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CH.

4: BONE
LESIONS
I. Benign Fibro-Osseous Lesions
A collection of non-neoplastic intraosseous lesions that replace normal bone and consist of a
cellular fibrous connective tissue w/in which nonfunctional osseous structures form.
A. Cemento-Osseous Lesions
1. Periapical Cemental Dysplasia
a. No longer considered odontogenic, but dysplastic condition where
multiple focal areas of normal bone and marrow are replaced by cellular
connective tissue lesions w/ limited growth potential.
b. Not a true neoplasm. Osteolytic stage (well-defined PA radiolucencies
Cementoblastic stage (radiolucencies containing nodular radiopaque
deposits) mature stage (well-defined, dense radiopacities).
c. Middle-aged, Afro-Am women, anterior mandible
d. Radiographic appearance: lucent; lucent/opaque; opaque
Distinct PDL
Lucent peripheral zone
Periapical location only
e. VITAL teeth. No tx necessary.
2. Florid Cemento-Osseous Dysplasia
a. diffuse asymptomatic, radiopaque and radiolucent intraosseous areas of
cemento-osseous tissue that involve one or both arches.
b. middle-aged, Afro-Am women
c. Sequelae = pain or discomfort if involved areas become infected as a result of
PA infection/post-ext. In edentulous pts, some of the dense sclerotic bone
nodules break thru surface b/c they do not resorb at same rate acute
osteomyelitis.
d. Radiographic = mixed lucent/opaque lesions; cotton ball, occupies entire jaw
e. Focal cemento-osseous dysplasia = solitary lesion in molar area.
B. Fibrous Dysplasia
a. Types of fibrous dysplasia
Monostotic
Juvenile
Juvenile, aggressive
Adult

Polyostotic
Craniofacial
McCune-Albright Syndrome
Jaffe syndrome

b. McCune-Albright Syndrome: polyostotic fibrous dysplasia, skin pigmentations,


endocrine dysfunctions
Jaffe Syndrome: polyostotic fibrous dysplasia, NO endocrine dysfunction (rare)

1. Juvenile Fibrous Dysplasia


a. Aggressive juvenile fibrous dysplasia grows at a faster rate than affected
bone, producing major, grotesque deformity loss of function. Tx. necessary
Craniofacial fibrous dysplasia = lesions occur in bones of jaws and cranium.
b. Clinical = initially unnoticed, mild asymmetry. Maxilla > mandible.
Asymptomatic. Teeth displaced, roated, malaligned.
Demographics = found in juveniles, young adults, occasionally adult-onset.
Regional overgrowth ceases in late teens or early twenties.
Radiographic = ground glass, orange peel. No line of demarcation. Lamina
dura obscured, displacement of tooth roots, cortical plates thinned.
Demographics = mostly monostotic in juveniles and young adults; occasionally
adult-onset
c. Treatment = Ortho to correct malocclusion. Invasive treatment with aggressive
form.
2. Adult Monostotic Fibrous Dysplasia
a. Clinical = asymptomatic diffuse expansion of cortices. Some mvmt of teeth.
Radiographic = cotton ball. Not demarcated. Expansion/thinning of cortical
plates
Demographics = occurs spontaneously in adulthood.
b. Treatment = not self-limiting. Completely remove smaller lesions, halt
progression of larger ones.
3. Polyostotic Fibrous Dysplasia
a. skin pigmentation, endocrine dysfunction. Bone lesions confined to
craniofacial or distribed diffusely throughout skeleton.
b. Clinical = Unpleasant appearance due to large expansile lesions (ribs, femur,
cranium, maxilla, tibia, humerus), caf au lait spots on torso. If endocrine
dysfunction precocious sexual dvlpt in women, thyrotoxicosos, pituitary
gigantism, cushing syndrome.
C. Cherubism
a. autosomal dominant fibro-osseous lesion of jaws, 4 quads, multilocular. When
in all quads results in chubby appearance, elevated pupils giving a cherubic
look.
b. Clinical = lesions begin in early childhood as slow-growing expansions of
posterior mandible/maxilla. Interfere with mastication, speech, malocclusion.
Lesions enlarge until puberty, then stabilize. Eventually reduce.

c. Radiographic = large radiolucencies that expand. Erupted/non-erupted teeth


randomly throughout enlarged arches. After stabilization ground glass.
d. Histopathology = early stages, almost all giant cell tissue. Tissue identical to
benign giant cell tumor. Later stages, fibrous tissue replaces giant cells,
random spicules of woven bone lamellar bone
e. Treatment = self-limiting with regression/remodeling after puberty. Cosmetic
surgery delayed until then.
II. Metabolic Conditions
A. Pagets Disease (Osteitis Deformans)
a. Uncoordinated increase in osteoclastic/osteoblastic activity of older adults, producing
larger but weaker bones, extensive pain, high levels of serum alkaline phosphatase and
urinary hydroxyproline. Incrased tendency to develop malignant bone neoplasms.
b. Clinical = monostotic or polyostotic. Altered physical appearance, pain, joint disease.
Increase in head size and shape, thickness of cranium compression of spinal
cord/cranial nerves paralysis and loss of hearing/sight. Maxilla more common than
mandible, diffuse enlargement.
Demographics = 2-3% of population over 60, Western countries
c. Signs & Symptoms = gradual increase in hat size, tight dentures, painful bones,
elevated surface temperature of bones close to surface. Elevated serum alkaline
phosphatase (osteoblast), urinary hydroxyproline (osteoclast).
d. Cardiac complications = Increase in peripheral vascularity high-output heart failure
major cause of death.
Osteogenic complications = increased incidence of sarcoma, benign/malignant
giant cell tumors
e. Radiographic = cotton ball. Teeth exhibit loss of lamina dura, hypercementosis.
Scintigraphy = surveys body for incipient lesions and evaluates degree of cellular activity
of all lesions.
f. histopathology = mosaic pattern with lines of resting and reversal.
g. Treatment = usually not treated. Tx options include bisphosphonates, surgery only to
relieve sever pain caused by pressure on nerves.
B. Hyperparathyroidism (Bones, stones, groans)
a. osteoporosis because of increased PTH secretion or increased demand for Ca2+
multiple systemic complications, loss of alveolar bone architecture, possible brown
tumors.
b. Primary Hyperparathyroidism = hypersecretion of PTH
Secondary = increased demand for calcium need more PTH
c. Lab findings = hypercalcemia, lowered serum phosphate level, elevated urinary
phosphate.
Radiographic = ground glass, lack of distinct lamina dura
d. Brown tumor = giant cell tumor of hyperthyroidism. Large destructive radiolucency.
e. treatment = Surgery if result of hyperplasia or neoplasia of parathyroid glands.
Otherwise, medical management using vitamins and minerals.
C. Osteopetrosis

a. generalized hereditary condition of excessive bone mineralization


b. Due to a reduction in osteoclastic activity, allowing osteoblastic fx to proceed
unabated.
c. Clinical = lack of resorption of calcified cartilage during endochondral growth, reduced
marrow space for RBC/WBC development, overly deposited and mineralized bones. Pts
becomes short in stature, highly susceptible to infection/hemorrhage, bone fracture. Can
have enlarged cranium.
d. Radiographic = increase in bone density, obliteration of normal internal architecture.
Thickened cranial plates. Embedded/impacted teeth. Teeth that erupt have a tendency to
ankylose.
e. Treatment = transplantation of allogenic bone marrow relieves hematologic/neurologic
problems in some forms. Calcium-deficient diet. Severe cases require resection of
mandible.
D. Osteogenesis Imperfecta
a. spectrum of diseases of bone caused by basic alteration in formation of bone
connective tissue matrix matrix cant mineralize multiple broken bones, blue
sclera, associated dentinogenesis imperfecta.
b. only 25% will have dentinogenesis imperfecta. Bulbous crowns, obliterated pulp
chamber, short roots.
c. treatment = orthopedic to prevent and treat fractures. Surgical intervention for
recurrent fractures or deformity that impairs fx.
III. Benign Tumors
A. Torus/Exostosis/Osteoma
a. Torus = rounded, smooth-surfaced, nonneoplastic growth of nodular dense bone.
Midline of palate (torus palatinus, 20%), lingual surfaces of mandible (torus mandibularis
(30%).
b. Exostosis = exophytic nodular growth of dense cortical bone. Maxillary or mandibular
buccal alveolar bone, bicuspid/molar area.
c. Osteoma = like tori or exostoses, but found in locations other than where those are.
When multiple occur, associated with Gardner Syndrome pre-malignant intestinal
polyps, unerupted normal/supernumerary teeth, cysts/fibromas of skin.
B. Osteoid Osteoma/Osteoblastoma
a. benign intraosseous lesions. Well-demarcated, rounded swellings. Active cellular
central nidus surrounded by wide zone of osteoid. Pain upon palpation. All occur in
young pts.
b. radiographic = rounded, well-defined central radiolucency (nidus) surrounded by zone
of increased radiopacity.
C. Cemento-Ossifying Fibroma (ossifying fibroma)
a. true neoplasm, female > male, 20-30 y.o. Well-demarcated, encapsulated, expansile
intraosseous lesion of jaws composed of cellular fibrous tissue containing spherical

calcifications and irregular, randomly oriented bony structures. Downward bow of


mandible, centrifugal growth (balloon-like).
Radiographic = well-defined, unilocular or multilocular, radiolucentradiopaque with
thin rim of radiolucency separating it from surrounding bone.
b. treatment = surgical removal, either local excision or block resection.
D. Giant Cell Lesions
1. Peripheral Giant Cell Granuloma
a. arises from connective tissue of periosteum and PDL. Sessile focal purplish nodule on
gingival, exophytic.
Radiographic = large lesions exhibit superficial erosion of cortical bone, widening of
adjacent periodontal space. In edentulous areas, cortical bone exhibits concave area of
resorption beneath lesion saucerization.
2. Central Giant Cell Lesions
a. Found in ages 2-80 (60% occur in pts 10-30 y.o.). Female > Male. Occur in anterior
mandible and maxilla, ~75% in mandible and crossing midline.
b. treatment = curettage, block resection if large
3. Aneurysmal Bone Cyst
a. Variant of central giant cell lesion. Occurs in young adults, symptomatic, multilocular
lucency, recurs 20% of time. Histologically, looks like blood-soaked sponge.
E. Traumatic Bone Cyst
a. also called simple bone cyst, hemorrhagic bone cyst, idiopathic bone cavity
b. occurs in molar/premolar region of mandible of pts < 20 y.o. Female > male.
Radiographic = scalloped appearance
c. histopathology = thing layer of loose connective tissue overlying zone of reactive bone
that exhibits remodeling
Treatment = surgical hemorrhage induced during diagnostic exploration and curettage of
cavity resolves lesion.
F. Langerhans Cell Histiocytosis
a. Also called histiocytosis X, idiopathic histiocytosis, Langerhans cell granuloma,
Langerhans cell disease. Involves the dendritic Langerhans cell.
b. Three categoris from tx and prognosis:
(1) chronic focal = solitary lesion in one bone, occasionally multiple bones, no soft
tissue/organ involvement; tx = curettage
(2) chronic disseminated = multiple bones, organs, lymph nodes, skin [Hand-SchullerChristian disease]; tx = chemotherapy
(3) acute disseminated = most organs, bone marrow, skin of infants [Letterer-Siwe
disease]; tx = chemotherapy
c. Radiographic = teeth appear to be floating in space
IV. Malignant Tumors

A. Osteogenic Sarcoma
a. very common malignant bone tumor; 7% occur in head and neck
b. average age of onset is 33 y.o.
c. radiographic = widening of PDL in adjacent teeth. Occlusal radiograph reveals
sunburst pattern of radiopacity radiating from periosteum.
d. 4 histologic variants: osteoblastic, chondroblastic, fibroblastic, telangiectatic.
e. treatment = surgical resection with wide margin of normal bone + chemo. Prognosis is
better in mandible than rest of skeleton. Pts. With juxtacortical osteogenic sarcoma fare
better in both skeletal and jaw locations
B. Chondrosarcoma
a. Malignant bone tumor that produces only cartilage and may be primary (arising
directly from bone cells as malignant neoplasms) or secondary (arising in preexisting
benign cartilaginous lesion). Associated with several systemic conditions Paget
disease, Ollier disease, Maffucci syndrome.
b. Occur in fourth decade, confined to anterior maxilla
c. Radiographic = PDL widening, expansile moth-eaten radiolucency, indistinct
boundaries
d. Tx = wide surgical excision
C. Ewing Sarcoma
a. Histogenesis is uncertain, but may be primitive bone cells
b. Rarely seen in pts >30 y.o. and 4% occur in craniofacial bones
c. Radiographic = moth-eaten, periosteum looks like onion-skin.
Histopathology = Cells can either be (1) small, round, darkly staned nuclei, delineated
cytoplasm, or (2) large, finely grandular nucleus, ill-defined cytoplasm. Silver nitrate
staining reveals septa surrounding lobules of cells.
d. Tx = chemotherapy, radiation. Surge for small lesions.
Prognosis = 30% recur w/in 5 yrs. Mandible lesions have most favorable survival rate.