This document provides an overview of fibrous osseous lesions of the jaws and their classification and management. It begins with an introduction to fibrous osseous lesions and their classification. It then discusses specific lesions in more detail, including fibrous dysplasia, cemento-osseous dysplasia, ossifying fibroma, and others. For each lesion, it covers clinical features, radiographic patterns, differential diagnosis, and treatment approaches. The goal is to review current knowledge around the diagnosis and management of these complex fibro-osseous lesions of the jaws.

1. GITAM DENTAL COLLEGE & HOSPITAL
DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY
SEMINAR ON
FIBRO-OSSEOUS LESIONS OF THE JAWS & ITS SURGICAL MANAGEMENT
Presented By:
Dr. Sambhav K Vora
II MDS
1

2. CONTENTS-
 Introduction
 Classification
 Fibrous dysplasia
 Cemento-osseous dysplasia
 Periapical cemento-osseous dysplasia
 Focal cemento-osseous dysplasia
 Florid cemento-osseous dysplasia
 Familial gigantiform cementoma
 Ossifying fibroma
 Juvenile ossifying fibroma
 Osteoblastoma & osteoid osteoma
 Cementoblastoma
 Differential diagnosis
 Controversies
 Conclusion
 References
2

3. FIBRO-OSSEOUS LESIONS OF THE JAWS
INTRODUCTION:. The term FibroOsseous lesions (FOL) has been used for
many years as a general description for a group of tumors and proliferative
disorders, which affect the jaws .They comprise a number of specific clinical
entities in which clinical, radiological and histological features often overlap
causing confusion to both pathologist and clinicians in diagnosis and therapy
A bewildering variety of names have been given to lesions within the FOL
group. These include fibrous dysplasia, osteitis fibrosa cystica, fibrous osteoma,
osseous dysplasia, osteofibrosis, periapical cementoma, and osteoid osteoma.
This multiplicity of names, frequently applied to the same pathological
condition has created confusion with regard to diagnostic criteria and
misunderstanding of individual biological behavior.
Fibro osseous lesions (FOL) refer to a diverse process in which the normal bone
architecture is replaced by fibroblast and collagen fibers containing variable
amounts of mineralized material1
.
Fibro osseous lesions of the jaws as a generic term used to describe a number of
apparently different pathologic entities that commonly affect the maxilla,
mandible and other facial bones1
.
FOL is a generic designation given to a group of disorders (ranging from
inflammatory to neoplastic) that microscopically exhibit, a connective tissue
matrix and islands / trabeculae of bone. Although the histological appearance
3

4. and frequently the clinical and radiological features may be similar for many of
these lesions, they demonstrate a wide range of biological behaviour1
.
The characteristics used to separate the clinical entities are the symptoms and
the radiographic appearance, both of which are extremely varied. Lesions vary
from small, localized, asymptomatic areas discovered on radiographs to well-
defined lesions that cause expansion of the single bone to a functionally
disturbing or cosmetically deforming enlargement of one or many bones. The
radiographic appearance varies from a large, diffuse, dense ground glass pattern
with indistinct boundaries, to localized cyst like radiolucent lesion to well-
defined solitary or multiple radiolucencies with varying foci of radiopaque areas
1
.
This presentation is aimed at reviewing the current knowledge and literature
of clinical, radiological, histological features, differential diagnosis, treatment of
fibro-osseous lesions and controversies related to varios lesions and its
management..
CLASSIFICATION
FIBRO OSSEOUS LESIONS OF JAWS
I. Fibrous Dysplasia
II. Cemento-Osseous Dysplasia.
a) Focal Cemento osseous Dysplasia
b) Periapical Cemento osseous Dysplasia
c) Florid Cemento osseous Dysplasia
III. Familial Gigantiform Cementoma
4

5. IV. Ossifying fibroma.
V. Juvenile ossifying fibroma
III. Miscellaneous
Osteoblastoma,OsteoidOsteoma.Cementoblastoma,
Charles Waldron’s classification:
I. Fibrous Dysplasia
Monostotic
Polyostotic
II. Fibro Osseous (Cemental) lesions presumbly arising in periodontal ligament.
Periapical Cemental Dysplasia
Localised Fibro Osseous Cemental Lesions (Probably reactive in nature)
Florid Cemento osseous Dysplasia (Gigantiform Cementoma)
Ossifying fibroma and cementifying fibroma.
III. Fibro- Osseous Neoplasm of Uncertain or Debatable Relationship to
those arising in the periodontal ligament.
Cementoblastoma, Osteoblastoma, Osteoid Osteoma.
5

6. Juvenile active ossifying fibroma and aggressive active
cementifying/ossifyingfibromas
Brannon and Fowler classification9
1.Fibrous dysplasia
A. Monostotic
B. Craniofacial
C. Polyostotic
D. McCune-Albright syndrome
2. Ossifying fibroma and juvenile ossifying fibroma
3. Osseous dysplasia
A. Periapical
B. Focal
C. Florid
D. Familial gigantiform cementoma
CLASSIFICATION OF RADIOLOGICAL PATTERNS OF THE FIBRO-
OSSEOUS LESIONS OF THE JAWS3
6

7. Divided into 3 groups-
i. Tumour
ii. Dysplasia
iii. Inflammation
These 3 groups were again divided into 5 types based on their radiographic
patterns-
A. Focal
B. Target
C. Radiolucent
D. Calcification
E. Multiconfluent
7

8. The importance of radiology to the diagnosis of FOL:
Maxillofacial FOLs are of particular interest to the radiologist because they
emphasize the central role of the radiologist in the diagnostic process. This role
arises because the pathology for all FOLs is identical, although they range
widely in behaviour, from dysplasia, hamatoma to benign neoplasia with
occasional recurrence. The late Charles Waldron wrote “In absence of good
clinical and radiologic information a pathologist can only state that a given
biopsy is consistent with a FOL. With adequate clinical and radiologic
information most lesions can be assigned with reasonable certainty into one of
several categories” Conversely in the absence of such information Eisenberg
and Eisenbud stated that “pathologists today will often rightly decline to render
a definitive diagnosis, Instead, the pathologist will resort to the noncommittal
designation of benign fibro-osseous lesions [their italics]. This is the only
acceptable approach considering the potential for inappropriate treatment
otherwise.” Therefore the identification of the majority of FOLs is made upon
clinical and radiological features Radiological assessment of the anatomical
location of a bone tumour, its shape and size, the pattern of its matrix and its
destruction, the definition of its margins and concomitant softtissue
abnormalities generally correlate with its behaviour (aggressive or benign).
“Periosteal reaction” an important feature considered by skeletal radiologists “is
not a feature of benign fibro-osseous lesions”.
Many FOLs, particularly COD, are symptomless and require no surgery.
Therefore diagnosis of the lesions on clinical and radiological features alone
may obviate the need for an otherwise unnecessary invasive procedure. This
avoidance of surgery could benefit the patient, because exaggerated growth of
FD may be stimulated by surgery in young patients.7
8

9. Radiological evaluation can be carried out with plain radiography ( P.A view,
lateral view, oblique view or waters projection), OPG, Intra oral periapical
radiograp and Occlusal radiograph. Bitewing radiograph can be useful only in
visualization of supracrestal bone formation, which if present is suggestive of
malignancy such as osteosarcoma or chondrosarcoma.
C. T scans are also excellent for demonstrating many subtle lesions especially
for the evaluation of expansile and destructive processes and also for the
visualization of cortical breakthrough and extraosseous extensions. I.V contrast
administration enhances the soft tissues. Dentascans can also be useful in
diagnosing fibro-osseous lesions.
M.R.I can be useful in differentiating solid from non-solid masses, for ex-
fibrous dysplasia complicated by the presence of Aneurysmal bone cyst.
C.T scan has advantage over MRI In its ability to show the matrix of lesion and
whether it contains fibrous, cartilaginous or calcified tissues. Such information
is helpful in the formulation of clinical differential diagnosis.
FIBROUS DYSPLASIA:
W.H.O (1992), defined Fibrous dysplasia (FD) as a benign lesion, presumably
developmental in nature, characterized by a presence of fibrous connective
tissue with a characteristic whorled pattern and containing trabeculae of
immature bone.
It is a condition in which normal medullary bone is gradually replaced by an
abnormal fibrous tissue proliferation. The mesenchymal tissue contains variable
amounts of an osseous matrix that presumably arises through metaplasia and
consists of only woven bone. THIS DISEASE PRODUCES SOLITARY or
multifocal lesions in which there is arrest of bone development in the woven
9

10. bone stage with failure to lamellar bone. The resultant fibro osseous tissue is
poorly formed and structurally in adequate.
The precise etiology remains unknown, although various theories have been
proposed. Many authorities accept the premise that fibrous dysplasia represents
a non neoplastic hamartomatous growth resulting from altered mesenchymal
cell activity or defect in the control of cell activity.
Marx and Stern (2003) stated that although the clinical development of FD
becomes apparent between 5 to 15 years of age , it begins in the embryo
with the spontaneous gene mutation or deletion of an intra cytoplasmic
transducer protein responsible for bone maturation .all the daughter cells of
the original aberrant cell will produce immature bone, therefore the earlier
this occurs in embryonic development, the more the widespread will be the
FD.
CLINICAL FORMS OF FIBROUS DYSPLASIA /TYPES
Philip et al (1997) – classified FD in to MONOSTOTIC and
POLYOSTOTIC types, where
Monstotic type of FD is further divided in to three subtypes:
• Juvenile
• Juvenile, aggressive
• Adult
Philip et al(1997) Polyostotic type of FD is divided in to three subtypes:
• Craniofacial FD – in which only the bones of craniofacial complex are
affected including the mandible and maxilla.
10

11. • Lichlenstein and jaffe type of FD – in which bones of the skeleton with
café au lait pigmentation.
• Albright syndrome type of FD- has a traid of severe polyostotic FD,
café au lait pigmentation and various endocrinopathies.
MONOSTOTIC FIBROUS DYSPLASIA
Monostotic fibrous dysplasia (MFD) is a type of Fibrous Dysplasia, which
involves only one bone.MFD is the most common type of regional deformity.
Waldron et al 8
(1992) classified Monostotic type of FD in to three subtypes:
• Juvenile
• Juvenile, aggressive
• Adult
JUVENILE FIBROUS DYSPLASIA
Philip (1997) In the head and neck area, monostotic juvenile fibrous
dysplasia is the most common type of regional deformity. It is slow growing
regional distortion that enlarges proportionately with the affected bone. The
regional over growth continuous until general body growth ceases in the late
teens or early twenties. An uncommon form known as aggressive juvenile
fibrous dysplasia grows at an ever faster rate producing major, often
grotesque deformity that results in loss of function of the affected bone
Clinical Features:
Seen in 1st
and 2nd
decades of life
Has equal sex predilection
11

12. Maxilla is effected more than mandible.
Wood N.K and Goaz P.W (1975) stated that the expansion is smooth and
covered with normal appearing mucosa or skin. Ulceration overlying the bony
enlargement is uncommon but may be seen when the mass disrupts the
occlusion or is traumatized during eating.
The first sign of disease is a gradually increasing painless swelling,
which is not well circumscribed and causes a gradually increasing facial
asymmetry. The enlargement is usually smooth, often fusiform in outline
and is more pronounced buccaly than lingually or palatally. When
maxilla is involved there is usually increased prominence of the cheek
and buccal expansion distal to canine, which may extend to involve the
tuberosity. Maxillary lesions commonly extend locally to involve the
sinus, Zygomatic process, floor of orbit and orbital contents are displaced
in some cases. Where the growth is rapid and extensive there may be
marked swelling of the cheek with exopthalmus and proptosis.
Mandibular lesions occur most frequently in the molar and premolar
regions and if the lower border is involved there may be an obvious
protuberance and increased depth of the jaws.
Radiological features:
It varies with the stage of maturity of the lesion, in early stages the lesion
may be radiolucent becoming radiopaque as more bone is formed. The
mature lesion retains none of the normal architecture of trabecular bone,
having replaced it with abnormal bone that produces a “ground glass” or
“orange peel” pattern on radiographs. There is no line of demarcation
because the lesion blends with surrounding bone. Expansion of the
cortical plates and displacement of tooth roots is common. The
laminadura is usually obscured and cortical plates are thinned.
12

13. Treatment:
Treatment is pursued only when lesions are cosmetically unacceptable or
interfere with sight, mastication and speech, most lesions of the normal
form of juvenile fibrous Dysplasia do not require treatment until the
patient has reached adulthood. Lesions should not be treated by
radiotherapy in an attempt to halt growth because of the risk malignancy
in later life.
ADULT FIBROUS DYSPLASIA:
It is a rare form that occurs spontaneously in adults. It resembles
ossifying fibroma in many ways and must be separated from it because
the treatment is very difficult.
Clinical features:
Are similar to mature juvenile FD. The affected area presents as an
asymptomatic diffuse expansion of the cortices. Some movement of teeth
with in the area may occur.
Radiological features:
Philip (1997) less homogenous than juvenile FD, exhibits a mixed
radiolucent and radiopaque “cotton – ball” pattern. As with other forms
of disease, individual lesions blend with the surrounding bone .expansion
and thinning of the cortical plates is usually evident.
.
Treatment:
Philip (1997) treatment aspect is different from juvenile FD because it is
not self-limiting. In adults, attempts are made to completely remove
13

14. smaller lesions and halt the progression of larger ones with continuous
conservative treatment.
POLYOSTOTIC FIBROUS DYSPLASIA
Philip (1997) polyostotic type of FD is divided in to three subtypes:
• Craniofacial FD – in which only the bones of craniofacial complex
are affected including the mandible and maxilla.
• Lichlenstein and jaffe type of FD – in which multiple bones of the
skeleton with café au lait pigmentation.
• Albright syndrome type of FD – has a traid of severe polyostotic FD,
café au lait pigmentation and various endocrinopathies.
Clinical features-
Seen in patients under 40 yrs of age
Females are commomly affected than males
Maxilla is commonly affected than mandible.
In the jaws, pain or fracture is rarely present. The most common
complaint is swelling, often toward the buccal side. On examination,
the tissue overlying the swelling is of normal color. The teeth usually
are not mobile, although in severe cases may be displaced. With
involvement of maxilla, the nose may be appear displaced and may
have nasal obstruction and exophthalmia. In most severe cases of
craniofacial involvement, the patients face may appear significantly
14

15. asymmetric. The serum laboratory values in FD are usually within
normal limits
Radiographic features:
Radiographic appearance of Fibrous Dysplasia is variable, ranging from a
RADIOLUCENT lesion to a densely radio opaque lesion. The classic
presentation has been described as a homogenous radioopacity with the
numerous trabecular of woven bone imparting “GROUND GLASS”
appearance. A 2nd
possible pattern is a radiolucent lesion with patchy, irregular
opacities resulting in a mottled radiographic appearance similar in Pagets
disease. An important distinguishing feature of Fibrous Dysplasia is POORLY
DEFINED clinical & radiographic margins of the lesion.
FD commonly displays an abnormal opacification, which ranges from the very
numerous, small and diffusely distributed opacities [“groundglass” and “peau
d’orange” to sclerosis , classically described as
“cotton–wool”. Different patterns may not only be present in different parts of
the same lesion, but may also depend on whether the film used is “direct
exposure” or “fluorescent screen film”.7
The expansion of FD of the mandible is classically spindle (or fusiform)-shaped
when viewed on a true (axial) occlusal film) or on a posterioanterior
projection of the mandible.
Differential diagnosis-
Ossifying fibroma: FD is well established at the age of 20 years but
ossifying fibroma is seen at an older age. Radiographically OF are well
demarcated, spherical or egg shaped, heterogeneous from the normal bone,
also shows expanded or thinned residual uninvolved cortex and
displacement of the inferior alveolar canal, whereas FD are not
15

16. demarcated, fusifiorm in shape an homogenous. The radiographs and scans
support the concept advanced by Worth that OF is a disease with in the
bone while FD is a disease of the bone .
Chronic sclerosing osteomyelitis :resembles FD in its diffuse and poorly
demarcated radiographic appearance. It too may occur in teenagers and
preteens, but it is more in adults. However, unlike FD, Chronic sclerosing
osteomyelitis is usually severely and constantly painful: there is frequently
a history of an abscessed tooth, or some other infection and appro[priate
cultures may yield actinomyces and eikenella corrodens
Pagets disease :can be distinguished by its onset on individuals older than
40 years and its incrases alkaline phosphate levels.
Osteosarcoma: may be difficult to distinguish from FD radiographically.
In general osteosarcomas do not remodel but resorb the cortex and expand
outward from the destroyed cortex.
TREATMENT and PROGNOSIS:
Once a jaw lesion is determined to represent fibrous dysplasia, the extent of
skeletal involvement should be investigated lesions of F.D. characteristically
exhibit a period of slowly progressive, persistent growth stabilization or
considerable showing of growth after the onset of puberty often follows.
Lesions that result in functional or cosmetic disability may be treated by
osseous recontouring via a transoral approach. This procedure is generally
initiated following the active growth stage and during the period of stabilization
of disease process. For large lesions involving the midface Weber- Fergussion
approach is good alternative for surgical recontouring procedures.
16

17. The incidence of Malignant transformation of existing F.D. is regarded as rare <
1%. Some investigators have suggested that the change of developing a
malignancy is greater in pts. With polyostotic form of the disease, some Patients
who have developed malignancy had received Radiation therapy, suggesting
that radiation had a sole in the transformation process. Rapid enlargement of a
lesion or onset of pain suggests the possibility of malignant degeneration. Most
SARCOMAS arising in Pre existing lesions of F.D. are high grade lesions with
Poor Prognosis. These have included Osteosarcomas, fibrosarcomas,
chondrosarcomas, malignant fibrous histiocytomas
CEMENTO – OSSEIOUS DYSPLASIAS:
These disease process defined by specific clinical and pathologic features have
been classified as
CEMENTO OSSEOUS DYSSLASIAS:
- Periapical cement osseous dysplasia
- Focal cemento osseous dysplasia.
- Florid cement osseous Dysplasia.
The precise etiology of these lesions is not known. Most investigators suggest
that the C.O.D are the result of disorders in the metabolism of cells normally
involved in the production of bone and cementum matrices. The aberrant
17

18. activity of these tissues may be the result of an unusual response to undefined
local factors.
PERIAPICAL CEMENTO OSSEOUS DYSPLASIA:
This peculiar condition characteristically involves the periapical bone at the
apices of teeth with vital, noninflammed pulps. The process involves multiple
teeth, usually the mandibular anterior teeth. Periapical cemental dysplasia most
commonly affects middle aged black women.
Clinical features:
Age: Most patients are between 30-50 years.
Site and Location: Mandible is the commonly affected site and anterior
mandible is the frequently affected location.
Waldron9
(1993) lesions are mostly asymptomatic, discovered when
radiographs are taken for other purposes. Solitary lesions may occur, but
multiple foci are present most frequently
Teeth associated with the lesions are almost invariably vital and seldom
have restorations,
Bone expansion is absent and pain is not a feature.
Teeth are vital, a feature, which distinguishes this condition from apical,
cystic and inflammatory process.
Radiological feature: The lesions are usually detected incidentally on routine
radiographic examinations, as the disease is almost invariably asymptomatic
18

19. Lesions of this type typically have three distinct stages of development.
(1)Osteolytic
(2)Cementoblastic
(3)Mature
Osteolytic stage: The osteolytic stage is characterized by a circular area of
rarefaction at the apex of the vital tooth. The lamina dura is usually absent in
the apical region of the adjacent tooth. The radiolucent area is well demarcated
from the surrounding alveolar bone and a sclerotic ring may be present,which is
thicker ,more irregular,and more diffuse than the margin of a cystic lesion. The
average lesion is approximately 0.5 to 1cm in diameter during this stage in rare
instances,the lesion may be larger than 1cm, in which case it is most likely that
multiple teeth will be involved. The lesion is usually round when it is smaller
than 1cm;it spreads laterally when it enlarges,eventually losing its circular
configuration.
Cementoblastic stage: The cementoblastic stage is characterized by the
appearance of a radiodense cemental mass towards the centre of the lesion.
Initially, a single mass which develops may be very faint. The radiolucent
component remains prominent. An outer rim of sclerotic bone may be
present,especially if active lysis of host bone is in progress. The radiolucent
zone between the central mass of sclerotic rim is divided into three
radiologically distinct bands. The outer band is the region in which calcific
spherules of cementum-like material are formed. In the intermediate band, one
can see individual calcific spherules coalescing with each other form calcific
massules. In the inner band,
Which is adjacent to the central mass, invidual massules are seen that coalesce
with the central mass.
19

20. Mature Stage: In the mature stage a single central mass develops. In some
instances the mass develops from the apex of the involved tooth, causing it to
have a crescent shape. The periphery of the mass tends to have a smooth
surface, although it may be irregular or even lobulated as a result of coalesced
massules. During periods of dormancy, the cemental mass is in direct apposition
with the adjacent bone and may be mistaken easily for idiopathic osteosclerosis.
During active periods, an outer radiolucent fibrocemento osseous band and
radiopaque margin of reactive bone reappear. The radiolucent band is usually
millimeters wide; however, it may be as thin as a normal periodontal ligament
space or as wide as 0.5 cm. in some instances, especially on panoramic
radiographs, the lingual aspect of the radiolucent outer rim may appear to
extend up on to the root of a tooth; however, this may represent a projection
artifact. The cemental mass may grow on either side of the root, but it usually
does not attach to the root apex. The outer rim of sclerotic bone is a variable
feature.
Histopathology:
These lesions are usually diagnosed on clinical and radiographic features.
When biopsied, they usually consist of multiple fragments of moderately
cellular, collagenous tissue investing variable amounts of bone and cementum
matrix. The relative amount and degree of mineralization of the matrix
components are variable, largely dependent on the length of time the lesions
have been present and therefore the stage of prognosis. The calcified tissue is
associated with osteoblasts and cementoblasts along the surface and is deposited
in variety of configurations, including trabecular, spherules or relatively
irregular masses.
20

21. Treatment and Prognosis:
Requires no definitive treatment following diagnosis only periodic observation
is necessary during which time one would expect to see the radiographic
changes association with maturation of the lesions.
FOCAL CEMENTO – OSSEOUS DYSPLASIA:
It is a recently described entity that is thought to fall between P.C.D. and florid
osseous dysplasia in the biologic spectrum of C.O.D.
Clinical features:
(1) Most common in females and a higher incidence in whites.
(2) Lesions are typically solitary involving the bone in POSTERIOR
MANDIBLE.
(3) Characteristically asymptomatic and frequently discovered during routine
radiographic examination.
(4) Most lesions are MIXED radiolucent – radio opaque areas, although the
radiographic appearance may very from well defined radiolucent lesion to a
densely radio opaque area.
(5) Most of lesions < 1.5 cm in size
(6) Many cases involve bone adjacent to the roots of asymptomatic vital teeth.
(7) Some cases of F.C.O.D. have been associated with development of
idiopathic bone cavities.
Histopathology:
21

22. (1) Characteristic feature of F.O.D. is consistency of tissue removed during
biopsy. The tissue is often difficult to correct from the lesion and is removed as
multiple fragments of gritty tissue this feature is especially helpful in distinction
of Ossifying fibroma which can be removed / separated easily from adjacent
normal bone.
(2) These fragments are associated with surgical hemorrhage.
(3) Soft tissue consists of cellular proliferation of fusiform, spindled cells in a
collagenous stroma.
(4) Small blood vessels observed.
(5) Connective tissue consists of small, irregular trabecular of woven bone and
globular deposits of cementum like matrix.
Treatment and Prognosis:
As lesions exhibits only limited potential for progressive growth, most lesions
require no additional treatment.
FLORID CEMENTO OSSEOUS DYSPLASIA:
This disease process represents the most clinically extreme end of the spectrum
of disorders classified as cemento – osseous dysplasias.
Clinicalfeatures:
Most patients who develop F.O.D. are adult, black women. The disease process
characteristically alters he normal bone pattern in a generalized, bilateral
faction.
FOD typically produces mottled, mixed radiolucent radioopaque lesions
adjacent to the teeth through out the affected portions of the jaws. As the
22

23. lesions mature over time, they may consist predominantly of irregular, diffuse,
sclerotic masses. Uncomplicated lesions of FOD may produce mild cortical
expansion but are otherwise complicated. However, the altered bone is
susceptible to the development of Osteomyelitis following traumatic episodes
such as extractions or biopsies or from mucosal ulcerations such as those
resulting from ill fitting removable prosthesis.
Treatment and Prognosis:
It is a non-neoplastic, self limited process that requires no treatment following
diagnosis. In fact, owing to the significant alterations in the affected bone any
form of trauma, including a biopsy procedure is best avoided.
FAMILIAL GIGANTIFORM CEMENTOMA:
• This is a disorder of jaw bones that ultimately leads to the formation of
massive sclerotic masses of disorganized mineralized material.
• In the past it was a synonym for florid COD.
• It is an uncommon hereditary disorder that demonstrates high penetrance
& variable expressivity.
• It is different from conventional cemento osseous dysplasia.
Clinical features
23

24. • Commonly seen in caucasians and african blacks, no sex predilection.
• The osseous pathosis appears to be limited to the jaws but multifocal
involving both maxilla and mandible.
• Rapid and expansile growth pattern of jaws in adolescence results in
facial deformity, impaction, malposition, and malocclusion of the
involved dentition.
• Anemia, multifocal polypoidal adenomas of the uterus may be present –
gynocologic consultation is required.
• The osseous enlargement ceases during fifth decade.
Radiographic features
• Resemble cemento osseous dysplasias.
• Initially they appear as multiple radiolucencies in the periapical regions.
• The affected sites expand and develop mixed radiolucent and radiopaque
pattern.
• With further maturation, they become predominantly radiopaque with a
thin radiolucent rim.
Histopathologic features
• It shows same spectrum of changes seen in the florid cemento oseeous
dysplasia, the two cannot be distinguished radiographically.
Treatment and Prognosis
24

25. • Shave down surgical procedures at the earlier stage to improve aesthetics
are not successful due regrowth.
• At the later stage (radiopaque) partial removal of affected bone will result
in sequestration of the remaining affectd bone.
• Extensive resection and reconstruction of the lesion is recommended at a
later stage if they are causing significant functional & esthetic deformity.
• The extent of surgical procedures is greater at a later stage.
OSSIFYING FIBROMA:
It is considered by most to represent a benign neoplasm arising from
undifferentiated cells of periodontal ligament tissue. This lesions has been
referred to as osteofibroma, fibro-osteoma and benign fibro-osseous lesion of
Periodontal ligament origin. In 1972, the World HealthOrganization (WHO)
considered ossifying fibroma to be a tumor of bone origin This lesion shares
identical clinical radiographic and histopathologic features of with cementifying
fibroma. Neoplastic etiology for ossifying fibroma includes persistent, locally
aggressive growth characteristic and finding of recurrence is seen. Some
investigators regard the lesion as example of localized dysplastic process in
which bone metabolism has been altered.
Clinical features:
It is typically a slow growing, expansible lesions that replaces normal bone as it
enlarges.
25

26. Most lesions are asymptomatic when detected with rare exceptions, lesions arise
in tooth bearing regions of jaws, with the body of mandible being the most
common site.
Most affected patients are adults with peak incidence between 20 and 40 years.
A definite female predominance (5:1).
When lesions remains undetected for a period of time, the lesion exhibits slow
but persistent progression, in gradual expansion and possible thinning of buccal
and lingual cortical plates.
Firbromas occur as solitary lesions.
In contrast to fibrous dysplasia, the most important distinguishing feature is well
circumscribed sharply defined border between lesion and adjacent bone.
Early lesions present as unilocular or multilocular radiolucencies. It progresses
gradually to a mixed radiolucent radiopaque stage and matrix material is
deposited and mineralized in the lesion.
Fully mature, long standing lesions appear as dense, radiopaque masses
surrounded by a thin, well defined regular, radiolucent rim.
As lesions enlarge, they may displace adjacent teeth and less commonly cause
resorption of tooth roots.
Histopathology:
The tumor consists of a collagenous stroma containing variable number of
uniform spindled or stellate cells. Collagen fibers are often arranged
haphazardly.
The degree of vascularity is variable some are relatively avascular and fibrotic,
whereas others exhibit a well vascular stoma.
26

27. Irregular partially interconnecting trabecular of woven bone are noted.
Presence of OSTEOBLASTS along the surface of bone deposits.
Basophitic spherical calcifications and anastamosing trabecular of cementum
like material are also frequently present.
Differential diagnosis-
1. Fibrous dysplasia-
S.No Fibrous dysplasia Ossifying fibroma
1. Site- common in maxilla Common in mandible
2. Seen at 1st
and 2nd
decade 3rd
and 4th
decade
3. Equal sex predilection Females are commonly
affected
4. Radiologically no line of
demarcation between normal
bone and immature bone
Line of demarcation seen
( encapsulated neoplasm)
5. Fusiform elongation or
expansion
Round or oval expansion
6. Histologically only woven
bone will be seen
Lamellar bone will also be
seen.
2. Osteoid osteoma and osteogenic sarcoma- gives an ill defined aggressive
appearance with radiographic signs of malignancy.
3. Condensing osteitis and focal sclerosing osteomyelitis- lacks the
surrounding radiolucent capsule seen in ossifying fibroma and thus easily
differentiated.
27

28. 4. Ameloblastoma – multilocualated, bubbly appearance, clear line of
demarcation present, root resorption may be present. Sometimes even
associated with unerupted tooth.
5. Adenomatoid odontogenic tumour-
Treatment & Prognosis:
An intraoral approach for the surgical excision of tumor by enucleation is the
preferred method of management adjacent normal structures including teeth,
neurovascular elements and bone should be preferred whenever possible when
large lesions are excised and potential risk for postoperative fracture, IMF
should be considered during initial healing stages. In extensive lesions surgical
resection and bone grafting is indicated.
Cryotherapy is also indicated in treating ossifying fibroma for conditions which
are lying adjacent to the bone or lying within the bone.1
JUVENILE OSSIFYING FIBROMA:
• Synonyms: juvenile aggressive ossifying fibroma, juvenile active
ossifying fibroma and aggressive psammomatoid ossifying fibroma.
• The term active juvenile ossifying fibroma is considered when the lesion
behaves in the more aggressive manner & the patient is under the age of
15 years. Recurrences rates of around 30 to 50 % are encountered in this
type of lesion.2
• This uncommon lesion is distinguished from standard OF based on
– its more clinicaly aggressive biologic behaviour,
28

29. – occurrence in younger age group,
– and tendency to occur in different anatomic sites.
Clinical features
• Most cases reported before the age of 15 yrs.
• The most frequent sites of occurrence include the orbital ,frontal and
ethmoid bones, the paranasal sinuses, and the maxilla.
• In contrast to standard OF mandible is less frequently involved.
• Common clinical presentation are proptosis, exophthalmos, visual
disturbances, nasal obstruction and facial asymmetry.
• Many tumors exhibit rapid and progressive enlargement.
• Some lesions produce expansion and thinning of cortices; others may
erode the bone and adjacent soft tissue spaces.
• Intra cranial extension through cribriform plate leading to elevation of
frontal lobe and pneumococcal meningitis is also reported.
Radiographic features
• Most tumors present as destructive, expansile lesion, often with fairly
well demarcated, even corticated, borders.
• Frequently the lesion exhibits a primarily radiolucent quality with varying
amounts of internal radiopacity, reflecting the degree of mineralization.
29

30. Histopathologic features
• Microscopic findings of this lesion are controversial.
• The tumor stroma consists of a highly cellular proliferation of spindled to
stellate cells with minimal intervening collagen.
• The cellular stroma invests thin strands and cords of osteoid, which
contain many osteocyte like cells.
• It also contains woven bone trabeculae with osteoblastic rimming.
• Some lesions contain numerous unoiform, round often laminateds
tructures described as ossicles or psammoma like bodies.
• Other features include –multinucleated goiant cells, myxoid stromal
altterations with areas of degenration, and pseudocyst formation.
Treatment and Prognosis
• The approach to surgical treatment is continually evolving.
• Complete surgical excision is the goal, taking into consideration the size,
location, and extent of the tumor.
• Small accessible lesions may be amenable to surgical excision with
enucleation alone or with peripheral ostectomy.
• Reported recurrence rates for this tumor is between 30% and 58% but no
evidence of metastasis.
• Larger, recurrent lesions may necessitate segmental resections and
reconstruction with bone grafts.
30

31. OSTEOBLASTOMA AND OSTEOID OSTEOMA:
Osteoblastoma and Osteiod Osteoma are recognized neoplasms in the
extragnathic skeleton and have been occasionally been reported in the jaws.
There is wide agreement that Osteoblastoma and Osteoid Osteoma are closely
related lesions and are separated only on the basis of their clinical and
radiologic characteristics. Some authorities prefer the term Osteoblastoma for
both lesions.
The radiographic findings in Osteoblastoma of the jaws and the remainder of
the skeleton are quite inconsistent and showing varying combinations of
radiolucency and calcification that sometimes are indistinguishable from typical
ossifying/ cementifying fibromas.
Histologically, osteoblastomas can show a range of features, but most typically
they have a highly vascularised stroma containing irregular, frequently
anastomosing trabecular of Osteoid and immature bones with varying decrease
of calcification. The osteoid trabecular are surrounded by prominent, plump
osteoblasts and similar osteoblast like cells are conspicuos in the inter trabecular
spaces. Varying number of multinucleated giant cells may also be present.
Although the histologic findings in the usual osteoblastoma are fairly
distinctive, they have enough overlapping features with some ossifying
fibromas so that the designation of a given lesion as an Osteoblastoma or an
ossifying fibroma may be constroversial.
CEMENTOBLASTOMA:
Clinical and Radiographic features:
• It is a odontogenic neoplasm of cementoblasts
31

32. • And also known as true cementoma.
• These are rare, less than 1 % of all odontogenic tumors.
• The most common site is posterior mandible that too first molar area
(50%).
• No sex predilection, rarely affects deciduous teeth.
• The common age group is 10-30 yrs.
• Pain and swelling may be present.
• Radiogrphically it appears as a radiopaque mass that is fused to one or
more tooth roots and is surrounded by a thin radiolucent rim.
• The outline of the roots of involved tooth is usually obscured as a result
of root resorption and fusion of tumor with the tooth.
Histopathologic features
• It resembles osteoblastoma and only difference is fusion of the tumor
with the root.
• It consists of sheets and thick trabeculae of mineralized material with
irregularly placed lacunae and prominent basophilic reversal lines.
• Cellular fibrovascular tissue surrounds the trabeculae, and giant cells are
often present.
• The periphery of the lesion corresponding to the radiolucent zone seen on
the radiograph, is composed of uncalcified matrix, which often is
arranged in radiating columns.
32

33. Treatment and Prognosis
• Surgical extraction of the tooth together with the attached calcified mass.
• Surgical excision of mass with root amputation and endodontic treatment
of the involved tooth may also be considered.
• The prognosis is excellent, tumor does not recur after removal.
• Progressive growth of the tumor after extraction of the tooth and
incomplete removal of the mass has been documented.
According to Eversole et al, the histopathological features of the benign fibro-
osseous process, and radiographic findings, such as evidence of bone cortical
expansion and well-defined margins, suggest the diagnosis of non-aggressive
OF, type B. However, the radiographic features seem to make a modest
contribution to the diagnosis of hybrid lesions, as indicated by the small number
of cases reported in the literature. In addition, Central giant cell granuloma
fundamentally presents radiolucent images, especially in lesions with huge
dimensions. It is recognized that CGCG may produce calcified material.
We emphasize that the CT images revealed the localization, nature and extent of
the lesion. The last feature seems to be present in all the cases reported. The
images led to a diagnosis of OF, and the anatomopathological examination
confirmed an association of CGCG and a fibro-osseous lesion. 7
Differential diagnosis of fibro-osseous lesions –
33

34. Radiolucent lesions-
a. Unicystic radiolucency with sclerotic margin-
1. Cyst- radiolucency will be smooth, thin and sharply defined. Tooth
will be vital and aspiration shows positive response.
b. Unilocular radiolucency without sclerotic margin with ill defined margins
should be differentiated with malignancies. Root resorption will also be
seen in all malignant lesions.
c. Multilocular radiolucent lesion-
Locules of trabeculae might be few in number and of poor density like
central giant cell granuloma or it may be coarse and thick resembling like
ameloblastoma.
Chronic osteomyelitis should also be considered as differential diagnosis.
Mixed radiolucent and radioopaque lesions-
1. Periapical cement osseous dysplasia- radiolucent lesion surrounds the
apex of the tooth, with either sclerotic margin or opaque masses within
the lucent lesion. Tooth will be vital, absence of pain, no expansion of
cortices.
2. Malignant metaststic lesions like osteogenic sarcoma and osteoblastic
carcinoma appears as mixed radiolucent – radioopaque lesions but they
are usually irregular and ill defined along with root resorption which is
not seen in fibro-osseous lesions.
34

35. 3. Odontoma- it is usually located above the crown of an unerupted tooth
and seldom it is found in the apical region . these are more radioopaque
compared to fibroosseous lesions.
4. Fibrous dysplasia- common in maxilla, seen in 1st
and 2nd
decade of life.
Has equal predilection for both male and female. Jaw expansion is seen
which is of fusiform type. there is noline of demarcation between
normal bone and defective bone.
5. Condensing osteitis- clinically pain, inflammation, drainage, tenderness
on palpation and regional lymphadenitis will be present.
6. Cement-ossifying fibroma- predilection for premolars and molars. Seen
under 30 years . Attains size of 2 to 4 cm, produces discernible
expansion.
Mixed radiolucencies and radioopacities not necessarily contacting
teeth-
1. Fibrous dysplasia
2. Chronic osteomyelitis
3. Cement-ossifying fibroma
4. Pagets disease
5. Chondrosarcoma
Radio-opaque lesions-
1. Fibrous dysplasia
2. Focal sclerosing osteomyelitis
35

36. 3. Diffuse sclerosing osteomyelitis
4. Focal cement-osseous dysplasia.
CONTROVERSIES
• Despite the many years of dedicated study by numerous investigators, the
concepts and parameters of fibro-ossoeus diseases are still in flux.
Among the new theories and contentions, there is now essential agreement that
the osseous dysplasias represent a single disease process, while the so-called
juvenile active ossifying fibroma and other aggressive, active, psammomatoid
ossifying/cementifying fibromas remain controversial2
• Are fibro-osseous lesions malformations, hamartomas, or neoplasms?
• It is strange that fibrous dysplasia, cemento-ossifying fibromas are
considered as fibro-osseous lesions not neoplasms and Osteoid osteoma
36

37. and osteoblastoma are considered as neoplasms and not fibro-osseous
lesions.
The debate as to tissue of origin is of little clinical significance, as long as one
differentiates ossifying fibromas from fibrous dysplasia. Hamner et al
advocated the periodontal origin of ossifying fibroma. The periodontal ligament
has been shown to be capable of producing cementum and osteoid, both of
which are characteristically found in ossifying fibromas. Krausen et al and
Spjut et al, however, postulated that primitive mesenchymal cells in areas such
as the ethmoid bone and long bones may produce cementum at sites distant
from odontogenic tissue. They discredited the notion that these tumors arise
from ectopic periodontal tissue in these locations.
.
37
The major controversies are:
1. Distinguishing various fibro-osseous lesions among themselves
and also with other neoplastic lesions.
2. Surgical management of this lesions also remain controversial as
to treat such lesions aggressively initially only or should wait for
its transformation into malignancy then en bloc resections should
be planned. Some lesions can only be treated by curetting and
enucleating.
3. Identifying and predicting aggressive lesions histologically

38. CONCLUSION
• FOLs are diverse group of processes and benign in nature.
• Diagnosis involves all aspects of the disease like clinical, radiographic,
and histopathological features.
• Histopathology of FOLs is similar, and confusing.
• Treatment largely depends on extent of esthetic and functional deformity.
REFERENCES
1.A.E. Abdullai, Benign fibro-osseous lesions of the facial skeleton: analysis of
52 cases seen at the korle bu teaching hospital. Ghana medical journal sept
2004;vol38: no 3
2. Alper Sari, Juvenile ossifying fibroma: report of a case. Gazi Medical Journal
2001;12:62-71
3.. ARAKI MASAO Classification of Radiographic Patterns of Fibro-osseous
Lesions in the Jaws Dental Radiology VOL.43;NO.3;PAGE.121-129(2003).
4. Brannon, Robert B.; Fowler, Craig B Benign Fibro-Osseous Lesions: A
Review of Current Concepts Advances in Anatomic Pathology:
May 2001 - Volume 8 - Issue 3 - pp 126-143
5. CA. Waldren , Fibro-osseous lesions of the Jaws, JOMS,1985; 43:249-62.
6. CA. Waldren ,Fibro-osseous lesions of jaws, -, JOMS, 1993.
7. D.S. MacDonald-Jankowski, Fibro-osseous lesions of the face and jaws.
Clinical Radiology (2004) 59, 11–25
38

39. 8.D.Summerlin, Diagnosis of fibro-osseous lesions of the jaw . JOMS ;64(9):1
9. Faizan Alawi, DDS, Benign Fibro-osseous Diseases of the Maxillofacial
Bones. Am J Clin Pathol 2002;118(Suppl 1):S50-S70
10. Fibro osseous lesions- Dental clinics of North America
11. Maxillo facial surgery- Peter Ward Booth
12. Necdet DOĞAN, Fibro-Osseous Lesions of the Jaws:
Report of Three CasesTurkiye Klinikleri J Dental Sci 2007, 13:146-152
13. Oral and maxillofacial surgery - Daniel M Laskin
14. Surgical pathology - Fonseca vol. 5.
15. TB of Differential diagnosis –Wood and Goaz
16. TB of Oral and maxillofacial pathology – Brad Nivelle
17. TB of Oral pathology - William Shafer
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