla • Osteoblastic activity create expansion and progressive enlargement of maxilla. • Alveolar ridge is widened • Palate is flattened • Involved teeth : undergo migration, tipping, loosening and increased interproximal spacing www.indiandentalacademy.com
  127. 127. • Dentures may be tight or may fit poorly in dentulous patients. • • In extreme cases, the alteration results in a lionlike facial deformity ( leontiasis ossea) www.indiandentalacademy.com
  128. 128. • Nasal obstruction, enlarged turbinates, obliterated sinuses and deviated septum may develop secondary to maxillary involvement. Bone scan of mandible may demonstrate marked uptake throughout the entire mandible from condyle to condyle , termed as black beard or Lincoln’s sign. Bone pain is an inconsistent symptom , most often directed toward the weight – bearing bones ; facial or jaw pain is uncommon. www.indiandentalacademy.com
  129. 129. Lab findings . • levels of serum alkaline phosphatase during osteoblastic phases of the disease upto 250 bodansky unit • levels of hydroxyproline in urine www.indiandentalacademy.com
  130. 130. Radiographic features A] Location: • Paget’s disease occurs most often in the pelvis, femur, skull and vertebrae and infrequently in the jaws. • Affects the maxilla about twice as often as the mandible. • Bilateral B] Internal structure • Depends on the developmental stage of the disease. • 1 stage : radiolucent resorptive stage • 2 stage : granular or ground glass appearing • 3 stage : denser more radiopaque appositional stage. www.indiandentalacademy.com
  131. 131. A) The initial stage is osteolytic and fibroblastic causing a generalized radiolucency. B) The intermediate stage is osteolytic and osteoblastic , producing some large trabecular clusters , which appears as radiopaque areas within the generalized radiolucency. C) The mature stage, some osteoclastic behaviour is predominantly osteoblastic and shows as a dense cotton- wool pattern on radiographs. www.indiandentalacademy.com
  132. 132. Paget’s Disease with multiple radiopaque masses that have cotton wool appearance www.indiandentalacademy.com
  133. 133. Trabeculae : • altered in number and shape, • may be long and may align themselves in a horizontal linear pattern ( common in the mandible) • short, with random orientation, and have a granular pattern similar to that of fibrous dysplasia. • organized into rounded, radiopaque patches of abnormal bone, creating a cotton- wool appearance. • The overall density of the jaws may decrease or increase depending on the number of trabeculae. www.indiandentalacademy.com
  134. 134. Paget’s Disease with an altered trabecular pattern www.indiandentalacademy.com
  135. 135. Effects on surrounding structures • Paget’s disease always enlarges an affected bone to affected bone . • Prominent pagetoid skull bones may swell to three or four times their normal thickness. • In enlarged jaws the outer cortex may be thinned www.indiandentalacademy.com
  136. 136. Paget’s Disease involving skull, maxilla and mandible www.indiandentalacademy.com
  137. 137. Paget's disease. Axial CT image demonstrates marked thickening of the bony structures, presenting mixed densities as sclerotic and osteolytic change. The changes are symmetric, the demineralization affects the outer portions (arrow) of the otic capsule first. www.indiandentalacademy.com
  138. 138. Paget’s disease Almost bilateral • Characteristically involve the complete jaw bone. • Simultaneously affects the several bone of the skeleton. • Presence of extensive hypercementosis and an age over 40 yrs favours Paget’s disease. • The extremely high serum alkaline phosphatase levels in Paget’s disease. Fibrous dysplasia • -unilateral • Single isolated lesion of fibrous dysplasia even if it is large and involves almost all the jaw. • - • Possibility of Albright’s syndrome because of two or more of the bones are affected with fibrous dysplasis. presence of café-au- lait spots on the skin, as well as precocious puberty in a young girl. • In maxilla FD has a tendency to encroach upon the antral air space. Differential diagnosis www.indiandentalacademy.com
  139. 139. Aneurysmal bone cyst • Exact etiology- unknown • Reactive bone lesion • May develop in association with a number of other osseous lesion including FD ,OF,osteoblastoma and osteosarcom • Some believes- exagrated, localised, proliferative response of vascular tissue in bone 139www.indiandentalacademy.com
  140. 140. • Females ,below 30 yrs • An ABC in the jaw usually manifests as a rapid bony swelling( buccal or labial) • Pain ( occasional complaint) • Involved area may be tender on palpation • Most lesions manifest as solitary , multilocular radiolucencies in the posterior mandible 140www.indiandentalacademy.com
  141. 141. ABC in the angle of mandible with illdefined septa in the internal structure www.indiandentalacademy.com
  142. 142. CGCG – Bluish purple mass present on the anterior alveolar ridge www.indiandentalacademy.com
  143. 143. Panoramic radiograph showing a large , expansile radiolucent lesion in the anterior mandible www.indiandentalacademy.com
  144. 144. Pedro Infante Cossío, Rafael Martínez de Fuentes, Andrés Carranza Carranza, Daniel Torres Lagares, José Luis Gutiérrez Pérez. Recurrent central giant cell granuloma in the mandible: Surgical treatment and dental implant restoration Med. oral patol. oral cir.bucal v.12 n.3 2007 www.indiandentalacademy.com
  145. 145. Cherubism • Formerly was known as familial fibrous dysplasia • It is now clear that cherubism is not a subtype of BFOL , let alone related to FD • It is a rare autosomal dominant , self – limiting disorder that exhibits 100% male and 50-70%female penetrance • Sporadic cases also have been reported www.indiandentalacademy.com
  146. 146. • Usually occurs : 2and 5 yrs of age but may develop as early as 1 year of age • Patients typically have painless , bilateral jaw enlargement resulting in marked facial assymmetry . • Mandibular poserior region is involved most commonly .In some case the walls of the maxillary sinus,orbital floor and tuberosity may be involved 146www.indiandentalacademy.com
  147. 147. • The resultant enlargement produce the cherub -like expression by tilting the eyeballs superiorly. • Typically progresses until puberty,then stabilize and slowly regress. • Bony architecture returns to normal by age 30. 147www.indiandentalacademy.com
  148. 148. Clinical Features • Facial appearance  Plump cheeked little angels (Cherubs) • “ Eyes Upturned to Heaven” 148www.indiandentalacademy.com
  149. 149. • An intraoral examination may reveal multiple missing teeth • Radiographically , the lesion usually manifest as a bilateral , multilocular radiolucencies with concomitant bony expansion • Numerous impacted or displaced teeth may be identified 149 www.indiandentalacademy.com
  150. 150. Cherubism with multiple lesions in maxilla and mandible www.indiandentalacademy.com
  151. 151. Osteoblastoma and osteoid osteoma • Osteoblastoma and osteoid osteoma are solitary benign neoplasms that may clinically , radiographically and histologically resemble BFOLs • Osteoblastoma and osteoid osteoma can’t be differentiated reliably based on histologic examination alone ,and thus two neoplasms may be the variant of same tumor www.indiandentalacademy.com
  152. 152. • However osteoblastoma may have a different clinical potential because of the propensity for recurrence ,locally aggressive behavior and in rare cases , malignant transformation • More common in males , most arise during the third decade and when jaw bones are affected , mandible is commonly affected www.indiandentalacademy.com
  153. 153. • The radiographic appearance of osteoblastoma often is characterized by a well- circumscribedlytic lesion more than 2 cms with varying amount of calcification • Cortical expansion often is noted , occasionally resulting in facial asymmetry • Spontaneous pain/or tenderness were identified in the majority of patients www.indiandentalacademy.com
  154. 154. • Osteoid osteoma typically manifests as a small (less than 2 cm), well-circumscribed , radiolucent nidus , with or without a central area of opacification , and surrounding bone sclerosis • Osteoid osteoma is classically manifested with severe nocturnal pain and is relieved substantially by nonsteroidal anti-inflammatory medications www.indiandentalacademy.com
  155. 155. Benign Cementoblastoma • Uncommon ,Slow growing , mesenchymal neoplasms composed principally of cementum • Most cases arise during 2nd or 3rd decades • No racial predilection • Most cases arise within the mandibular premolar or molar regions , mostly first molar www.indiandentalacademy.com
  156. 156. Clinical features • Tumor is a solitary lesion that is slow growing but displace teeth • Tooth is vital and painful. • May cause expansion of the jaw. • Bulbous growth around and attached to the apex of a tooth root. www.indiandentalacademy.com
  157. 157. Radiographic features • Radiographically the tumor manifests as a well- circumscribed mass surrounded by a radiolucent halo • The mass appears fused to one or more tooth roots • May have exrernal root resorption • OFs usually are not associated with the apices of teeth • www.indiandentalacademy.com
  158. 158. Large ,bulbous,radiopaque mass associated with the apical portion of mandibular first molar. www.indiandentalacademy.com
  159. 159. Central giant cell granuloma • CGCG is a giant cell lesion that commonly develop within the jaw bones • Often demonstrate clinical , radiographic and microscopic features that are similar to those seen in BFLOs • More common in females • May occur in maxilla but most cases are seen in mandible • The lesions often are anterior to the molar teeth and may cross the midline www.indiandentalacademy.com
  160. 160. • Occurs over the wide age range , however the majority of cases develop before the 30 yrs of age • A CGCG occurring in patients over 30 yrs of age warrants further clinical evaluation for hyperthyroidism • Clinically present as an asymptomatic , localized swelling www.indiandentalacademy.com
  161. 161. • Occasional CGCG may be aggressive resulting in local destruction , pain and/or paraesthesia • Appear as a solitary , unilocular or multilocular radiolucent lesion with or without well- demarcated borders • In some cases cortical perforation may be seen • Unlike BFOLs , discrete radiopacities are rarely seen in CGCG www.indiandentalacademy.com
  162. 162. Giant cell lesion in Hyperparathyroidism • Found in patients with primary,secondary or tertiary hyperparathyroidism. • Multiple lesions may be identified • It is commonly called as Brown Tumor because it’s gross appearance is characerized by a red –brown color • The clinical , radiographic and microscopic appearances are indistinguishable from those of CGCG www.indiandentalacademy.com
  163. 163. Granular bone pattern and a brown tumor related to the apical region of molars. www.indiandentalacademy.com
  164. 164. Bone loss with loss of lamina dura and granular texture of the bone. www.indiandentalacademy.com
  165. 165. Thank You www.indiandentalacademy.com
  166. 166. www.indiandentalacademy.com
  167. 167. www.indiandentalacademy.com
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