Diseases Of Bone

Front 1

Systemic disease defined as an absolute decrease in the amount of bone below the level required for adequate mechanical support

Back 1

Osteoporosis
- Caused by metabolic resorption of bone.

Front 2

What is the term for increased amounts of calcified bone?
&
What are some of the causes?

Back 2

Osteosclerosis

Seen in pt.s with metastatic tumors, lead poisoning and hypothyroidism

Front 3

Generalized bone loss and replacement by fibrous tissue
- "Ground Glass Appearance"

Back 3

Hyperparathyroidism
- There may be shifting of teeth, pathologic bone fractures are uncommon.
HISTO: cellular fibrous stoma, much like ganulatin tissue.
- Very vascular thus associated with foci of hemorrhage. Gives lesion brown color glossy. often referred too as brown tumor of hyperparathyroidism.

Front 4

DZ caused by poor renal function. Resultant lack of Vit. D3 causes decrease in calcium absorption.

Back 4

Secondary Hyperparathyroidism of bone.
- Ca is lost in the urine and there is hyperplasia of the Parathyroid gland to compensate by increasing output of PTH to maintain serum Ca levels

Front 5

Caused by a functional benign parathyroid adenoma

Back 5

Primar Hyperparathyoidism of bone.
- Increased PTH secretion leads to Elevated serum Ca.
- Associated w/ bone resorption and bone lesions as Ca is liberated from skeleton

Front 6

What do Stone, Moans, and groans refer to?

Back 6

Primary Hyperparathyroidism of bone.
Stones - Urolithiasis, Nephrolithiasis and Cholelithiasis.
Moans- abdominal pain from peptic ulcer disease
Groans - Psychiatric changes.

Front 7

Normal bone apposition - Abnormal to no bone resorption.

Back 7

Osteopetrosis "marble bone disease" - osteoclast disfunction
Benign = Dominant, middle-age to older onset.
- Multiple pathologic fractures (40%), Pain Cranial nerve palsy, Osteomylitis
Malignant = Recessive - Congenital, death by 20
- optic Atrophy, hepatosplenomegaly, loss of hearing, pathological fractures, & secondary infections.

Front 8

Dental finding of Osteopetrosis

Back 8

-Delayed eruption (due to bone sclerosis); -Premature exfoliation due to defect in pdl; - Enamel hypoplasia; -Predisposition to oseomyelitis; -Pathologic Jaw fracture.
Radiographic
-Dense homegenous milky opague changes; increased cortical thickening; tooth roots may be obscured by dense bone.

Front 9

Back 9

Cherubism - autosomal Dominant.
- 100% penetrance in Males; 50-75% in Females
- Mutation in gene that codes for a protein involved in signal transduction to upregulate osteoblasts and osteoclasts activity.
- Upturned "cherubic" eyes. Premature loss of decidous teeth. Defective permanent teeth
- " soap bubble" patter = classic, teeth may be displaced or "floating in air."
- Some regression at puberty.

Front 10

Flat based bony protuberance AT THE MIDLINE mid hard palate.

Back 10

Torus Palatinus
-20-35% of US population, increased incidence in Asian and Inuit populations. 2:1 = F:M
- initiate at puberty, w/ peak age of diagnosis of 30.

Front 11

Flat based bony protuberances at the lingual mandibular cortex - usually bicuspid area

Back 11

Torus Mandibularis
- 7-10% U.S. population, increased incidence in Asian and Inuit populations. Slight Male predominance
- More common with bruxism and missing mandibular teeth. usually bilaterally, 20% unilateral.

Front 12

Bony lesions that occur on the alveolar ridges, especially buccal to the molars.

Back 12

Buccal exostoses and palatal tubercles.
- Less common than tori
- The maxilla is affected more often than the mandible.
- Buccal exostoses are more common than palatal tubercles.

Front 13

Bacteria caused this "moth-eaten" radioluecency

Back 13

Acute Osteomyelitis
- Acute inflammation w/ pus production.
- Pain, swelling and cellulitis in affected region. Fever &/or rub or. Lymphadenopathy
- Bony trabeculae appear indistinct.
HISTO: Medullary spaces packed w/ neutrophils, some fibrin. Necrosis of bone - lacunae are empty.
- Incise and Drain (I & D) - and antibiotics.

Front 14

Complications of Acute Osteomyelitis

Back 14

Sequestrum - Dead bone, surrounded by bacteria and pus
Involucrum - dead bone, surrounded by living bone
Pathologic fracture is Uncommon.
Acute Osteomyelitis is often seen in people w/poor oral hygiene problems.

Front 15

An (Acute or chronic) inflammatory process that is spreading in the medullary spaces or cortical surface of bone as an extension of an initiating infection (usually bacterial).

Back 15

Osteomylitis
- Most cases in the jaws arise from an odontogenic infection. These infections are virtually always mixed.
- Predisposing factors include chronic systemic disease, immunocompromise, and decreased vascularity of bone.

Front 16

HISTO: Necrotic bone trabeculae
- & Marros Spaces contain mostly plasma cells.

Back 16

Chronic Osteomyelitis.
- Chronic inflammation, generation of granulation tissue, scar formation, and sequestration of dead bone.
- Swelling pain, drainage, and pathologic fracture.
- Difficult management since infection is walled off by granulation tissue.
- High does IV antibiotics. Surgical removal of dead and infected bone to obtain margins with good vascularity. - may have to stabilize weakened bones, to prevent fracture.

Front 17

Back 17

What are you going to do about it?

Front 18

A proliferative reaction in inflamed or irritated bone. It occurs in young people, well below 25, as an attempt to contain the infection.

Back 18

Osteomyelitis with Proliferative Periostitis
- Usually involves the mandible, pt. may have toothache or dental complication such as pericoronitis.
- Presents as bony hard swelling.
Radiographic - "onion-skin" layering of new bone over the cortex. Source of the infection should be apparent.
Treatement
- Remove carious tooth, or other source of infection, biopsy if desired.

Front 19

Ability of bone to react to infection is decreased. This is related to vascular damage, hypoxia, and hypocellularity.

Back 19

Osteoradionecrosis - inflammatory and necrosing condition of the bone that develops primarily dur to compromised blood supply in previously irradiated bone.
- Osteoblasts - affected, reduced cellularity
- Vascularity - Severely damaged, greatly reduced blood supply
- Bone marrow- Dramatically affected, recovers
- Usually has a contributing factor: trauma (extractoins = major), Infection, malnutrition.

Front 20

Radiographs usually show ill- defined area of radiolucency containing foci of opacity (which represent the sequestra).

Back 20

Osteoradionecrosis
Mandible is affected far more commonly than the maxilla, due to blood supply...
Symptoms:
- Intractable pain, fistulation, and pathologic fracture.

Front 21

Back 21

Bisphosphonate-Associated osteonecrosis of the Jaws (BONJ)
- Bisphosphonates are used to treat osteoporosis, cancer metastatic to bone, Paget's disease of bone and multiple myleloma.
- 94% of reported cases have been associated with IV administration. Risk of BONJ w/IV is 6-10%
- For oral bisphosphonates it is about 0.7/100,000.

Front 22

Back 22

BONJ
- Bisphosphonates act by inhibiting osteoclasts - thus inhibiting bone resorptions, which may be helpful for osteoporosis and other diseases that breakdown bone.
- However they also prevent normal remodeling and maintenance of bone, which may not reduce risk of bone fracture.

Front 23

Back 23

BONJ
- Stopping medication may not reduce risk b/c of long half life of drug (10-12 years)
- Risks include: Age > 65, concomitant meds - corticosteriods and chemotherapy, Diabetes Mellitus, smoking or alcohol abuse, poor oral hygiene...
Radiographic
- localized increased radiopacity may precede osteonecrosis. Periostal hyperplasia may occur. Sever cases may show moth eaten appearance and ill-defined radiolucency w/ or w/out central area of opacity.

Front 24

Disease where: Mandible is affected most commonly, but condition may also be the maxilla only or even in both jaws. 60% of cases have developed following invasive dental procedures. Even minor trauma may initiate the condition. Presents with sequestration or denudation of dead bone.

Back 24

BONJ
- Sinus tract formation may occur
- pathologic fracture is possible
Histo
- Sclerotic lamellar bone with empty lacunae (dead bone)
- Bacterial colonies may be visible
Prevention is important - avoid invasive dental procedures. NO EFFECTIVE TREATMENT... Only palliative: systemic antibiotics w/ CHX

Front 25

- Note the carious tooth.

Back 25

Condensing Osteitis (Focal Sclerosing Osteomyelitis)
- Localized area of osteosclerosis associated w/ the apex of a tooth having pulpal inflammation or necrosis.
- Most commonly in children and young adults, and most commonly in the mandibular premolar or molar areas.
- Associated tooth is expected to have a large carious lesion or large existing restoration.
- No bony expansion.

Front 26

Residual lesion after extraction

Back 26

Bone scare - still Condensing Osteitis
- Pure radioapaque lesion present at the root apex and contiguous w/ the lamina dura. Entire root outline is usually visible.
- PDL separates root from lesion - may be widened at the apex.
- Border may blend w/ adjacent normal trabecular pattern, but shows NO lucent rim.
- Lesion itself requires no treatment but treat the source of the irritation/infection.

Front 27

Most cases arise in the first or early second decade.

Back 27

Idiopathic Osteosclerosis
- Bony sclerosis without evidence of inflammation, dysplasia, neoplasia or systemic disorder. May be radiographically indistinguishable from condensing osteitis.
- 90% in mandible, w/ &1st molar is most common spot.
- Associated tooth is healthy and vital

Front 28

Back 28

Idiopathic Osteoslerosis
- Radiopaque lesion present most often in periapical area, but may involve interadicular bone.
- Lesion is contiguous w/ lamina dura and may obscure the root outline in some cases
- Border is well defined, but may blend w/ adjacent normal trabecular pattern. NO radiolucent rim.

Front 29

The most common fibro-osseous lesions encountered in dentistry

Back 29

Osseous Dysplasias (Cemento-Osseous Dysplasias)
- Occur in tooth-bearing areas and may be in direct continuity with the lamina dura of a tooth.
- Difficult to tell if origin is bone or cementum
- Either reactive or dysplastic in origin. not developmental or neoplastic.
HISTO
Amount of calcifications increase as the lesions mature.

Front 30

What are the three stages of Osseous Dysplasias, and their distinct histology?

Back 30

Osteolytic Stage - Proliferating cellular fibroblastic tissue

Blastic Stage - irregular immature bone or cemental spicules within a fibrous stroma

Mature Stage - Central core of dense cementum/bone w/ fibrous tissue periphery.

Front 31

Defining characteristic for this lesion is: Confined to the periapical areas of anterior mandibular teeth.

Back 31

Periapical Osseous Dysplasia (Periapical Cemental Dysplasia, Cementoma)
- 30 to 50 years old (NEVER under 20)
- Strong FEMALE predilection - 10:1 to 14:1 and 70% are African Americans.
- Associated teeth are vital

Front 32

Back 32

Periapical Osseous Dysplasia
- Osteolytic Stage - Periapical pure lucencies
- Blastic Stage - mixed lucency - opacity around apices
- Mature Stage - dense opacity w/ Radiolucent rim.
- No specific treatment needed, Don't extract unless you have to. won't resorb w/ bone so can have problems with future dentures.

Front 33

Age: 30-60
- 90% females
- More common in Caucations.

Back 33

Focal Osseous Dysplasia ( 9 years later after other x-ray)
- always solitary lesion, may occur in any area of the jaws
- posterior mandible is predominant.
- well defined less than 1.5 cm, may have irregular outline
- Lesions vary form pure lucency to dense central opacity w/ radiolucent rim. Once it is mixed w/ a rim = diagnostic.
No treatment necessary, but if radio is not diagnostic excisional biopsy may be necessary

Front 34

Must involve all four quadrants

Back 34

Florid Osseous Dysplasia
- Favors posterior areas but may also involve the anterior mandible.
- Most are completely asymptomatic, but may have dull pain, usually w/ secondary infection.
Radio: same, but may not have a lucent rim, and may coalesce to form large opaque masses.
- rarely require treatment

Front 35

Back 35

Florid Osseous Dysplasia
As lesions mature, they may become more avascular. This increases risk of complications, complications will require treatment.
- Secondary infection - resulting in vague pain, fistula formation, bad taste, and sequestration
- Poor healing following extractions.
- increased risk of developing simple bone cyst
- resorption of ridges down to level of lesions can be problem for denture wearers.
Easier to prevent complications than to treat.

Front 36

This classic "Ground glass" appearance is not generalized. And it is expansile.

Back 36

Fibrous Dysplasia (monostotic in this picture)
- Tumor-like,it is a developmental anomaly
- Post-zygotic mutations of GNAS 1.
- Adolescent for most cases, but may be earlier in polystotic cases. persist for life
- Different from hyperparathyroidism in that it is NOT generalized, and Fibrous dysplasia IS expansile.

Front 37

HISTO - irregular C-shaped trabeculae of woven bone.
- No osteoblastic rimming.
- Bone trabecular appear to arise directly from stroma

Back 37

Fibrous Dysplasia
- Monostotic, most common(70%). single bone affected. Ground glass appearance - classic(for monostotic)
- Polystotic , invovles two or more bones, can be multilocular and has more of a cotton wool appearance, no distinct edge - blends gradually into surrounding bone.Two subtypes of polystotic

Front 38

May halt naturally after puberty

Back 38

Fibrous dysplasia
- For mild cases surgical recontouring is possible, but WAIT till after growth has ceased.
- No effective treatment for progressive
- DO NOT treat with radiation.

Front 39

Back 39

Polystotic Fibrous dysplasia, Jaffe-lichten stein sydrome
- Multiple bones affected, but not entire skeleton
- Features Cafe-au-lait spots
- NO endocrine involvment

Front 40

- Severe form of disease affecting many bones (up to 75%)
- involvement may tend to be somewhat unilateral
- Cafe-au-lait spots are present
- Endocrine disturbances are characteristic of this type. May involve thyroid, parathyroid, pituitary or ovaries.
Precocious puberty is common in affected females w/ menstrual bleeding occurring as early as 2-3 years old.

Back 40

McCune-Albright syndrome
- Polystotic Fibrous Dysplasia

Front 41

Thought to be caused by slowly developing disease from viral effects of childhood viral illnesses: Possible measles or respiratory syncytial virus

Back 41

Osteitis Deforemans (Paget's Disease of Bone)
- Most pts. over 40, affects men and women equally
- only 17% have jaw involvement
- may have bony swelling (enlargement)-increase hat size
- Compression on the 8th, 2nd, and 7th CN's can cause Deafness, Blindness, and Facial paralysis, respectively.
- Increased serum alkaline phosphatase - Classic

Front 42

Cotton - wool opacities are classic

Back 42

Osteitis Deforemans (Paget's Disease of Bone)
- lesions can be mixed radiopaque-radiolucent
- Loss of lamina dura around teeth
- Hypercementosis
- Pt may complain they can not wear dentures anymore
- Diastemas may increase
- Occlusion may progressively change.

Front 43

Back 43

Osteitis Deforemans (Paget's Disease of Bone)
HISTO: - Mosaic pattern of bone or jigsaw puzzle, -Prominent resting and reversal lines
- Osteoclasts in Howship lacunae
- Highly vascular stroma
Increased risk for developing osteosarcoma (30X)
DO not treat w/ radiation. No single treatment is effective in all cases. Drugs that keep serum alkaline phosphatase w/in normal limits seem to control the disease.

Front 44

Benign tumor that grows slowly by expansion. may cause displacement of teeth or facial deformity.

Back 44

Central Ossifying Fibroma ( Cemento-ossifying Fibroma, cementifying Fibroma)
- Peak incidence is in the 3rd and 4th decades (20-40, useful b/c younger than osseous dysplasia at this age)
- More common in the mandible, most in molar or bicuspid region.
- 2:1, Female to male ratio.

Front 45

Back 45

Central Ossifying Fibroma ( Cemento-ossifying Fibroma, cementifying Fibroma)
- This radiograph goes with pic above.
- May be lucent, mixed or opaque depending on the stage; lesions develop more opacity as they mature.
- Well- circumscribed w/ smooth borders
- May displace teeth.
- May cross the midline.

Front 46

Back 46

Central Ossifying Fibroma ( Cemento-ossifying Fibroma, cementifying Fibroma)
HISTO -Cellular fibrous stroma w/ delicate collagen fibers
- Calcified tissues: scattered small, round to ovoid, basophilic, acellular cementum-like masses which coalesce as the lesion matures
- Flecks or islands of calcifications resembling bone
- stroma often pulls away from trabecular.
Osteoblastic or cementoblastic rimming is common.
Mild pleomorphism - some mitoses
Treatment: conservative surgical excision, good prognosis.

Front 47

HISTO features normal appearing dense, compact bone.

Back 47

Osteoma - May occur at any age.
- Found on endosteal or periosteal locations. Most often seen on the inner surface of skull. Present as slowly enlarging swelling, seldom painful.
- Multiple osteomas are seen in Gardner's syndrome.
- Radiographs show well-circumscribed radiopaque mass
Treatment- surgical excision; does not recur.

Front 48

Back 48

Osteoblastoma.
- Rare in the jaws
- Osteoblastomas are larger than 2 cm.

Front 49

What is histologically idential to osteoblastom, except a central nidus containing nerve fibers can sometime be identified?

Back 49

Osteoid Osteoma
- Osteoid Osteomas also produce prostaglandins, which makes the accompanying pain out of proportion to the size of the lesion.
- Also rare in jaw

Front 50

Back 50

Osteoid Osteoma
- closely related to osteoblastoma, but can generally be distinguished in the Jaw b/c Osteoid Osteomas are smaller than 2 cm, & Osteoblastomas are larger than 2 cm
- Young people under 30, often under 20
- Rare aggressive osteoblastomas occur after 30
- Slight male predominance

Front 51

HISTO: Increased Vascularity is the key to diagnosis. Giant cells (few) in fibrous stroma. Osteoblasts piled upon trabecular may appear atypical. May be mistaken for osteosarcoma or cellularity and atypia

Back 51

Osteoid Osteomas & Osteoblastomas.
Radio:
- Well-circumscribed mixed radiopacity-radiolucency
- May or may not obscure the root outline
- Classic "bull-eye" lesion usually not seen in jaws
Treatment: conservative surgical excision or en bloc excision.
- Aspirin can relieve the pain.

Front 52

Common benign neoplasms of the skeleton, frequently involving the small bones of the hands and feet.
However, these benign cartilaginous neoplasms, are very rare in the orofacial complex.

Back 52

Chondromas and enchondromas.
- 3rd and 4th decades
- painless slow growing mass
- Occasionally associated with root resorption and tooth mobility.
- Site of predilection - condyles and anterior maxilla
Radiolucent lesion w/ central opacity.
HISTO - mature hyaline cartilage; orderly architecture.
Complete surgical excision, good follow-up important b/c there is a risk that the lesion was actually well-differentiated sarcoma.

Front 53

Back 53

Osteochondroma
- Benign neoplasm formed of dense cortical bone with a cartilage cap. It is a knobby growth that protrudes from the metaphyseal surface of long bones.
- Osteochondroma, like other benign cartilaginous tumors, is rare in the head and neck area. On rare occasions, they are found at the condyle.

Front 54

Back 54

Central Giant Cell TUMOR (PKA central giant cell granuloma)
- Wide age range, 60% of pts are younger than 30.
- More common in females
- Most asymptomatic, but may have bony selling.
- Pain and paresthesia occasionally occur.
- 70% are in the Mandible

Front 55

Back 55

Central Giant Cell TUMOR
- Pure Radiolucency w/ no border Reaction
- May be unilocular or multilocular. Though the classic soap bubble appearance is not often observed in jaw lesions.

Front 56

Back 56

Central Giant Cell TUMOR
HISTO:
- Stroma of plum or spindled fibroblast-like cells
- Many scattered multinucleated giant cells resembling osteoclasts
- Focal hemorrhage and hemosiderin deposition
- Don't usually see bone and cartilage formation.
- Histologically indistinguishable from brown tumor of hyperparathyroidism (must rule out in pts over 40)
Treated by curettage: 15-20% recurrence.

Front 57

Back 57

Central Hemangioma and vascular malformations:
(specifically Intrabony arteriovenous malformation)
-Vascular harmartomas and arterio-venous malformations are congenital anomalies that may occur centrally in the jaws on rare occasions.
- 10-20 years; 2:1 female predilection.
- 2/3 in the mandible
S & S
- Bony destruction, expansion and facial asymmetry
- Gingiva overlying a bone lesion may be discolored - purple to reddish blue.
MOST COMMON SHOWS NO RADIOGRAPHIC CHANGES!
honey comb = soap bubble radiolucency

Front 58

Back 58

Intrabony Venous malformation (Central Hemangioma and vascular malformations)
- Honeycomb = soap bubble radiolucency
ALWAYS aspirate before surgically entering ANY multilocular radiolucent lesion since it may be a hemangioma or AV malformation (low likelihood, but very bad outcome).
Treated by surgery, sclerosing agents (Na morrhuate), or cryosurgery

Front 59

Back 59

Osteosarcoma = Osteogenic Sarcoma

Front 60

Back 60

Osteosarcoma = Osteogenic Sarcoma

Front 61

Back 61

Osteosarcoma = Osteogenic Sarcoma

Front 62

Back 62

Osteosarcoma = Osteogenic Sarcoma

Front 63

Back 63

Chondrosarcoma

Front 64

Back 64

Ewing Sarcoma

Front 65

Back 65

Ewing Sarcoma

Front 66

Back 66

Metastatic Tumor to the Jaw.