Fibro-Osseous Lesions of the Jaws PDF

Fibro-Osseous Lesions of the Jaws Dr. Didem Dagdeviren Fibro-Osseous Lesions of the Jaws • • • Diverse group of processes that are characterized by replacement of normal bone by fibrous tissue containing a newly formed mineralized product Histologic features overlap Accurate diagnosis depends on...

Fibro-Osseous Lesions of the Jaws Dr. Didem Dagdeviren Fibro-Osseous Lesions of the Jaws • • • Diverse group of processes that are characterized by replacement of normal bone by fibrous tissue containing a newly formed mineralized product Histologic features overlap Accurate diagnosis depends on correlation of clinical and radiographic data Fibro-Osseous Lesions of the Jaws • Bone dysplasias – Fibrous Dysplasia – Periapical (cemento) osseous dysplasia – Florid (cemento) osseous dysplasia • Fibro-osseous neoplasms – Cemento-ossifying fibroma • Metabolic diseases – Paget’s disease of bone Fibrous Dysplasia • Replacement of normal cancellous bone with cellular fibrous tissue containing foci of immature woven bone • Mutations in the Gs alpha (GNAS1) gene Fibrous Dysplasia ⚫ ⚫ Monostotic (solitary) 70% Polyostotic 30% ⚫ Jaffe’s type ⚫ ⚫ ⚫ Multiple bones affected Café-au-lait spots McCune-Albright’s syndrome ⚫ ⚫ ⚫ Multiple bones affected Café-au-lait spots Endocrine abnormalities ▪ ▪ ▪ ▪ ▪ Precocious puberty (most common abnormality) Hyperthyroidism Hyperparathyroidism Cushing syndrome Pituitary adenoma (Acromegaly) Fibrous Dysplasia Clinical Features ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Children Incidental finding in many patients Swelling in others Unilateral in the jaws Anosmia, deafness, blindness Stops growing with the end of skeletal growth Fibrous Dysplasia Radiographic Features • Location – Any bone – Maxilla >> Mandible • Posterior areas more common, usually unilateral – Cases affecting maxilla often affect contiguous bones such as zygoma and sphenoid – If affects sphenoid, zygomatic, frontonasal bones, and base of skull, termed "craniofacial FD" Fibrous Dysplasia Radiographic Features • Periphery: - Ill defined; gradually blend with surrounding normal bone • Internal structure: – Radiolucent, radiopaque, or a mixture of densities – Depends on lesion maturity: • Early lesions more radiolucent than mature lesions – Simple bone cysts may occur Fibrous Dysplasia Radiographic Features Granular or ground-glass pattern Fingerprint pattern Fibrous Dysplasia Radiographic Features orange-peel pattern amorphous bone Cotton-wool pattern Fibrous Dysplasia Radiographic Features Simple bone cyst in fibrous dysplasia Fibrous Dysplasia Radiographic Features • Effects on surrounding structures: – Expansion • Bone larger but maintains overall shape – Displaces the cortical boundaries of the maxillary sinus – Teeth displaced or impacted – Superior displacement of mandibular canal (pathognomonic) Fibrous Dysplasia Swelling right mandible Fibrous Dysplasia Ill-defined, mixed lesion causing expansion of the right mandible inferiorly, buccally and lingually. Fibrous Dysplasia Ill-defined lesion in the right mandible with a ground glass appearance and displacement of the mandibular canal superiorly. Fibrous Dysplasia Right side of the face and right maxillary alveolar ridge are larger. Fibrous Dysplasia The right maxilla is more radiopaque. The lesion is diffuse and its pattern is mixed. Fibrous Dysplasia Mixed lesion, causing severe expansion of the left maxilla, displaces the walls of left maxillary sinus Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 28129 McCune-Albright Syndrome Café au lait pigmentation Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9550 Fibrous Dysplasia Differential Diagnosis Paget’s disease • Older age • Bilateral involvement of jaws Paget’s disease Fibrous Dysplasia Fibrous Dysplasia Differential Diagnosis Osteomyelitis • New bone is laid down on the surface of the outer cortex • Presence of sequestra Osteomyelitis Fibrous Dysplasia Periapical Osseous Dysplasia Clinical Features ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Very common Middle age (40 yo) Female/male ratio 9:1 Common in African-American, Asian Affected teeth are vital Asymptomatic May cause notable expansion of the alveolar process Periapical Osseous Dysplasia Radiographic Features • Location: - Near apex of any tooth, commonly mandibular anterior teeth • Periphery and Shape: – Well-defined, round or irregularly shaped – Radiolucent border surrounded by sclerotic bone Periapical Osseous Dysplasia Radiological Features Internal structure: • Early stage: – Entirely radiolucent • Intermediate stage: – Gradual deposition of amorphous bone masses within radiolucency • Late stage: – Uniformly radiopaque ⚫ Periapical Osseous Dysplasia Radiological Features • Effects on surrounding structures: – Loss of lamina dura – Pdl wider or less apparent – Hypercementosis – Large lesions may cause expansion Periapical Osseous Dysplasia Differential Diagnosis - Early stage POD vs. Rarefying osteitis • Vitality test Periapical Osseous Dysplasia Differential Diagnosis - Mature POD vs. dense bone island • Radiolucent capsule Periapical Osseous Dysplasia Dense bone island Periapical Osseous Dysplasia Differential Diagnosis - Mature POD vs. Benign cementoblastoma • Pain • Better defined radiolucent soft tissue capsule Periapical Osseous Dysplasia Benign Cementoblastoma Florid Osseous Dysplasia Clinical Features ⚫ ⚫ ⚫ ⚫ Widespread form of POD POD in 3 or 4 quadrants or extensive throughout one jaw Similar clinical features with POD Susceptible to infection Florid Osseous Dysplasia Radiographic Features ⚫ • • Location: Usually bilateral, both jaws Mandible > maxilla Posterior to cuspid Periphery - Well defined, sclerotic border Internal structure - Mixed radiolucent-radiopaque or completely radiopaque - Simple bone cysts may develop within FOD lesions Florid Osseous Dysplasia Radiographic Features ⚫ Effects on surrounding structures - Displacement of IAN canal inferiorly - Displacement of maxillary sinus floor superiorly - Expansion of buccal and lingual cortical plates - Hypercementosis Florid Osseous Dysplasia Florid Osseous Dysplasia Florid Osseous Dysplasia Florid Osseous Dysplasia Florid Osseous Dysplasia Simple bone cysts within FOD lesions Florid Osseous Dysplasia Differential Diagnosis • Paget’s disease - Affects entire mandible - Polyostotic Paget’s disease Florid Osseous Dysplasia Differential Diagnosis • Chronic Sclerosing Osteomyelitis Sclerosis FOD Sequestrum Secondarily infected FOD Chronic Sclerosing osteomyelitis FOD Ossifying fibroma ⚫ ⚫ Encapsulated benign neoplasm composed of varying amounts of bone in fibrous tissue Juvenile ossifying fibroma is an aggressive form of ossifying fibroma Ossifying fibroma Clinical Features ⚫ ⚫ ⚫ ⚫ Young adults Female > male Asymptomatic Swelling Ossifying fibroma Radiographic features • • • Location: - Mandible, premolar - molar region Periphery: - Well defined border, sometimes hyperostotic - Radiolucent rim Internal structure: - Radiolucent, mixed rl-ro, radiopaque Ossifying fibroma Radiographic features • Effects on surrounding structures: - Displacement of IAN canal - Resorption and/or displacement of roots - Expansion of cortical plates - May grow into maxillary sinus Ossifying fibroma Differential Diagnosis • Fibrous Dysplasia - OF has soft tissue capsule (rl) surrounded by cortex (ro), well-defined borders - OF expands bone concentrically Fibrous Dysplasia Ossifying fibroma Ossifying Fibroma Well-defined corticated lesion with expansion and calcifications Ossifying Fibroma Differential Diagnosis • - Lesions with internal calcifications Calcifying odontogenic cyst Adenomatoid odontogenic tumor Calcifying epithelial odontogenic tumor Ossifying fibroma Ossifying Fibroma Internal structure: the “fingerprint” is a pattern characteristic of fibroosseous lesions. Paget’s Disease • • • • Osteitis deformans Results from abnormal resorption and apposition of poor-quality osseous tissue in one or more bones Etiology - Autosomal dominant trait - Paramyxoviral infection Radiographic monitoring for increased incidence of osteogenic sarcoma (around 10%) Paget’s Disease Clinical Features ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ 40 yo Male > Female Many bones can be affected, particularly the skull Enlargement of skull, bowing of legs, curvature of spine, large head, diastemas, denture/hat too tight, deafness Serum alkaline phosphatase Hydroxyproline in urine Paget’s Disease Radiographic features • • Location: - Pelvis, femur, skull, vertebrae infrequent in jaws - Maxilla>mandible - Entire jaw is involved Internal structure: - 3 stages: radiolucent, mixed rl-ro, radiopaque - Alteration of the bone pattern, ground glass, finger print, cotton wool appearance, linearity in mandible Paget’s Disease Radiographic features • Effects on surrounding structures: - Severe expansion of the bone - Reduction in size of maxillary sinus - Lamina dura is less evident - Generalized hypercementosis - Diastemas Paget’s Disease ⚫ ⚫ Expansion of the maxillary alveolar ridge Development of diastemas Paget’s Disease ⚫ ⚫ Enlargement of the head Increase in density and thickness of the cortex of the skull, increase in density of the mandible Paget’s Disease ⚫ ⚫ ⚫ Diastemas Hypercementosis Granular, ground glass appearance Paget’s Disease ⚫ ⚫ ⚫ Ground glass in the right maxilla, cotton wool in the left maxilla Linearity in the mandible Hypercementosis Paget’s Disease Enlargement of the maxillary alveolar ridge with displacement of teeth. Paget’s Disease ⚫ Increase in density of the maxilla. The maxillary sinuses are small and difficult to identify. Paget’s Disease Ground glass and cotton wool patterns and generalized hypercementosis. Paget’s Disease Fingerprint pattern Cotton wool patterns Paget’s Disease From: White & Pharoah Paget’s Disease Differential Diagnosis Fibrous Dysplasia • Younger age • Unilateral involvement of jaws Fibrous Dysplasia Paget’s disease