FIBRO OSSEOUS

Lesions

Guided by : Dr. Mandeep Kaur Ma’am

Presented by : Iram Jamal
 FIBRO OSSEOUS LESION
Fibro-osseous lesion is a genric histologic designation for a diverse
group of bone lesion characterized by replacement of bone by benign
connective tissue matrix.

Eversole classification
1. Bone dysplasia
a) Fibrous dysplasia
i. Monostotic
ii. Polyostotic
iii. Polyostotic with endocrinopathy
iv. Osteofibrous dyplasia
b) Ostitis deformans
c) Pagetoid heritable bone dysplasia of childhood
d) Segmental odontomaxillary dysplasia
2. Cemento – osseous dysplasia
a) Focal cemento-osseous dysplasia
b) Florid cemento-osseous dysplasia
3. Inflammatory /reactive process
a) Focal sclerosing osteomylitis
b) Diffused sclerosing osteomylitis
c) Proliferative periostitis
4. Metabolic disease (hyperthyrodism)
5. Neoplastic lesion (ossifying fibroma
a) Ossifying fibroma
b) Hyperthyrodism jaw lesion syndrome
c) Juvenile ossifying fibroma
i. Trabecular type
ii. Psammomatoid type
d) Gigantiform cemantomas
2 . Classification on the basis of origin
a. Lesions of medullary bone origin
• fibrous dysplasia
• Fibro-osteoma
• Cherubism
• Juvenile ossifying fibroma
• Gaint cell tumor
• Jaw lesions in hyperparathyroidism
• Paget’s disease
b. Lesions of periodontal origin
• periapical cemental dysplasia
• cemento –ossifying fibroma
• ossifying fibroma
Waldrone classification
•Fibrous dysplasia
•Reactive lesions arising in the tooth bearing area
-periapical cemental dysplasia
-focal cemento – osseous dysplasia
-florid cemento – osseous dysplsia
•Fibro osseous neoplasm
-cementyfying fibroma
-ossifying fibroma
-cemento ossifying fibroma
 FIBROUS DYSPLASIA
Is a skeletal developmental anomaly of bone forming mesenchyme
characterized by replacement of bone with fibro osseous tissue.
Is basically a disease of children, adolescent & young adults that
tends to stabilize and essentially stop growing as skeletal maturity
reached.

Forms of presentation of fibrous dysplasia

Types Bone involvement
Café au Soft
Single Multiple Endocrine
lait tissue
Mono ostotic 
Poly ostotic 
Mac Cune albright
  
syndrome
Mazabraud
 
syndrome
Features Fibrous Dysplsia Paget’s disease
Is localised change in normal bone Is a disease involving osteoclast
metabolism resulting in replacement of all resulting in abnormal resorption and
Definition component of cancellous bone by fibrous apposition of poor quality osseous
tissue containing varying amount of tissue in one or more bone.
abnormal appearing bone.

Caused by post zygotic mutation in GNAS 1 Is an autosomal dominant trait with

Etiology
gene on chromosome 20q13.32 genetic heterogenicity
• Is a disease of children & young adults • Is a disease of middle & old age
• No sex prediliction • Has slight male prediliction.
• The lesion form a painless expansion • Affected bone enlarge deformly
Clinical
which grow slowly over years. and have ill defined neurologic pain
features
due to bone impingement on
foramina or nerve canal
 Imaging
Fibrous dysplasia Paget’s disease
feature
Maxilla > mandible Maxilla > mandible
Location More commonly is unilateral Entire maxilla or mandible are involved

Early lesion are radiolucent. Has 3 radiographic stage

Late lesions have granular 1. Early radiolucent resorptive phase
Internal appearance resembling ground 2. A granular or ground glass appearance
structure glass, orange peel surface, cotton 3. Denser, more radiopaque appositional
wool late stage

• Involved bone show expansion with • Involved bone enlarges with intact outer
maintenance of thinned outer cortex.
cortex • Teeth may become spaced or displaced
Effect on • Teeth can be displaced & there in enlarging jaw.
surrounding can be interference with normal • Exuberent & irregular hypercementation
structure eruption. develops on a few or most of the teeth
• Involved teeth may have in invovled jaw.
hypercementosis. • Lamina dura may become less evident
• Lamina dura disappearance
 Pain Fibrous dysplasia Paget’s disease
•Paget’s disease •Fibrous dysplasia
•Peri apical cemental dysplasia •Focal cemento osseous dysplasia
Differential
•Endochondroma •Hyperthyroidism
diagnosis
•Non ossifying fibroma •Osteomalacia
•Hyperthyroidism
•Gaint cell tumour
• Alkaline phosphatase level • Alkaline phosphatase level
elevate elevated
Biochemistry • High level of hydroxyproline in
the urine
• Monitoring of the lesion • Is managed medically
• Orthodontic & cosmetic • To relieves pain & reduce SAP
surgery delayed until level Calcitonin, sodium
Management skeletal maturity completed etidronate, bisphosphonate are
used
• Surgery required to correct
deformities.
 OSSIFYING FIBROMA AND
CEMENTIFYING FIBROMA
• These are slow growing, well circumscribed, benign tumour of bone.
• Probably arises from cells of periodontal ligament.
Clinical features:
• Occurs at any age; more common in young adult.
• Marked prediliction for females.
• Lesion is generally asypmtommatic until the
growth produces a noticeable swelling and mild deformity.
• Displacement of teeth may be early clinical features.
Histopathology:
• Is composed of cellular fibrous connective tissue containing varying
amount of osteoid & bone.
• Cementifying fibroma has rounded cementoid calcification.
Radiographic features
1. Location
• Appears exclusively in the facial bones
• Mostly in mandible Inferior to premolar and molar and superior to
the inferior alveolar canal.
• In maxilla it occur in canine and zygomatic arch area .
2. Periphery
• Borders are well defined. A Thin radiolucent line represent a
fibrous capsule.
3. Internal structure:
• Internal structure is mixed radiolucent – radioopaque density with
a pattern that depends on the amt and form of the manufactured
calcified material.
• Patterns appears as wispy (similar to strechted tuft of cotton) or
flocculent (similar to large , heavy snowflackes)
4. Effects on surrounding structure
• Displacement of teeth and alveolar canal.
• Outer cortical plate displaced and thinned, remain intact.
• Lamina dura of involved teeth usually , missing and resorption of
teeth may occur .

Differential diagnosis:
• Fibrous dyplasia
• Periapical osseous dysplasia
• Giant cell granuloma
• Calcifying odontogenic cyst
• Adenomatoid odontogenic tumour

Treatment :
The lesion should be excised conservatively. Recurrence is rare
 Cherubism
It is a autosomal dominant fibro – osseous benign heriditary condition which
affects only the jaw bones and it is characterized by “bilateral symmetrical
enlargment “ of mandible sometimes maxilla .
Pathogenesis
• heriditary disease
•Inherited as an autosomal dominant trait
•Gene for cherubism present on chrosome 4q16.3.
Classification
on the bases of severity and location of lesion and extent to which jaws are
affected
GRADE 1 : expansion tend to be bilateral and symmetrical . In ramus area
Grade 2: ramus and body of the mandible involved
Grade 3 : lesion affect maxilla and mandible result in considerable facial
deformities
Clinical features
•At birth , apperence is normal .
• between 1 to 5 yr , symmetrical , painless ,
bilateral mandibular swelling with cheeck
fullness give apperance of
(chubby face ) to a child .
•In extensive maxillary swelling , pressure on floor of orbit result in
upward turn of pupil , revealing a rim of white sclera below iris
(heavenward look /apperence )
•Expansion and widening of aleveor ridge ,flattening of palatal vault
•Submandibular lymphadenopathy
•Premature exfoliation of decidious teeth , rotation transition teeth
and occasionally resorption of root , malocclusion occurs.
•Difficulty in mastication , speech and swallowing .
 Radiographic features
• Location : bilateral affects both jaws involving posterior mandible
ramus , tuberosity .
•Periphery : well defined , corticated .
•Internal stuctures : fine granular bone and wispy trabeculea forming
prominent multilocular “cyst – like “ pattern.
•Effect on surrounding structures : expainsion of cortical boundries ,
severe enlargment of jaws .
•Multiple unerupted and displaced teeth appear to be floating within
the cyst – like spaces ( floating tooth syndrome )
Differential diagnosis
Fibrous dysplasia , gaint cell granuloma , multiple odontogenic
keratocysts , hyperparathyrodism , ameloblastoma ,gaint cell
granuloma .
Treatment
•The lesion tend to show varying degree of remission after
puberty .
•By 4th decade facial features approach normally .
•Early surgical intervation for cosmesis has given results.
 CEMENTO –OSSEOUS DYSPLASIA
Occurs in the tooth bearing area of the jaw.
Is the most common fibro–osseous lesion encountered in clinical
practice.
Is a disease of periodontal ligament origin
It is of three group
• Focal
• Periapical
• Florid
 Peri apical osseous
Features Florid osseous dysplasia
dysplasia

• Peri apical cemental • Florid cemento osseous dysplasia

dysplasia • Gigantiform cementoma
Synonyms • Cementoma • Familial multiple cementoma
• Sclerosing cementoma

It is localized change in It is widespread form of periapical

Disease normal cancellous bone & osseous dysplasia > 4 quadrant
Mechanism replacement with fibrous
tissue & amorphous bone
• Commonly occurs in middle • Age sex ethinicity predilection
age are same
• Female predilection • It produce no symptoms & is
Clinical • The involved teeth are vital found incidentally during
Features with no history of pain radiograph
• Lesion found as a incidental • Occasionally patient complain of
finding during radiograph low grade intermittent, poorly
localized pain in affected bone.
Imaging Peri apical cemental
Florid cemental dysplasia
features dysplasia
• Commonly seen in mandibular • Usually bilateral & present in
anterior teeth region both jaw
Location • Lesion is multiple & bilateral • When present in 1 jaw mandible
• Epicenter lie apical to the is more commonly affected
tooth • Epicenter lie apical to the tooth
• Periphery is well defined with • Periphery is well defined
radiolucent border surrounded sclerotic border
Periphery by a band of sclerotic bone
& shape • Lesion have an overall round
or oval shape centered over
the apex of the tooth
• Early stage – radiolucency at • Mix of radiolucent and radio
apex of involve tooth opaque regions to almost
• Mixed stage – radio opaque complete radio opacity
Internal tissue appears in radio lucent • The radio opaque regions can
structure structure vary from small oval & circular
• Mature stage – area become regions (cotton –wool
completely radio opaque appearance) to large irregular,
amorphous area of calcification.
 Peri apical Cemental
Feature Florid Cemental Dysplasia
Dysplasia
• Lamina dura of involved teeth • Large lesion displace inferior
may become lost alveolar canal
• Hypercementosis seen in the • Roots of associated tooth may
Surrounding involve teeth show hypercementosis which
Structure fuse with surrounding foci of
amorphous bone.

• Benign cementoblastoma • Paget’s disease

Differential
• Odontoma • Chronic sclerosing osteomyelitis
Diagnosis
• Cemento ossifying fibroma
Treatment is not required • It doesn’t require treatment
normally • Patient should be encourage to
If the teeth is removed & maintain an effective oral
Management infection occur in amorphuous hygiene to avoid odontogenic
bone it should be removed infection.
surgically.