diseases of bones of the jaw Flashcards
what 3 broad groups can bone diseases be divided into?
describe and give examples
- lesions of the jaw bones as part of a systemic bone disease
- most / or all bones affected
- e.g. osteogenesis imperfecta
- localised bone disease occuring in the jaws
- may affected almost any bone, including the jaws
- e.g. osteomyelitis
- lesions occuring only in the jaw bones
- e.g. dental cyst, ameloblastoma
Bone diseases can also be divided into groups depending on aetiology, what are the groups?
- developmental
- inflammatory
- cystic
- metabolic
- disorders of growth
give examples of developmental bone diseases
- torus palatainus
- torua mandibularis
- cleido-cranial dysostosis
- osteopetrosis
- osteogenesis imperfecta
- fibroud dysplasia
- monostotic
- poly stotis
- albright’s syndrome
- condylar hyperplasia
give examples of inflammatory bone diseases
- fracture
- healing extraction socket
- dry socket
- chronic periodontal disease
- osteomyelitis
- actinomycosis
- enostosis
- syphilis
- osteoradionecrosis
- increasingly common in patients treated with radiotherapy for head and neck cancer
give examples of cystic bone diseases
- odontogenic cysts
- developmental
- inflammatory
- non-odontogenic cysts
give examples of metabolic bone diseases
- vitamin deficiency
- vitamin D - rickets and ostemalacia
- vitamin C - scurvy
- endocrine
- acromegaly
- hyperparathyroidism
- steroid drug therapy
- osteoporosis
- functional atrophy - alveolar bone resorption following tooth extraction
- paaget’s disease
give examples of disorders of growth bone diseases
- dysplasia
- giant cell granuloma
- fibrous dysplasia
- neoplasia
- benign - osteoma, chondroma
- malignant primary bone tumours - osteosarcoma
- malignant bone marrow tumours - multiple myeloma, malignant lymphoma
- malignant secondary bone tumours - e.g. from primary breast, prostate and bronchus carcinoma
- odontogenic tumours
what is torus palatinus?
cause?
symptoms?
treatment?
- slow growing, sessile exostosis in the midline of the vault of the palate
- consists of normal lamellar bone
- cortical bone on the surface and lamellar bone in the centre
- strong genetic factor - simple autosomal dominance
- F:M 2:1
- symptomless - usually flat but may be lobular if large
- overlying mucosa may become ulcerated by trauma
- treatment:
- usually requires none but may be removed if it interferes with insertion of denture
what is this?
describe the symptoms you would expect and treatment
torus palatinus
- symptoms :
- symptomless
- treamtent :
- usually requires no treatment but may be removed if it interferes with insertion of denture
what is torus mandiularis?
cause?
symptoms?
treatment?
- exostosis on the lingual aspect of the mandible in the premolar region
- broad base with smooth or lobular surface
- consists of lamellar bone
- cortical bone on the surface and lamellar bone in the centre
- genetic basis
- autosomal dominance with 100% penetrance in females, 70% in males
- bilateral in 80% of cases
- no treatment but may be removed if interferes with insertion of denture
what is this?
symptoms expected?
treatment?
torus mandibularis
- no symptoms
- treatment not required unless interferes with denture insertion
aetiology of osteogenesis imperfecta
hereditary disease
- autosomal dominant most common but recessive forms and spontaneous cases occur
- heterogenous group of related disorders characteristed by defects in type I collagen synthesis
clinical features of osteogenesis imperfecta
- generalised osteoporosis with slender bones
- tendency for the bones to fracture on slight provocation
- slender long bones have narrow, poorly formed cortices composed of immature woven bone
- thin skull - may be wormian bones in the skull
- jaws rarely affected
- sclera may appear blue
- deafness due to distortion of ossicles
- joint hypermobility with lax ligaments
- translucent skin
- heart valve defects
what oral manifestations are associated with osteogenesis imperfecta
- often associated with dentinogenesis imperfecta
- esp. primary dentition
- increased tendency to class II occlusion and impactions of molar teeth
What is diagnosis? Why?
typical presentation of dentinogenesis imperfecta
- brown dentine shown through translucent enamel
- enamel has poor attachment
- defects at dentinal junction
- dentine exposed and slowly worn away
- on radiograph - short roots
what is osteopetrosis?
cause?
- excessive density of all bones
- with obliteration of marrow cavities and development of secondary anaemia
- defect in osteoclastic activity leading to failure of bone remodelling
- excessive formation of mechanically weak bone
- fractures common
- autosomal recessive form severe and progressive - usually death before puberty
- autosomal dominant less severe
what can be seen on a radiograph of someone with osteopetrosis
- bones very dense
- increased thickness and dentistry of lamina dura of tooth sockets
what is cleidocranial dysplasia (cleidocranial dysostosis)?
abnormalities of many bones - particularly skull, jaws and clavicle
- widened cranium
- fontanels and sutures remain open
- skull appears flat
- prominent frontal, parietal and occipital bones
- partial or complete abscence of clavicles
- super numerary and unerupted teeth
describe the steps of a tooth socket healing
- socket fills with extravasated blood which clots
- blood clot is organised to form granulation tissue
- macrophages begin to remove clot at periphery
- fibroblasts in remnants of PDL divide and migrate into clot
- endothelial cells in remnents of PDL divide and produce new thin walled vessels
- osteoclast resorption of crestal bone and spicules of bone detacted during extraction
- gingival epithelial proliferation and migration across defect
- migration between bloot clot and granulation tissue
- osteoblasts appear in granulation tissue at base of socket
- produce unmineralised osteoid
- granulation tissue is replaced by woven bone
- remodelling of woven bone and removal of lamina dura of tooth socket
- radiologically socket usually obliterated 20-30 weeks after extraction
at what times after extraction do the steps of tooth socket healing occur?
when is a patient with dry socket expected to present?
Either
- Immediately after LA has worn off
- Same day as tooth extraction or day after
- Blood clot has failed to form
- 4-6 days after extraction
- Blood clot has disintegrated prematurely before granulation tissue can form on the surface of the tooth socket
in what cases is dry socket more common?
- more in
- molar teeth than anteriors
- mandible than maxilla
- LA than GA
- difficult extraction than simple extraction
- most commin with lower third molar extraction
how does dry socket occur?
aka alveolar osteitis
- localised inflammation of bone following either failure of blood clot to form or premature loss of disintegration of clot
- loss of clot exposes alveolar bone to saliva, food debris and bacteria
- bone becomes necrotic with inflammation in adjacent bone
- healing slow, dead bone separated by osteoclasts, granulation tissue extends from surrounding bone
what are the types of osteomyelitis?
- suppurative osteomyelitis
- chronic sclerosing osteomyelitis
- special
- they are uncommon in the jaws
what suppurative osteomyelitis is there?
acute and chronic suppurative osteomyelitis
- may become chronic if too much dead bone
- continuing pus formation and pus escaping through sinuses
what is chronic sclerosing ostemyelitis?
what types of chronic sclerosing osteomyelitis are there?
- increased bone formation
- focal sclerosing ostemyelitis
- diffuse sclerosing ostemyelitis
- over a large area
- chronic sclerosing ostemyelitis with proliferative periostitis
- if periosteium is raised then new bone is formed under the periosteum
what are the special types osteomyelitis?
- radiation osteomyelitis
- chemical osteomyelitis
- ostemyelitis of newborn infacts
- esp. affecting maxilla
describe acute suppurative osteomyelitis
cause? predisposing factors?
- usually due to spread of local infection
- e.g. periapical infection
- very occasionally due to haematogenous spread
- infection brought from the long bones
- surprisingly rare
- predisposing factors
- reduced host resistance, either local or systemic
- virulent bacteria
- more common mandible than maxilla
- thicker bone trabeculae and cortical plates
- blood supply from central end artery more earily compromised
what would expect to see on a radiograph of someone with osteomyelitis?
- acute osteomyelitis
- ragged moth-eaten radiolucency
- Fragments of bone separated throughout the radiolucent area
- may be sequestra
- subperiosteal bone formation
- chronic osteomyelitis
- moth eaten ragged radiolucency
- sclerosis of the surrounding bone
- increased dentistry of the bone surrounding the radiolucent area
- sequestra
- involucrum formation
pathogenesis of acute suppurative osteomyelitis
- infection of marrow produces acute inflammatory reaction
- tissue necrosis and pus formation (suppuration) follow
- thrombosis may produce widespread necrosis of osteogenic tissues
- inflmmation, necrosis and suppuration extends through marrow spaces which are filled with pus
- pus reached periosteum
- periosteum is elevated
- blood supply is reduced
- pus may discharged through sinuses to mouth and skin
- granulation tissue seen in marrow spaces beyond areas of necrosis
- osteoclasts differentiate and separate off necrotic bone from vital bone - forms sequestrum
- new bone (involucrum) may be formed beneath elevated periosteum
what would you expect to see histologically in osteomyelitis?
bone with empty osteocyte lacunae
necrotic bone
necrotic fatty marrow - filled with granulation tissue with dense inflammatory cell infiltrate
describe radiation osteomyelitis & osteoradionecrosis
- radiotherapy involving jaw bone causes ischaemia
- reduced blood flow
- ischaemia due to proliferation of intima blood vessels - may occlude vessels
- mandibular central artery may be occluded - may produce ischaemic and necrotic bone
- bone now very susceptible to infection from teeth, periodontium, tooth extraction, mucosa
- extensive and painful necrosis of bone with sloughing of overlying mucosa exposing more bone to infection
what is BRONJ
Bisphosphonate Related Osteo Necrosis of the Jaw
- AKA medication related osteonecrosis of the jaw
- localised osteonecrosis
- associated with bisphosphonate therapy
- inhibits osteoclast function - inhibits bone turnover
- used for osteoporosis, paget’s, myeloma
- related to drug used, IV or oral, length of treatment
- exposed bone, localised pain, failure of extraction socket to heal
- tooth extraction should be avoided in these patients
- management
- prevention
- daily irrigation and antimicrobial rinses
- antibiotics to control infection
- surgical treatment to remove the necrotic bone may be advisable in more advanced cases
what diagnosis can you make from this clinical presentation and radiographs
BRONJ
what are the stages of BRONJ
Stage 1
- exposed bone
- no indication of disease or inflammation of soft tissues surrounding
Stage 2
- painful areas of exposed bone
- softi tissues or bone are inflamed and signs of infection
Stage 3
- significant feature : fracture of bone tha thas been weakened by disease
- extensive amount of exposed bone
- soft tissue inflammation and infection
what are the groups of bone tumours affecting the jaws?
- benign primary bone tumours
- malignant primary bone tumorus
- malignant bone marrow tumours
- malignant secondary bone tumorus
- odontogenic tumours
give examples of primary bone tumours
- osteoma (exostosis)
- osteoblastoma
- chondroma
- haemangioma of bone
describe an osteoma
where is it more common?
benign, slow growing tumour consisting of well differientiated mature bone
- more frequent in mandible than maxilla
- multiple osteomas seen in gardener’s syndrome
- indistinct borderline between exostosis and osteoma
- osteoma shows persistant slow growth with well defined margin
describe a haemangioma of bone
where is it more common?
- rare
- causes radiolucency in the jaw
- may also produce swelling
- osteolytic, often multiocular ‘honeycomb’ appearance
- aspiration reveals fresh blood
- usually cavernous type
- extraction of teeth may produce severe haemorrhage
- life threatening
- more common in mandible than maxilla
give examples of malignant primary bone tumours
- osteosarcoma
- chondrosarcoma
describe an osteosarcoma
- relatively rare in the jaws
- rapidly enlarging swelling
- may be pain
- inferior alveolar nerve is involved
- numbness of lip, trismus
- displacement of the teeth
- the tumour cells produce bone or osteoid
- present around 30 years of age
- occasionally seen in the elderly
- slightly more common in mandible than maxilla
give examples of malignant bone marrow tumours
- multiple myeloma
- malignant lymphoma
describe multiple myeloma
- age
- site
- size
- radiographically
- shape
- outline
- radiodensity
- effect on adjacent structures
- malignancy of plasma cells
- age = middle aged
- site = multiple sites including skull vault and mandible
- size = variable
- radiographically
- shape = round
- outline = punched out
- radiodensity = uniformly radiolucent
- effect on adjacent structures = if large may lead to pathological fracture
describe langerhans cell disease
- age
- site
- size
- radiographically
- shape
- outline
- radiodensity
- effect on adjacent structures
- treatment options
- age = depends on disease type
- site = skull and jaws
- size = 1-2cm in diameter
- radiographically
- shape = round
- outline = punched out
- radiodensity = uniformly radiolucent
- effect on adjacent structures = teeth may appear to be ‘floating’
- roots are embedded in soft tissue
- treatment options =
- curettage
- resection
- chemotherapy
what is a likely diagnosis
langerhans cell disease
the roots are embedded in soft tissue and appear to be floating
what are common symptoms for malignant secondary bone tumours in the jaw?
- pain
- paraesthesia
- anaesthesia of lip
- IAV involvement
- swelling
- looseness of teeth
- many are asymptomatic
- majority of osteolytic - produces areas of radiolucency
- some are osteoblastic - produces areas of opacity
what features are shown in this radiograph
which bone diseases have these typical characteristics
the bone has a ground blast appearance
the lamina dura is absent
typical of : hyperparathyroidism, fibrous dysplasia, paget’s bone disease
why does gigantism occur?
when does it occur?
treatment?
occurs due to the overproduction of growth hormone
may be due to adenoma of the pituitary gland
gigantism occurs if this is before growth finishes
treatment : surgically remove/irradiate the adenoma
why does acromegaly occur?
when does it occur?
what does it affect?
treatment?
occurs due to the overproduction of growth hormone
- may be due to adenoma of the pituitary gland
acromegaly occurs if this is after normal growth
- only some bones are affected
- growth centres in the condyle, small bones of hands and feet
- facial soft tissues are also affected
- lips, nose, tongue
treatment : surgically remove/irradiate the adenoma
what are common features of a patient with acromegaly?
- enlarged mandible, lips, nose, ears
- ‘spade-like hands’
- enlarged hands and feet
what are common radiographic freatures of acromegaly shown in the skull?
- enlarged skull - thickening of the bones
- enlargement of the paranasal sinuses
- including maxillary sinus
- enlargement of pituitary fossa
- may be due to tumour arising in pituitary gland
what are common radiographic freatures of acromegaly shown in the jaws?
- enlarged mandible
- enlargement of inferior dental canal
- spacing of anterior teeth
- occurs as tongue enlarges which displays and splays the teeth
what features are shown here?
what are these characteristics typical of?
enlarged pituitary fossa
enlarged prognathic mandible
acromegaly
what are the types of hyperparathyroidism?
- primary hyperparathyroidism
- most often due to adenoma of pituitary gland
- sccondary
- most like due to underlying chronic renal disease
- tertiary
- following prolonged secondary hyperparathyroidism
what occurs in primary hyperparathyroidism?
what are the clinical features?
treatment?
- Calcium is immobilised from skeleton -> increase in plasma PTH
- increased serum calcium
- decreased serum phosphate
- increased serum alk phos
- clinical features
- stones, bones, abdominal groans and psychic moans
- treatment
- parathyroidectomy
what are the radiographic features of hyperparathyroidism in the skull?
osteopenia - ‘pepper-pot skull’
what are the radiographic features of hyperparathyroidism in the jaws?
- osteopenia - ‘ground-glass appearance’
- loss of lamina dura, floor of maxillary antrum, cortication of the inferior dental canal
- no bony expansion
- may be ‘brown tumours’
what is this?
what features are present?
- multilocular lesion
- displaces teeth
- lightly corticated
-> brown tumour
what is monostotic fibrous dysplasia?
affects one bone
most common type
typically starts in childhood then burns out
what are the subdivisions of polyostotic fibrous dysplasia?
what are the differences?
Jaffe-Lichenstein type
- skin lesions without endocrine disturbance
McCune-Albright syndrome
- endocrine disturbance and skin lesions
what are oral manifestations of fibrous dysplasia?
where is it more common?
- more common in maxilla
- present in childhood or adolescence
- gradually increasing painless swelling produces facial asymmetry
- smooth surfaced
- more pronounced bucally than palatally
- tooth displacement
- maxillary lesion may involve inus, zygomatic process, floor of oorbit
what is this?
what features are present?
fibrous dysplasia
- swelling with smooth surface
- bucally pronounced
- tooth displacement
what are the radiographic features of fibrous dysplasia?
- localised lesion
- margins merge with normal bone
- ground glass appearance of bone
- loss of lamina dura
- enlargement of bone
- teeth displaced
- antrum may be involved
what is this?
what radiographic features are present?
- localised lesion
- on left side of lesion - able to see the contrast between normal and abnormal
- loss of lamina dura
- ground glass appearance
describe the histology of fibrous dusplasia
- fibrous tissue with islands of metaplastic bone replace normal bone
- newly formed bone trabeculae is delicate and irregular shapes
- course fibred woven bone
what is the management for fibrous dysplasia?
- conservative surgical removal to reduce deformity
- best to wait until bone growth ceases
- patient will not have to undergo multiple surgical procedures
- bisphosphonate therapy
- radiotherpy may produce malignant transformation (sarcomas) - it is not radiosensitive
what are the phases of Paget’s disease of bone
the phases overlap
- predominantly osteolytic phase
- mixed ostolysis and ostogenesis
- predominantly osteoblastic or sclerotic phase
what are the clinical features of paget’s disease of bone?
- over 40s
- more common in males
- commonest in weight bearing bones of the axial skeleton
- sacrum, vertebrae, femur, skull
- uncommon in jaws
- produces varying degrees of bone deformity and distortion
- bone pain
what would be required to make a diagnosis of paget’s disesase of bone?
what would you expect?
blood chemistry
normal serum calcium
normal serum phosphate
elevated alkaline phosphatase
what are the oral manifestations of Paget’s disease of bone?
- maxilla affected more
- progressive enlargement of alveolar ridge
- spacing of teeth
- difficulty with dentures
- sensory and motor disturbance
- compression of nerves
- blindness, deafness, facial paralysis
- hypercementosis
what is the dental clinical relevance of Paget’s disease of bone?
early stages
- bone is being replaced by fibrovascular tissue
- extraction of tooth can lead to marked haemorrhage
late stages
- bone is being laid down
- increased ankylosis and hypercementosis - difficult extractions
- can lead to osteomyelitis and post extraction infection
describe the radiographic features of paget’s disease of bone in the skull in the early stages
- in skull - zones of osteoporosis - ‘osteoporosis circumscripta’
- where bone has been replaced by fibrovascular tissue
- can see margin between normal and abnormal bone
describe the radiographic features of paget’s disease of bone in the jaw in the early stages
- whole bone is affected
- osteopenia - ground glass appearance
- enlargement of bone
- loss of lamina dura
describe the radiographic features of paget’s disease of bone in the skull in the late stages
- sclerotic bone laid down
- cotton wool patches appearance
- enlargement and distortion of the skull
describe the radiographic features of paget’s disease of bone in the jaws in the late stages
- cotton wool patches
- enlargement of affected jaw
- hypercementosis of teeth
- loss of lamina dura
- displacement of teeth
what is this?
what radiographic features are present?
late stages of pagets disease of bone
- cotton wool patches
- hypercementation of the bone
where is central giant cell granuloma more common?
how does it present?
- majority in under 20s
- more in mandible
- more in females
- in anterior part of the jaws
- in site of primary dentition
- presents as a bony swelling
- growth can be rapid
- differing radiographic features
what is the management of central giant cell granuloma?
readily heals after curettage
recurrence unusual even if incompletely removed
what is cherubism
who is it common in?
how does it present?
- autosomal dominant condition
- more in males
- childhood disease
- bilateral expansion of the jaws
- if maxilla involved - ‘cherubic appearance’
what is the management of cherubism?
slow regression - no intervention usually necessary
in severe cases - surgical intervention
what are common radiological features of giant cell lesions?
shape?
outline?
radiodensity?
effects on adjacent structures?
- shape
- often multilocular
- outline
- well defined corticated
- radiodensity
- uniformly radiolucent with radiopaque septa
- effects on adjacent structures
- teeth displaced
- expansion of the buccal/lingual bone
- dont tend to resorb tooth
what is multiple myeloma?
who is it most common in?
where does it usually occur?
malignancy of plasma cells
occurs in middle aged
multiple sites including skull vault, mandible, rest of skeleton
what are the radiographic features of multiple myeloma?
shape:
outline:
radiodensity:
effects on adjacent structures:
shape:
- round
outline:
-
punched out
- well defined but not corticated
radiodensity:
- uniformly radiolucent
effects on adjacent structures:
- if large may lead to pathological fracture
what is langerhans’ cell histiocytosis
where does it usually occur?
treatment?
tumour of Langerhans cell
in skull and jaws
treatment depends on type but includes
- curettage
- resection
- chemotherapy
What are the radiographic features of langerhans’ cell histiocytosis?
single or multilocular?
size:
shape:
outline:
radiodensity:
effect on adjacent structures:
can be single or multilocular
size: 1-2cm diameter
shape: round
outline: punched out
radiodensity: uniformly radiolucent
effect on adjacent structures: teeth may appear to be ‘floating’
