Chapter 14 Flashcards
Benign bone neoplasia
Asymptomatic
Slow growth – displaces teeth and expands the cortex of bone
Symmetrical
Does not metastasize
Corticated rim
(Expanded cortex –> slow pressure: osteoclasts remove bone and signal to osteoblasts to lay down new bone)
Benign lesion
Malignant bone neoplasia
Symptomatic
Grows RAPIDLY - bone resorption
Asymmetrical
Ragged or poorly defined margins
Destroys cortex
Lay bone down outside of the cortex
Capable of metastasis
Osteogenesis Imperfecta
Defect in COLLAGEN TYPE I maturation
(most common type of inherited bone disease)
Bone has –>
Thin cortex
Fine trabeculation
Diffuse osteoporosis
Bone healing may occur – but may be inappropriate healing
Signs and symptoms:
Bone fragility
Blue sclera
Altered teeth – blue/brown opalescent teeth, premature pulpal obliteration, Class III malocclussion (simmilar to dentinogenesis imperfecta)
Hearing loss
Long bone and spine deformitites
Joint hyperextensibility
Xrays: Osteopenia (low bone density), Bowing, Wormian bone of skull
patients may be on BISPHOSPHONATES
Xray features of osteogenesis imperfecta
Osteopenia (low bone density)
Bowing
Wormian bones in the skull
Oral cavity findings in osteogenesis imperfecta
Teeth - blue to brown translucence
Premature pulpal obliteration
class II malocclusion
Similar tooth look to dentinogenesis imperfecta
What is defective in osteogeneis imperfecta?
Type I collagen maturation
Blue sclera!
Unique to osteogenesis imperfecta
( Bowing of bones – another symtom)
Osteopetrosis
Marble bone disease
Skeletal disorder with a marked increase in BONE DENSITY (no bone is broken down)
** Defect in remodeling caused by FAILURE of normal OSTEOCLAST function **
VERY radio-opaque radiographs
Loss of marrow space – loss of nutrients (blood supply) –> may becoe osteomyelitits
Usually class III
Osteopetrosis
Failure of normal osteoclast function
May develp osteomyelitis
Cleidocranial Dysplasia
Characterized by clavicle and dental abnormatlities
Clavicles – varying degress of hypoplasia (unusual mobility of shoulders)
Appearance (DIAGNOSTIC): Short stature, big head. Pronounced frontal bossing, Occular hypertelorism, broad base of nose
Oral ->
HIGH arched palates.
increased prevalance of cleft palate
Prolonged retention of deciduous teeth
Delay or failure of eruption or permanent teeth
Abnormally shaped teeth
**Numerous unerrupted permanent teeth and supernumerary teeth **
No treatment
Moveable shoulders
Cleidocranial Dysplasia
Oral complications of cleidocranial dysplasia
High arched palate
INCREASED prevalence of cleft palate
Prolonged retention of deciduous teeth
Delayed or failure of eruption of permanent teeth
Abnormally shaped teeth
Numerous unerupted permanent and supernumerary teeth
Focal osteoporotic marrow defect
Area of hematopoietic marrow – producing a radiography lucency (varies in size)
Marrow has pushed the bone away creating a defect
NOT PATHOLOGY - asymptomatic and incidental finding on radiograph
Radiolucency - ill defined borders with fine central trabeculations (multilocular)
Occurs in posterior mandible typically
NO jaw expansion
Biopsy is required for diagnosis – will just have bone marrow
No treatment necessary
No association with any hematologic disorder
Focal osteoporotic marrow defect
Idiopathic osteosclerosis
Focal area of increased radiodensity
UNKOWN cause
Typically associated with a healthy tooth
Can be present with NO teeth – after extraction
ASYMPTOMATIC
No cortical expansion
Diagnosis – history, clinical findings, radiographic findings
Biopsy is considered if symptomatic
If found in adolescence – periodic XRAYS are prudent until the area stabilizes. No treatment necessary.
Idiopathic osteosclerosis XRAY manifestations
Well defined - Round or Elliptical
Radiopaque
Usually associated with root apex
NO radiolucent rim
Idiopathic osteosclerosis
Healthy tooth
Radioopaque
Well defined
NO radiolucent rim
Condensing osteitis vs idiopathic osteosclerosis
Condensing osteitis –> associated with infection
Cemento-osseous dysplasia vs idiopathic osteosclerosis
Cemento-osseeous dysplasia –> Radiolucent rim
Cementoblastoma vs idiopathic osteoscelerosis
Cementoblastoma –> fused with the tooth
NO PDL SPACE
bulges out
Massive osteolysis
Gorham Disease
spontaneous and progressive destruction of one or more bones - affected area does not regenerate or repair
Destroyed bone is initially replaced by vascular proliferation
Eventually filled with dense fibrous tissue
No known cause
Mandible affected more than maxilla
Treatment: Surgical and bisphosphonates
Surgical + bone graft –> bone graft will undergo osteolysis (not a successful treatment)
Massive osteolysis signs and symptoms
Mobile teeth
Pain
Malocclusion - movement of teeth
Deviation of the mandible
Clinically obvious deformity
Pathologic fracture
Massive osteolysis xray manifestation
Radiolucent foci of varying size with indistinct margins
Coalesce to become larger - involve cortical bone
Large prortions of invovled bone disappear
Loss of lamina dura
Paget’s Disease
Abnormal resorption and deposition of bone
Relatively common
Distortion and weakening of affected bones
UNKOWN cause
Affects older adults
Affects more than one bone - Polyostotic
Symptoms: bone pain, bone distortion, and weakening of bones, bowing deformity, increase circumference of head
* enlargment of midde 1/3 of face – resulting in Leontiasis ossea (lionlike facial deformity)*
Most common bones affected –> vertebrae, pelvis, skull, femur.
Maxilla > mandible
Generalized hypercementosis
Slow and chronically progressive – rarely leads to death
Treatment - NSAIDS for pain, Bisphosphonates
INCREASED risk of developing a malignant bone tummor – OSTEOSARCOMA
Head and neck symptoms of Paget’s Disease
Increased circumference of head
Enlargement of middle 1/3 face – Leontiasis ossea (lionlik facial deformity)
Alveolar ridges are symmetrical – grossly enlarged (dentures no longer fit)
Hypercementosis
Diagnostic of Paget’s Disease
Cotton wool appearance on xray
Generlized hyper cementosis
HIGH serum alkaline phosphatase levels
NORMAL calcium and phosphorus levels
What medications are Paget disease patients typically taking?
BISPHOSPHONATES
NSAIDS
Paget disease patients have an increased risk of developing?
Malignant bone tumors - Osteosarcoma
Xray manifestatsion of Paget’s Disease
Cotton wool bone appearance
Generalized hypercementosis
Generalized hyper cementosis
Paget’s Disease
Dentures don’t fit anymore
Hat has seemed a little tight lately
Paget’s Disease
Increased head circumference - ill fitting hat
Gross bone expansion – ill fitting dentures
Lentiasis ossea
Lionlike facial deformity
SEVERE case of Paget’s disease of the jaw - enlargement of middle 1/3 of face.
Giant Cell Granuloma
Painless bone expansion
Non-neoplastic lesion
Some – aggresive behavior (associated with pain, paresthesia, and perforation of cortical plate)
Discoverd during xrays or painless bone expansion
More common in ANTERIOR jaw - frequently cross the midline
Central Giant Cell Granuloma - XRAY manifestations
Not diagnositc!!
Radiolucent lesion – multilocular OR unilocular
Well delineated
Noncorticated margins
Histo – similar to brown tumor of hyperparathyroidism and lesions of cherubism
(patients must be evaluated for hyperparathyroidism)
Cellular, vascular stroma, prominent multinucleated giant cells
Treatment: Curettage with recurrence (20% of the time)
No risk of metastasis
Central Giant Cell Granuloma
NONNEOPLASTIC lesion (no unlimited growth)
Some may demonstrate aggressive behavior – and act like a neoplastic lesion
ANTERIOR JAW – CROSSES MIDLINE
(Most things tend to NOT cross the midline)
Young adults
Painless bone expansion – some can cause pain (minority)
Xray:
RL lesion with multilocular or unilocular
Well delineated
Noncorticated margins
Histo:
Identical to brown tumor of hyperparathyroidism and lesions of cherubism
Giant cell
Treatment:
Curettage – liklihood of recurrence
Good long term prognosis
What lesions most commonly crosses the midline?
Central giant cell granuloma
What are the xray features of Central Giant Cell Granuloma (4)
Not diagnostic
RL lesion – multilocular or unilocular
Well delineated
Noncorticated margins (aggressive growth)
What is the histology of central giant cell granuloma similar to?
Brown tumor of hyperparathyroidism
Lesions of cherubism
Nonneoplastic
Central Giant Cell Granuloma
Cherubism
AD inherited condition
Bilateral involvement of posterior mandible that produces chubby cheeks.
Due to overgrowth of GIANT CELLS – will displace bone. Will regress after puberty.
Symptoms:
Eyes turned to heaven - wide rim of exposed sclera below iris
(due to infraorbital rim involvment)
Enlarged cheeks - due to displace bone in posterior mandible
Stretching of upper facial skin
May lead to failure of toot eruption
Mandibular lesions – painless, bilateral, posterior, expansile
Maxillary – posterior involvemed
Marked widening and distortion of the alveolar ridges
Cherubism Xray features:
Multilocular
Expansile
Radiolucent
(Identical to those in central giant cell granuloma)
Cherubism treatment
Typically regresses after puberty
BUT…
Early surgical curretage may lead to good results or rapid regrowth with worsening deformaty
NO radiation indicated –> due to postirradation sarcoma
Cherubism
Cherubism
Traumatic Bone Cyst
“simple bone cyst”
benign, EMPTY or fluid filled cavity within bone
NOT a true cyst – lesion does not have an epithelial lining
Trauma hemorrhage theory
Young patients
Xray:
Well delineated
RL
Margins ill or well defined
Dome like projections - SCALLOP between roots
teeth are VITAL
Treatment: surgical exploration is necessary. Typically curative.
Cause bleeding and new bone will form to fill in the void
Traumatic Bone Cyst – Trauma hemorrhage theory
Traumatic Bone Cyst
EMPTY cavity when surgically explored
Aneurysmal Bone Cyst
Intraosseus accumulation of blood filled spaces surrounded by CT
** NOT a true cyst – no epithelial lining**
Posterior Mandible
Clinical manifestation –> Swelling that develops rapidly, Painful
Xray:
RL lesion – marked cortical expansion and thinning (ballooning)
Uniloculuar - can be multilocular
Variable borders
Described as “BLOW OUT” – ballooning distention of affected bone
Surgical exploration: Surgical soaked sponge
Treatment: Curretage or enucleation
No need for bone graft - new bone formation
Good prognosis
Blood soaked Sponge
Aneurysmal bone cyst
Ballooning distention of cortical bone
Aneurysmal Bone Cyst
Ballooning distention
Aneurysmal Bone Cyst
Fibrous osseous lesions
Replacement of NORMAL bone by fibrous tissue containing mineralized product
(No fibrous CT in bone normally)
Clinical and radiographic findings are necessary to establish a diagnosis.
Benign Fibro-osseus lesions:
Fibrous dysplasia
Cemento-osseus dysplasia
Ossifying fibroma
Examples of Benign Fibro-osseus lesion
Fibrous dysplasia
Cemento-osseus dysplasia
Ossifying fibroma
Fibrous Dysplasia
Tumor like condition
Fibrous CT intermixed with bone
POST ZYGOTIC MUTATION
Depending on when the mutation takes place the process involve:
1 bone –>monostotic
multople bones –> polyostotic
Skin
Endocrine system
Two types: Monostotic, polyostotic
Fibrous Dysplasia – MONOSTOTIC
Majority of fibrous dysplasia cases
JAW –> mx >mn
Teenage years
Painless, slow growing swelling
Involvement of MANDIBLE –> leads to expansion of both BUCCAL and LINGUAL plates
Involvement of MAXILLA – can lead to maxillary sinus
Xray:
Ground Glass Opacification
Poorly calcified bone in a disorganize fashion
Not well demarcated –> margins blend into adjacent normal bone
What type of fibrous dysplasia accounts for the majority of cases?
Monostotic
Radiographic appearance of Ground Glass
Monostotic Fibrous Dysplasia
Fibrous Dysplasia – Monostotic
Ground Glass Appearance
Fibrous Dysplasia – Polystotic
Involvement of two or more bones
Two Disease: Jaffe-Lichtenstein and McCune - Albright Syndrome
Clinical management - challenging
Disease tends to stabilize and stop growing at skeletal maturity
No radiation therapy
Surgical removal - best option
Cemento Osseeous Dysplasia
Tooth bearing areas of the jaw
MOST COMMON - fibrous osseous lesion encounterd in practice
Three types:
Focal
Periapical
Florid
Three types of Cemento osseous dysplasia
Focal
Peripheral
Florid
Jeffe-Lichtenstein Syndrome
Type of fibrous dysplasia POLYSTOTIC
Cafe au lait spots (coast of main - rough)
McCune- Albright Syndrome
Polystotic fibrous dysplasia
Cafe au late (coast of maine)
multiple endocrinopathies
Multiple endocrinopathies:
Sexual percocity
Pituitary adenoma
hyperthyroid
Multiple endocrinopathies of McCune Albright Syndrome
Sexual precocity – early onset puberty
Pituitary adenoa
Hyperparathyroidism
Focal Cemento Osseous Dysplasia
SINGLE site of involvement
Females, 40, caucasians
POSTERIOR mandible
Asymptomatic
Xray:
Completely radiolucent – Densely radiopaque
(depends on calcification: less – RL, more –RO)
Radiolucent rim
Commonly mixed RL and RO pattern
Lession is usually well defined
Focal Cemento osseous dysplasia
posterior mandible – common
RL rim, RO or RL lesion
Periapical Cemento - Osseous Dysplasia
Periapical region of ANTERIOR MANDIBLE
MULTIPLE foci
40, female, AA
Teeth are vital
Asymptomatic
Early lesions –> circumscribed areas of RL involving apex of tooth
End stage lesion –> densely RO with RL rim
PDL will be intact – the lesion will not fuse to the tooth
(FUSION to tooth – cementoblastoma)
Self limiting– NO progressive growth
Periapical Cemento osseuos dysplasia
Also associated with a ground glass appearance
Fibrous dysplasia monostotic
Involvment o mandible –> leads to expansion of buccal and lingual cortical plates
Florid Cemento - osseous dysplasia
MULTIPLE focal involvment – NOT limited to anterior mandible
Female, AA
Bilateral and symmetrical
Asymptomatic
Xray:
Lesions demonstrate identical patterns of maturation
Initial lesion – RL
Overtime become RO -RL mixed
End stage – predominately RO
DON’T extract the tooth – don’t want to open bone to cause further infection
Florrid Cemento-Osseous Dysplasia
Mutlifocal
Bilateral and symmetrical
Ossifying Fibroma
NEOPLASM with significant growth potential
fibrous CT containing variable mixture of bone and cementum
Wide range of age
Female Mandibular
Small lesions – do not cause symptoms and are detected by xray
LARGE TUMORS – painless swelling
Xray:
Well defined
Unilocular
Completely RL or more commonly RL-RO mix
Root divergence or resorption of roots occur
DOWNWARD bowing of the INFERIOR CORTEX of mandible
Treatment –> enucleation
Prognosis good, recurrnece rare
DO NOT undergo malignant transformation
Ossifying Fibroma
Mandible
Downward bowing of inferior cortex of mandible
Root divergence
Unilocular
LARGE tumor
Juvenile (active) ossifying fibroma
Distinguised from ossifying fibroma because of.. (3)
Distinguished from ossifying fibroma:
Age
Common sites
Clinical behavior
Juvenile (acitve) ossifying fibroma
Slowly progressive growth – some exhibit Rapid growth
Well circumscribed
Lesions are typically –> RL with central RO
Two types: TRABECULAR and PSAMMOMATOID (more common)
MALE MAXILLARY
The younger the pt –> MORE aggressive the tumor
Treatment – curettage (small lesions), wide resectio (rapid large lesions)
NO malignant transformation
Recurrence may occur (30-60%)
Two types of Juvinille Ossifying Fibroma
Psammomatoid
Trabecular
BOTH occur in MALES in the MAXILLA
Juvinille Ossifying Fibroma
MAXILLARY - large and aggressive
RL with RO center
Osteoma
Benign tumors of mature bone
ARISE on the surface of bone or withing medullary bone
Head and Neck –> Inferior border of mandible, forehead. Somewhere on the head and skull.
More commonly in the SINUS (looks radiographically the same as antral pseudocyst
Attached mucosa –> tori
May cause pain, swelling, sinusitis, or nasal discharge
Can continue to GROW
Treatmet –> conservative excision
Rarely reoccur
ASSOCIATED WITH GARDNER’S SYNDROME
Gardner Syndrome
Bowel Polyps – will transform into adenocarcinoma (around 30yrs)
Osteomas (skull, sinus, and mandible), multiple
Supernumerary teeth
Impacted teeth
Odontomas
Prophylacticlly –> will REMOVE the colon
Osteoma
What 2 syndromes have supernumerary teeth?
Cleidocranial Dysplasia
Gardner Syndrome
Osteoblastoma vs Osteoid Osteoma
Closely related
BENIGN bone tumors
arise from OSTEOBLASTS
Histo –> identical
Produce prostaglandins –> OSTEOID OSTEOMA is smaller and produces less therfore pain can be relieved by ASPIRIN
Osteoid osteoma –> smaller than 2 cm
Osteoblastoma –> larger than 2 cm
Treatment –> local excision or curretage
Malignant transformation is rare
Osteoblastoma
RARE, occurs in the jaws
MD>MX
Posterior>anterior
2-4 cm
Pain, tenderness, and swelling
pain is NOT relieved by aspirin
Osteoid Osteoma
Rare in the jaw
PAIN – nocturnal and relieved by aspiring
Xray:
Well circuscribed
RL
Less than 1 cm
Small RO nidus –> TARGET LIKE APPEARANCE
Osteoid Osteoma
Nocturnal pain relieved by aspirin
Cementoblastoma
Odontogenic neoplasm of cementoblasts
MANDIBLE - molar and premolar region
Typically on permanent teeth
Xray:
RO mass fused to tooth root – NO PDL
Outline of root is obscured
Surrounded by RL rim
Treatment –> surgical extraction of the tooth with calcified mass
Cementoblastoma
Chondroma
Benign tumor of cartilage
Diagnosis of jaw with skepticism – most examples occur in condyle or anterior maxilla
RL with a central RO
May be a potential CHONDROSARCOMA
Synovial Chonromatosis
Rare
Benign
Nonneoplastic
Develpment of cartilaginous nodules within the synovial membrane
Can affect the TMJ
middle aged
xray:
loose bodies seen (joint mice)
Treatment –> removal of synovium and loose bodies
Low recurrance
Synovial Chondromatosis
Loose bodies – joint mice
Osteosarcoma
MESENCHYMAL malignancy
Production of osteiod or immature bone through uncontrolled growth
One of the most common malignancy to originate in the bone (besides leukemia and langerhans histocytosis)
Intramedullary
Juxtacortical
Extraskeletal
Extragnathic osteosarcomas – 10-20 years old, 50 years old
Jaw osteosarcoma –> 7% of all osteosarcomas
Mandibular – posterior jaw
Maxillary – inferiorly ( alveolar ridge, sinus floor, palate)
Symptoms: Pain and Swelling
Jaw lesions–> less likely to metastasize
Osteosarcoma Radiographic Appearance
Spiking resorption of roots – Tappered narrowing of root
SUNBURST APPEARANCE - best seen withan occlusal xray
Codman’s Triangle – triangular elevation of periosteum
Early finding –> SYMMETRICAL widening of the PDL or one or more teeth
Most common location for osteosarcoma in young adults
Distal femur
Proximal Tibia
Osteosarcoma
SUNBURST appearance
Spikin resorption
Postirradiation Bone Sarcoma
Sarcoma arising in the bone that has been previously subjected to radiation therapy
Well recognized phenomenon
_May develop 3 years – 15 years_ following radiation
Chondrosarcoma
MALIGNANT bone tumor of Cartilage
MAXILLARY>mandibular
Painless mass or swelling
May be associated with separation or loosening of teeth
RL poorly defined borders
Variable amounts of RO foci
+/- root resorption, symmetrical PDL widening
Demonstrate extensive infiltration between osseous trabeculae or preexisting bone without causing significant resorption - tumor is difficult to determine the extent radiographically
Death – due to direct extension into vital structures rather than metastases.
Best treatment – tumor resection
Ewing Sarcoma
Primary MALIGNANT tumor of bone
3rd most common osseous neoplasm – osteosarc and chondrosarc
Translocation in chromosome 11 and 12
Long bones - Jaws affect 2% of the time
PAIN, swelling
Parasthesia and loosening of teeth are common findings in oral
Xray:
Irregular RL with ill-defined margins
Onionskin periosteal reaction
Frequently metastasize
Metastaic Tumors to the Jaws
Metastatic carcinoma is the MOST COMMON form of cancer involving bone
Most common origin of gnathic mets:
Breast
Lung
Thyroid
Prostate
Kidney
Affects older patients
Majority occurs in the MANDIBLE
Symptoms:
Pain
Swelling
Loosening of teeth
Parasthesia
Numb-chin syndrome
Mets may be discoverd in a nonhealing ext site
MOTH EATEN – worrisome category of bone lesions
POOR prognosis - stage IV disease
5 year survival is exceedling rare
succumb to cancer within a new year
Moth-eaten: Worrisome Category of bone lesions
Metastatic Tumors of the jaw
Codman Triangle
Osteosarcoma
