FIBRO-OSSEOUS LESIONS - II

CLASSIFICATION
 Cemento osseous dysplaisa(COD)

• Benign fibro osseous lesions of the jaws closely

associated with the apices of teeth and containing
amorphous spherical calcifications thought to
resemble an aberrant form of cementum: lesions are
usually without signs and symptoms.
WHO,2005
 • In previous versions of the WHO classification these
lesions were referred to as cemento-osseous lesions
and were clearly divided into three entities.
• Now they are spectrum of lesions, reactive in nature.
• Differ only by clinical & radiological appearances.

Paul M. Speight, Roman Carlos. Maxillofacial fibro-osseous lesions. Current Diagnostic Pathology
(2006) 12, 1–10
• Develop only in tooth bearing areas , so it is
theorized that they arise from PDL space.
• Term “Dysplasia” here refers to the abnormal
production and disordered development of bone and
cementum-like material.

Faizan Alawi. Benign Fibro-osseous Diseases of the Maxillofacial Bones . Am J Clin Pathol
2002;118(Suppl. 1):S50-S70
Etiology
• Unknown
• Thought to be reactive
 CLASSIFICATION

NON HEREDITARY TYPES: HEREDITARY/FAMILIAL TYPE:

Periapical Familial Florid

osseous osseous dysplasia /
dysplasia familial gigantiform
cementoma

Focal osseous
dysplasia

Non familial
Florid osseous
dysplasia

Leon Barnes. Surgical Pathology of the Head and Neck, Second Edition,Volume 1
Periapical osseous dysplasia (POD)
 Periapical osseous dysplasia

• PCOD is a well-defined clinical-radiologic entity, predominantly

involving the apical areas of vital mandibular incisors.
• Synonyms

• Osseous dysplasia

• Cemental dysplasia

• Cementoma

Neville, damm, allen, bouquot. Oral & maxillofacial pathology. 3rd edn. Saunders 2009
 Pathogenesis
• Occur as result of proliferation of principle fibres of
PDL in apical region of root

• Thoma - 3 stages in its development

• Osteolytic
• Cementoblastic
• Mature
Faizan Alawi. Benign Fibro-osseous Diseases of the Maxillofacial Bones . Am J Clin Pathol
2002;118(Suppl. 1):S50-S70
Clinical features
• Age -30-50yrs
• Sex – F>M
• Site – periapical region of anterior mandible
• Race – Blacks >Whites
• C /P –asymptomatic, no expansion
Teeth –vital
Solitary/mutiple lesions
Rarely exceeds 1.0 cm
 Radiographic features

Mature
Osteolytic

osteotoblastic
 Differential diagnosis
Differentiating
Stage of Pod D/D
feature
• Vitality of toot
• Cementum
• Periapical deposition on
• Early stage granuloma & cyst lateral surface of
• Mature stage • Hypercementoses the root,
,focal sclerosing radiopacity
• Multiple ostemyelitis,ceme surrounded by
mature lesions ntoblastoma radiolucent rim
• Pagets disease • No jaw
enlargement & no
serum alkaline P

Leon Barnes. Surgical Pathology of the Head and Neck, Second Edition,Volume 1
 Focal osseous dysplasia(FocCOD)
• First defined and classified as a separate entity by
Waldron 1985
• Misdiagnosed as ossifying fibroma
Clinical features
• Solitary lesion
• More common in women than in men (8:1)
• Predilection for the posterior mandible.
• Age – 4th & 5th decades
• No cortical expansion
• Mostly tooth bearing areas or at the extraction site
• Maximum 2cm in diameter
 Radiographic features

R/F are not sufficiently specific to differentiate from other

COD’s. “ An absolute key is – gross appearance at surgery “

D.S. MacDonald-Jankowski. Fibro-osseous lesions of the face and jaws. Clinical Radiology (2004)
59, 11–25
 Differentiating features
FocCOD PCD
Edentulous as well as dentulous areas Always associated with the tooth
No gener predilection Black women

FocCOD Ossifying fibroma

Benign non neoplastic process True neoplasm
Mixed radiolucent – opaque pattern Mostly radiolucent
No expansion Typical jaw expansion
Continuous with adjacent bone Shell out

Leon Barnes. Surgical Pathology of the Head and Neck, Second Edition,Volume 1
 Florid osseous dysplasia(FCOD)
• When lesions with radiologic and microscopic
features similar to FocCOD extend to 2 or more
quadrants of the jaw.
• Usually affects mandible bilaterally

Roy Eversole,Lan Su, Samir El Mofty. Benign Fibro-Osseous Lesions of the Craniofacial Complex-A
Review. Head and Neck Pathol (2008) 2:177–202
Clinical & radiographic features

• Asymptomatic
• Black females predilection
• Multiple radiopaque lesions fuse to form lobulated sclerotic masses
• Extensive lesions often have an associated bony swelling. If the
lesions become secondarily infected, features of osteomyelitis may
develop, including mucosal ulceration, fistulous tracts with
suppuration and pain.
 Differential diagnosis
1.Paget’s disease – polyostotic
Affects the bone of the entire mandible,
whereas FOD is centered above the inferior alveolar canal.
Maxilla most common site in pagets. Serum alkaline p increase
2.Chronic sclerosing osteomyelitis – can be differentiated by
cinical & radiographic features
3. Familial gigantiform cmentoma - expansile

Leon Barnes. Surgical Pathology of the Head and Neck, Second Edition,Volume 1
 • NOTE: Important association of COD is the traumatic
(simple) bone cyst.
• Appears as moderately defined radiolucency,
which in a dentate area displays “scalloping”, as its
superior border (in mandibular TBCs) undulates
around and between the roots.

D.S. MacDonald-Jankowski. Fibro-osseous lesions of the face and jaws. Clinical Radiology (2004)
59, 11–25
 Traumatic bone cyst

TBC+COD
No expansion

Shows expansion
Do heal after surgery

May not heal after surgery

D.S. MacDonald-Jankowski. Fibro-osseous lesions of the face and jaws. Clinical Radiology (2004)
59, 11–25
 Familial gigantiform cementoma

• It is an autosomal dominant disorder.

• Similar in presentation to florid osseous dysplasia but it has a
familial basis.
• Lesions often manifest at an early age.

Paul M. Speight, Roman Carlos. Maxillofacial fibro-osseous lesions. Current Diagnostic Pathology
(2006) 12, 1–10
Clinical & radiographic features

• No gender & racial predilection

• The gnathic enlargement in most patients results in significant
facial deformity, as well as impaction, malposition, and
malocclusion of the involved dentition
• Radiographic appearance is identical to that of florid osseous
dysplasia.
HISTOPATHOLOGY
• All the 3 patterns of COD shows similar features.

• The tissue consists of fragments of cellular

mesenchymal tissue composed of spindle shape
fibroblasts , collagen fibers , numerous blood vessels.

• Mixture of woven bone, lamellar bone, cemetum like

particles.
OSTEOMYELITIS
Osteomyelitis
Myelo- Itis-
marrow
Is defined as an inflammation ofinflammatio
Osteon-bone
bonen
and its marrow contents

osteo
myelit
is

Shafer’s textbook of oral pathology, 7th edition 2012,elsevier 29

Etiology

Bacteria associated with all types of osteomyelitis :

• Staphylococcus aureus, albus (most common)

• Streptococci
• Anaerobes – bacteroids and porphyrmonas

Shafer’s textbook of oral pathology, 7 th edition 2012,elsevier 30

Predisposing factors
Local factors
• Trauma
• Radiation damage
• Periapical lesion

Systemic conditions
• Malnutrition

• Uncontrolled Diabetes mellitus

• Chronic alcoholism

• Sickle cell anemia

• Paget’s disease, osteopetrosis Shafer’s textbook of oral pathology, 7 th

edition 2012,elsevier 31
 CLASSIFICATION
• Majority of cases caused by bacterial infections result
in destruction of bone with suppuration & sequestra
formation.
SUPPURATIVE / BACTERIAL/SECONDARY OSTEOMYELITIS

Acute ( within Subacute ( 1- Chronic ( few

2 weeks ) several months)
months)

Marc Baltensperger and Gerold Eyrich. Osteomyelitis of the jaws : definition and
classification
 CLASSIFICATION
• Some idiopathic inflammatory disorders that donot
respond consistently to antibiotics and typically
demonstrates sclerosis without suppuration or
sequestra formation.
NON SUPPURATIVE / PRIMARY CHRONIC OSTEOMYELITIS

Chronic focal Chronic diffuse Garre’s

sclerosing sclerosing osteomyelitis
 Etiology & Pathogenesis
Suppurative Sclerosing

Caries Low virulence bacteria

Inflammatory response Stimulation of osteoblasts

Periodontal tissues Woven bone & reactionary fibroblastic tissue

Abcess /granuloma/cyst Microscopic features resemble FOL

 Chronic focal sclerosing ( Condensing
osteitis)
• Mildest & most self limited form
• Seen in children & young adults
• Mandibular 1st molar – predominant site
• No other symptoms except mild pain with an infected
pulp
Radiographic features
 Differential diagnosis
•Vitality of tooth
•Radiolucent border delineating

Cementobl
•No widening of pdl
astoma
Hyperceme
ntosis
•Vitality of tooth
 Chronic diffuse sclerosing

•Analogus to focal form

•Etiology unknown
•Unilateral involvement
•Repeated episodes of dull pain
•Mostly mandibular involvement
Roy Eversole,Lan Su, Samir El Mofty. Benign Fibro-Osseous Lesions of the Craniofacial
Complex-A Review. Head and Neck Pathol (2008) 2:177–202
HISTOPATHOLOGY
 FLCOD CDSO
Multiple quadrants involvement Unilateral involvement
Several lobulated sclerotic radiodensities Poorly demarcated radiodensity
Confined to tooth bearing areas Can extend from alveolar process to
inferior border of mandible and penetrate
into ascending ramus
Often accompanied by simple bone cysts -
Predomint in black women No racial predilection
Asymptomatic Swelling & tenderness
 GARRE’S OSTEOMYELITIS
• Hyperplastic periosteal reaction to an inflammation
• Spread of infection through buccal cortical plate

• Stimulation of periosteum to deposit bone – forms

several rows of reactive bone that parallel each other

onion skin appearance

Clinical features

• Age : children and adults (mean age – 13)

• Most frequently mandibular premolar and molar regions.
• Toothache in the jaw with swelling on outer surface of the jaw

44
Radiographic features
• Charecteristic
multiple thin
layers of new
bone– onion skin
appearance.

45
Histopathologic features

46
THANK YOU
 REFERENCES
• Roy Eversole,Lan Su, Samir El Mofty. Benign Fibro-
Osseous Lesions of the Craniofacial Complex-A
Review. Head and Neck Pathol (2008) 2:177–202.
• Paul M. Speight, Roman Carlos. Maxillofacial fibro-
osseous lesions. Current Diagnostic Pathology (2006)
12, 1–10.
• D.S. MacDonald-Jankowski. Fibro-osseous lesions of
the face and jaws. Clinical Radiology (2004) 59, 11–
25
• Shafer'sTextbook Of Oral Pathology (6th
Edition).Elsevier India
• Faizan Alawi. Benign Fibro-osseous Diseases of the
Maxillofacial Bones . Am J Clin Pathol
2002;118(Suppl. 1):S50-S70
• Gillian Hall . Mini symposium : osteoarticulr
pathology.Fibro-osseous lesions of the head and
neck. Diagnostic histopathology
• Marc Baltensperger and Gerold Eyrich. Osteomyelitis
of the jaws : definition and classification.
• Neville, damm, allen, bouquot. Oral & maxillofacial
pathology. 3rd edn. Saunders 2009