fibroosseous lesions of the jaws/ dental implant courses

FIBRO OSSEOUS
LESIONS OF THE JAWS
Clinco-Radiographic Diagnosis and Differential
Diagnosis
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

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

• 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

• 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

• 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

WHO Classification --1971
6www.indiandentalacademy.com

Waldron classification - 1985

WHO Classification -- 1992

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

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

• A number of other disease processes
demonstrate clinical , radiographic and
microscopic features that bear
resemblance to those encountered in
recognized fibroosseous conditions
• However , it must be noted that these
lesions donot completely fulfill the
histologic criteria for BFLOs as defined by
Waldron

• 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

• 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

• 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

FIBROUS DYSPLASIA
• First described: Von Recklinghausen in
1891
• Termed by : Lichtenstein in 1938
• Commonly known as focal osteoid fibrosa

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

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

• 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

• 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

• 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
•

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

• 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

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

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.

• 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

• 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)

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.

• 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

• 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

• 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

• 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

• 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
•

• 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

• 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

• 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

Shepherd crook deformity
Lateral bowing of
proximal part of thigh
Widening of hip
region
Hockey stick
deformity

• Fibrous dysplasia in
posterior maxilla ,
with an ill-defined anterior
Margin that blends into
normal bone pattern
in the region of the
unerupted cuspid.

In early stage internal
Structure has very little
bone and therefore is
radiolucent .

• A granular or ground
glass or orange peel
pattern

• A Very dense amorphous pattern

• A cotton wool pattern ( almost circular
radiopaque regions)

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.

Mature radiopaque Lesion
• Orange peel- due to bone of
increased density
• Normal structure is replaced
by stippled appearance
resembles ring of orange

• 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

• A coronal CT scan –
has lesion displaced
Inferior alvolar canal in
superior direction.

Smoky mottled appearance
• As lesion matures,
dysplastic bony
trabeculae increased
in size & no. and
appear like smoky
mottled radiopacities
• Dense structureless
homogenous

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

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.

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

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

5.Oseoblastic Metastatic Carcinoma
• Pattern as monotonus as that of the mottled type of
fibrous dysplasia.
• Older age group.

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)

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.

Lab. Investigation
• In 50% of cases- serum alkaline phosphatase
level – elevated
• Pituitary follicle stimulating hormone –
premature secretion
• Basal metabolic rate -- Moderately elevated

Treatment
medical surgical

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

Treatment
Surgical
Based on Size of Lesion Based on Age

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

• 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

• 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

Classification
Based on clinical and radiographic appearance
Nonhereditary
• Periapical COD
• Focal COD
• Florid COD
Hereditary
• Familial gigantiform Cementoma

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

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

• 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

• 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

• 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

• 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

• 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

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.

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

• 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
•

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

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

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

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

• 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

• 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

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

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.

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

Fibro Osseous Neoplasms
• Cementifying Fibroma
• Ossifying Fibroma
• Juvenile Ossifying Fibroma

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

• 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.

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

• 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

• 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

• 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

Cementifying fibroma

Homogenous ,radiopaque internal structure and radiolucent band at the periphery

• 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.

Wispy trabecular pattern
Fibrous dysplasia granular like
patttern

A flocculent pattern with larger tufts of bone formation

• 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

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

• 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

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.

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

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.

Management
• Surgical enucleation / Resection

PAGET’S DISEASE
(OSTEITIS DEFORMANS)
• First described in England by Sir James
Paget in 1876
• Etiology : unknown
: Inflammatory ,
genetic,
endocrine factors

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

• 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

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.

• 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.

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

• Dentures may be tight or may fit poorly in
dentulous patients.
•
• In extreme cases, the alteration results in
a lionlike facial deformity ( leontiasis
ossea)

• 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.

Lab findings
.
• ⁭⁭levels of serum alkaline phosphatase during
osteoblastic phases of the disease upto 250
bodansky unit
• ⁭levels of hydroxyproline in urine

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.

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.

Paget’s Disease with multiple radiopaque masses that have cotton wool appearance

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.

Paget’s Disease with an altered trabecular pattern

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

Paget’s Disease involving skull, maxilla and mandible

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.

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

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

• 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

ABC in the angle of mandible with illdefined septa in the internal structure

CGCG – Bluish purple mass present on the anterior alveolar ridge

Panoramic radiograph showing a large , expansile radiolucent lesion
in the anterior mandible

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

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

• 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

• 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.

Clinical Features
• Facial appearance 
Plump cheeked little
angels (Cherubs)
• “ Eyes Upturned to
Heaven”

• 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

Cherubism with multiple lesions in maxilla and mandible

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

• 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

• 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

• 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

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

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.

• 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
•

Large ,bulbous,radiopaque mass associated
with the apical portion of mandibular first molar.

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

• 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

• 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

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

Granular bone pattern and a brown tumor related to the apical region of molars.

Bone loss with loss of lamina dura and granular texture of the bone.

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