Bone Diseases & others Flashcards
What are the 3 types of Benign Fibro‐Osseous
Lesions?
- Fibrous Dysplasia
- Cemento-osseous Oysplasia
- Ossifying Fibroma
Fibrous Dysplasia
Cemento‐osseous Dysplasia
are both type of
Type of Bone Dysplasia
Ossifying Fibroma is a ———
Benign neoplasm
What are the types of Fibrous Dysplasia?
Monostotic
Polystotic
McCune‐Albright Syndrome
Craniofacial
Mazabraud Syndrome
What is the most common type of Fibrous dysplasia?
Monostotic
What is Monostotic Fibrous dysplasia?
a Fibrous dysplasia involving one bone
o Ex: when only the mandible involved or only the maxillae
(Most common type (70%)
What is Polystotic Fibrous dysplasia?
a Fibrous dysplasia involving more than one bone
What is the Second most common type of Fibrous dysplasia?
Polystotic Fibrous dysplasia
What are the two types of Polystotic Fibrous dysplasia?
Jaffe Type
McCune‐Albright Syndrome (involving multiple bones with
endocrine abnormalities)
What is Craniofacial Fibrous dysplasia?
-a Fibrous dysplasia limited to Skull and Facial Bones...
What is Mazabraud Syndrome
-Fibrous dysplasia with intramuscular myxomas
What happens in Fibrous Dysplasia?
an aberrations in osteoblastic/osteoclastic function ► normal bone turn over affected ► normal bone structure will be affected!
What is
fibrous dysplasia ?
Developmental lesion characterized by substitution of normal bone by poorly organized woven bone and fibrous tissue.
What is the etiology of fibrous dysplasia?
GNAS1 gene mutation in fibrous dysplasia is a potential diagnostic adjuvant, as it is not
found in normal bone tissue (etiolog
What gender and age affected by Fibrous Dysplasia?
- No gender predilection
- commonly seen in pediatric patients and young adults
What are the clinical charcterstics of fibrous dysplasia?
- Clinically, it causes bone expansion and asymmetry
- most typical presentation of monostotic fibrous dysplasia is a slow growing painless enlargement in the affected area.
- so the patient may notice a slight asymmetry that won’t bother them intially, but over time~months to years ►they’ll notice that this area is slowly and steadily growing more and more ( slow and painless)
What are the most common sites of Fibrous Dysplasia?
• Most common sites of FD include the ribs, femur, tibia, maxillae and mandible
the Maxillae is affected more than the mandible
What is the radiographic features of Fibrous dysplasia (FD)
• Maxillae affected more than mandible
• Ill‐defined borders, blends in with the surrounding bone (not necessary to be corticated)
• Variable density and orientation of the trabecular pattern (radiolucent, radiopaque or a combination)
- *• Ground‐glass appearance** (common)
- *• Peau d’orange (surface of an orange)** (common)
- *• Cotton wool appearance** (common)
- *• Fingerprint pattern** ( uncommon pattern)
• Typically the lesionss in the maxillae are more homogenous and radiopaque, whereas they may appear more heterogenous and mixed in the mandible.
*typically you’ll see the ground glass appearnce and Peau d’orange on the maxilla as they are homogenous the cotton wool appearance more commonly found in the mandible since it is heterogenous.
What is this disease?
Patient CC: painless mass that is growing on one side
FD
Radiographically: you have altered trabecular pattern
Clinically: Painless mass slowly growing over time
is is typical
presntation of Fibrous Dysplasia
What is this disease?
Fibrous Dysplasia
- ill‐defined radiolucent/radiopaque/mixed radiolucent‐radiopaque entities that blend with normal bone.
- The left side is affected. Left body of the mandible and the ramus.
- The cortical outlines have been expanded near the inferior border of the mandible.
What is this trabecular pattern of the FD?
Ground Glass Pattern
it appears granular in nature. (Grainy)
What is this trabecular pattern of the FD?
Peau d’orange
surface of an orange – the bone shows a “pitting” appearance.
What is this trabecular pattern of the FD?
Cotton wool
appearance
Irregullary shaped and outlined radiopacities blending in with adjacent bone
What is this trabecular pattern of the FD?
Fingerprint pattern
The arrow indicating the inter‐radicular area of this molar. You can see the trabecular
bone has been altered into a fingerprint pattern.
This is a case of localized fibrous dysplasia.
Very uncommon.
How does Fibrous dysplasia affects the
Surrounding structures?
- May have no effect ( especially if it hasn’t reached the cortical outlines)
- Expansion and thinning of cortical walls
- Displacement of teeth ( espically in advanced cases)
- One of the few entities that cause SUPERIOR displacement of the mandibular canal
What is this Radigraphical finding?
Fibrous dysplasia on
the right mandible.
Note the superior displacement of the IAN Canal
This is not odontogenic ( as they are usually above the canal)
Anything below th canal ►think of it as originiating from the bone itself
What is this Radigraphical finding?
Fibrous Dysplasia in
the left of the
maxillae.
Always compare both side left and right
- We see granular/glass appearance of the bone ( blue arrow) and compare it to the contralateral maxillae. The trabucular pattern has changed signficantly.
- Also compare the maxillary sinus space. The left maxillary sinus appears radiopaque.
- That is because the maxillae has been enlarged to the point where it is pushing the floor of the maxillary sinus superiorly and reducing the total volume of the sinus.
- The purple arrows indcate the displaced floor of the maxillary sinus.
what is this radiographic finding?
FD
Note the normal left maxillary sinus and the obliterated space of the right maxillary sinus ( blue arrows).
A ground glass appearing entity (humogenous radiopaque lesion) has obliterated the space secondary to expansion of the right maxilla.
These findings are consistent and quiet common in advanced cases Firbous dysplasia
What is Differential Diagonsis
for Firbous Dysplasia
(FB)
?
Generalized FD
- Metabolic bone diseases (hyperparathyroidism) (any disease that incrase trabacular bone density)
- Paget’s disease
Localized FD
- Osteomyelitis
- Osteosarcoma
What is the management of Fibrous Displysia?
- Consultation with an OMFR is advisable. Monitoring of the area is also advised.
- Typically treatment is not needed unless there are clinical symptoms or patients present with cosmetic concerns if clinical symptoms are severe
- Implants and surgical intervention should be avoided when possible as these areas are void of blood supply
What is CEMENTO‐OSSEOUS
DYSPLASlA (COD)?
Dysplastic lesions that are confined to the jaws.
COD can be divided in to:
1) Periapical COD
2) Focal COD ( not covered)
3) Florid COD
Two types of COD
instead of three
Perapical COD
&
Florid COD
Cemento‐Osseous Dysplasia is Similar to Fibrous dysplasia where
cancellous bone is
replaced with fibrous tissues & cementum‐like material.
CEMENTO‐OSSEOUS
DYSPLASlA
COD
is it symptomatic?
is there bony expansion?
- Typically asymptomatic, almost always captured as incidental finding
- Generally, no bony expansion but is not uncommon in the florid type
Cemento‐osseous dysplasia COD
Gender?
Age?
Ethincity?
• Commonly seen in middle‐aged patients
female predilection
- more commonly seen in the Black population
- also frequently seen in Asian population
What is this radiologic finding
Early Periapical COD
well defined radiolucency surrounding the apeces of these two central
When looking at such cases, it is also imporant to:
1. look at the crowns to look for carious lesions. If there is no restorations or no
evidence of caries, it is likely that these lesions are arising from the bone and not
secondary to pulpal involvement.
2. It also important to look at the PDL and Lamina dura, typically in COD lesions they
should be visisulized and intact ( but because this is a 2D image and this area may
superimpose on this region and obsecure the visulizing of the lamina dura and the
PDL)
what’s the difference between COD and Inflammatory lesion?
COD won’t have effect on the PDL space itself, because it orginates from the bone!
Vitality testing can help us differntiate between inflmmatory lesion and something that happeing inside of the bone.
What is this radiologic finding
Early & mature Periapical COD
Preapical radiographs of the anterior mandible of the same patient at different times.
Note the differnece in density between the two radiolecency:
Note the internal structure of the radiopacity is quite radiolucent ( purple arrow)
The Preapical radiographs of the same region taken at a later time shows a more
radiopaque internal structure (pink arrow). This reflect the maturing of the COD lesion.
The lesion with Pink arrow can be described as well‐defined mixed
radiolucent/radiopaque entity. ( because you have radioleucent part and radipaque part)
What is this radiologic finding
Periapical COD
Sagital cross section of the anterior Mandible.
Mixed radiolucent/radiopaque area (green circle)
What is this radiologic finding
A very mature Periapical COD
( purple arrow)
Well‐defined radiopacity in the periapical region.
Sometimes you may or may not be able to differentiate a very thin radiolucent line as in
this case.
you might include ddx of other lesions which might present with
radiopacity in the preapical region
There are certain tests you can do clinically to differentiate too.
or do clinical tests
What is this radiologic finding?
mature Periapical COD
You see a nice radiolucent rim and radiopaque center
so mixed radiolucent/radiopaque
entity in the periapical region of tooth #31
most likely diagonsis would be Periapical
COD.
What is this radiologic finding
mature Periapical COD
You can have these lesions in endentulous areas as well.
So this is is an endeulous area, but if there was a tooth here, this would be in the
periapicel region or near it with mixed radiolucent/radiopaque entity the differential
diagonsis of this area could include Periapical COD.
What is this radiologic finding
mature Periapical COD
Coronal cross section of the posterior mandible in the region of the premolar
~ mixed radiolucent/radiopaque entity, the center is radiopaque and the periphery is
radiolucent.
What is this radiologic finding
Periapical COD
green arrow
Simple bone cysts may develop in regions of COD ( periapical or florid type)
So look for areas void of trabucular bone and has scalopping of the lesion.
red arrow
What is this radiologic finding
Florid COD
Multiple regions of COD.
Notice the wide areas of scelortic/radiopaque areas on mandible and also on maxillae
What is this radiologic finding
Florid COD
Two periapical radiographs of the left and right posterior mandible of the same patient.
In this case, note the areas of radiolucency and radiopacity are rather ill defined but widepsread to affect most of the teeth.
Most of the teeth noted here are restored.
So even if the radiographs suggest a cemento‐osseous process, it is important to keep an eye for these teeth in term of vitality and prevent a periapical infections which would otherwise secondarily infect the altered bone of COD.
What is this radiologic finding
Florid COD
Axial section of the mandible.
- Notice mixed radiolucent/radiopaque entity on the patient right side. And on the left the area is more radiopaque centrally and has a thin radioluceny around it.
- The arrows indicate well‐defined radiopacities immedietly surrounded by radiolucent rims.
- Note that the radiolucent rim on the left side is thin when compared to the lesion on the right. This likely means that the lesion on the left is more mature ( more time has passed for the entity to produce more woven bone).
Cemento‐ossifying
Fibroma
is classifed as ———–
and why?
Classified as a benign neoplasm
Because it acts like a benign neoplasm.
Once you examine it under microscope, you’ll see features resmeble benign fibrous osseous lesions. You’ll see:
Fibrous connective tissues
cementum like material
even altered bone material (woven bone)
Cemento‐ossifying
Fibroma
Types
and
Location
There are two types: classic and juvenile form
-juvenile seen in younger patients and
tend to be more aggressive in nature ( both radiographically and clinically aggressive features)
• Young adults and females affected mostly
• Bony expansion and displacement of teeth can be seen in many cases ( not suprising
since it acts like a neoplasm)
• More commonly seen in the mandible and in posterior regions
Cemento‐ossifying
Fibroma
Radiographic features
- Well‐defined, round or oval lesion
- Periphery of the lesion is corticated and may exhibit a radiolucent periphery (sometimes referred to as a soft tissue capsule)
- Internally, the lesion is typically granular or radiopaque but may show variations (mixed radiolucent/radiopaque)
- Strong tendency to displace teeth and cortical outlines
what is this radiographic finding?
Cropped Panaromic showing
a case of
Cemento‐ossifying
Fibroma
- Appreciate the radiolucent rim indicated by the black arrows.
- Also note the internal structure of the trabucular bone and compare it to adjacent unaffected areas. It is more granular and radopaque compared to adjacent areas.
- Another important feature to appreciate is the displacement of the anterior teeth (diverging roots)
- These features are usually seen in lesions with benign neoplastic characterstics.
what is this radiographic finding?
Cemento‐ossifying
Fibroma
Note the internal granular appearance of the trabucular bone ( black arrows)
The purple arrows shows the wall of the expanded buccal/facial and lingual cortical plates caused by the neoplastic entity.
This was a confirmed cased of ossifying fibroma* mainly because of two things:
1. siginficant cortical expansion on buccal and lignual side
2. altered trabacular pattern.
ddx of fibrous dysplasia but you should look for a radiolucent rim
if you can and if not, they maybe considered under the same differential diagosnsis.
Note that may help you in differentiating :
The maxilla is affected more in Fibrous dysplasia
The mandible is affected more in Ossifying fibroma
What is this radiographic finding?
Cemento‐ossifying
Fibroma
Axial section of the
mandible
- The granular radiopacity immediately surrounded by a radiolucent rim ( purple arrow)
- Also note the extent of the expansion of the buccal and lingual cortical plates, a feature which is common of ossifying fibroma.
- This is more clear radiographically where we see a radiolucent rim surrouding a mixed radiolucent/radiopaque center and there is a siginficant expansion of the buccal and lingual plates. ► very common in ossifying fibroma
What is this disease?
Cleido-Cranial
Dysplasia
Treatment: For children, facial reconstructive surgery on the bones of the face to reshape the forehead or cheekbones. Spinal fusion procedures to support the spinal column. Lower leg surgery to correct knock knees (knees that bend inward toward the center of the body)
What is this disease?
Gardner’s Syndrome
Synonym: Familial Multiple Polyposis.
Remember this:
GarDENse Bone Island.
GARDEN-FOREST:
F- Familial adenomatous polyposis.
O- Osteomas.
RE- Retinal epithelial hypertropy.
ST- Supernumerary teeth.
Treatment:
Because people with Gardner’s syndrome have a higher risk of developing colon cancer, treatment is usually aimed at preventing this.
Medications such as an NSAID (sulindac) or a COX2 inhibitor (celecoxib) may be used to help limit the growth of colon polyps.
Treatment also involves close monitoring of the polyps with lower GI tract endoscopy to make sure they do not become malignant (cancerous). Once 20 or more polyps and/or multiple higher risk polyps are found, removal of the colon is recommended in order to prevent colon cancer.
If dental abnormalities are present, treatment may be recommended to correct problems.
What is this disease?
Osteopetrosis
Osteomyelitis is a complication in patients with osteopetrosis as can be seen in pan image!
Treatment: Bone marrow transplant (to stimulate osteoclast formation).
What is this disease?
Paget’s disease stages
Early Linear lines: The bone is being resorbed in a very distinct
pattern > linear patterns of trabeculation
Middle -MAY see the “cotton wool” appearance (but this is more
pronounced in the third stage)
-the trabecular pattern may or may not be slightly affected
Late - There is MORE bone deposition -the “cotton wool” appearance
is very very clear in this stage! Also-hypercementosis and spacing of teeth.
What is this disease?
Paget’s Disease
Also Known As: Osteitis Deformans.
Skeletal disorder involving osteoclasts
Treatment: Osteoporosis drugs (bisphosphonates) are the most common treatment for Paget’s disease of bone
What is this disease?
Cherubism
Treatment: Usually not needed as the cyst-like lesions fill in with granular bone during adolescence- conservative surgical procedures may follow for cosmetic reasons.
What is this radiographic finding??
Idiopathic
Osteosclerosis
AKA: Dense Bone Island
Not associated with any dysplastic, neoplastic, inflammatory or systemic disorder.
Common incidental finding.
Slow growing, typically stops growing by the time of skeletal maturity.
Peak prevalence in the third decade of life.
No treatment required; monitoring is suggested.
Idiopathic
Osteosclerosis
vs
PCOD
Differentiating factor: Radiolucent zone surrounding the radiopacities of COD lesions. No such radiolucent areas for idiopathic osteosclerosis.
Important: The root of the tooth #28 appears to be resorbed but is likely not.
Look at the root of #29. These teeth are still undergoing development in a young patient.
Left is showing dense bone island.
Right is showing Periapical COD- this is intermediate stage, not fully mature. You should see a radiolucent rim.
Another more obvious radiographic feature: you see radiolucent areas surrounding in both images, the common feature is: because PCOD and dense bone island do not affect the PDL spaces – you should be able to see the PDL spaces.
Sometimes it’s not the case. Look for the PDL, look for radiolucent area surrounding possible central radiopacity, idiopathic osteosclerosis can cause resorption; PCOD hasn’t been associated with root resorption.
Idiopathic
Osteosclerosis
vs
Hypercementosis
Differentiating Factor: A well-defined radiolucent border that is continuous with the PDL of the tooth, in the case of hypercementosis. This means that whatever is happening is within the confines of the tooth-bearing region. In this case, the
cementum.
Hypercementosis- Cementum is overraeacting, so there’s enlargement of cementum.
If cementum is larger, it should be pushing the PDL out (black arrow). So the PDL is enlarged meaning you should be able to see a radiolucent rim around the area. And the radiolucent rim should be continuous with the PDL of the
remaining root structure.
Idiopathic
Osteosclerosis
vs
Cementoblastoma
Differentiating Factor: A well-defined radiolucent border that is continuous with the PDL of the tooth, similarly seen in the previous case of hypercementosis.
(sometimes it is difficult to differentiate hypercementosis and cementoblastoma, in this case, the beige arrow indicates the resorbed root surface, which normally occurs in benign neoplastic cases, such as cementoblastoma.
Cementoblastoma is more of a heterogenous radiopacity- meaning you may see
gaps, like radiolucent voids, in between the areas.
See radiolucent rim.
But more common feature include root resorption because it’s a neoplastic condition. It should act like a neoplasms in which it’s destroying some of the root structure.
Idiopathic
Osteosclerosis
vs
For condensing osteitis, look for heavily restored or carious teeth. Condensing osteitis typically surrounds the initial rarefying osteitis lesion. The teeth in these cases are non-vital as they represent a condition that is secondary to pulpal necrosis.
Open necrosis, eventual PDL space widening and then once the infection reaches the bone, you have bone loss.
Now you have an overreaction or inflammatory reaction surrounding the initial inflammation.
What is this disease?
Focal Osteoporotic
Marrow Defect
A large marrow defect that may mimic a
cystic/neoplastic radiolucency in the jaw.
common incidental finding
a variation of normal anatomy within trabecular bone.
What is this disease?
Simple Bone Cyst
Also known as
1.) Solitary Bone Cyst.
2.) Traumatic Bone Cyst.
3.) Idiopathic Bone Cyst.
4.) Hemorhhagic Bone Cyst.
Remember radiographic feature
tend to Scalop between teeth
Treatment includes surgical curettage- spontaneous healing has been reported.
What are these two disease?
Sometimes, simple bone cysts should be differentiated from odontogenic keratocysts (OKCs)
CGCG should be differentiated from ————-
brown tumor.
What is this disease?
central giant cell granuloma
CGCG
What is this disease?
Aneurysmal Bone Cyst
What is this radiographical presentation?
Mucositis
Thickening of the mucous of the sinus
- normally we don’t see mucosa
because it is very thin membrane
10 to 15 times thicker.
Most common
incidental findings
that we can see on
radiographs
What is this radiographical presentation?
Sinusitis
Sinus mucosa becomes inflamed and thickened from infection or
allergen, which may lead to ciliary dysfunction, retention of sinus
secretions and blockage of sinus drainage
● 10% of maxillary sinusitis are related to dental infections
What is this radiographical presentation?
Sinusitis
In this cone beam CT scan, we can see opacification of the sinus +
sometimes we see gaseous bubbles. It is fluid that is forming inside the
sinus.
What is this radiographical presentation?
Sinusitis
Sinusitis can be secondary to oral antral communication (communication
between maxillary sinus and oral cavity)
this can happen due to
extraction
What is this radiographical presentation?
Antral Pseudocyst (Retention Pseudocyst)
Localized, submucosal accumulation of fluid forming a sessile, domeshaped
swelling along a sinus border
● Common incidental radiographic finding on panoramic
● Well-defined, non-corticated and dome shape radiopacity mostly along
the floor of maxillary sinus
What is this radiographical presentation?
Antral Pseudocyst (Retention Pseudocyst)
What is this radiographical presentation?
Antral Pseudocyst (Retention Pseudocyst)
Radicular Cyst VS
Antral Pseudocyst
One of the ways to differentiate antral pseudocyst from radicular cyst is by the presence of cortication.
‐ Reticulosis is a cystic lesion that happens around the apex of the nonvital
tooth.
‐ They have a round and domed shaped appearance too, but they are from
a different origin happening inside the alveolar processes
What is this radiographical presentation?
Antrolith
Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus
● Pediatric and adult population
‐ Small antroliths – incidental radiographic finding
‐ Large antroliths – sinus obstruction, sinusitis, nasal discharge,
pain
● Mostly adjacent to the floor of the maxillary sinus
● We see combination of radiopacity and radiolucency due to layers
of calcification.
What is this radiographical presentation?
Antrolith
Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus
We see a presence of radiopacity which is antrolith inside the
maxillary sinus
What is this radiographical finding?
Foreign Body in
Maxillary Sinus
What is this radiographical finding?
Foreign Body in
Maxillary Sinus
What is this radiographical finding?
Periostitis
•Lamellar, periosteal reaction from periapical inflammatory disease
•Exudate from infected tooth diffuses through the cortical bone,
(elevation of periosteum) lifts and stimulates the periosteal lining to
produce layer(s) of new bone
•Floor of maxillary sinus
•Inferior, buccal, lingual mandibular cortices
