Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 8...

Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. 1

Chapter 8

Nonneoplastic Diseases of Bone


OutlineOutline Benign Fibro-osseous LesionsBenign Fibro-osseous Lesions Paget Disease of BonePaget Disease of Bone Central Giant Cell GranulomaCentral Giant Cell Granuloma OsteomalaciaOsteomalacia


Nonneoplastic Diseases of BoneNonneoplastic Diseases of Bone

(pg. 277) (Box 8-1)(pg. 277) (Box 8-1) These diseases fall into several These diseases fall into several

categories.categories. Several are discussed in other chapters.Several are discussed in other chapters.

• Inherited diseases affecting bone – Ch 6Inherited diseases affecting bone – Ch 6• Benign and malignant neoplasms – Ch 7Benign and malignant neoplasms – Ch 7• Central and peripheral giant cell granulomas – Ch 2Central and peripheral giant cell granulomas – Ch 2• Aneurysmal bone cyst – Ch 5Aneurysmal bone cyst – Ch 5

This chapter covers several other This chapter covers several other nonneoplastic diseases not included nonneoplastic diseases not included elsewhere.elsewhere.


Benign Fibro-osseous LesionsBenign Fibro-osseous Lesions

Periapical Cemento-osseous DysplasiaPeriapical Cemento-osseous Dysplasia Focal Cemento-osseous DysplasiaFocal Cemento-osseous Dysplasia Florid Cemento-osseous DysplasiaFlorid Cemento-osseous Dysplasia Fibrous DysplasiaFibrous Dysplasia


Periapical Cemento-osseous Periapical Cemento-osseous DysplasiaDysplasia

(pgs. 277-278)(pgs. 277-278) A relatively common disease of unknown cause A relatively common disease of unknown cause

that affects periapical bonethat affects periapical bone Clinical and radiographic featuresClinical and radiographic features

Discovered on radiographsDiscovered on radiographs Occurs most commonly in the anterior mandible of Occurs most commonly in the anterior mandible of

patients older than 30 patients older than 30 More common in women than men – many studies More common in women than men – many studies

indicate a predilection for black women.indicate a predilection for black women. Early lesions are well circumscribed and radiolucent.Early lesions are well circumscribed and radiolucent.

• With time, they become increasingly calcified.With time, they become increasingly calcified.• Older lesions may be radiolucent with central Older lesions may be radiolucent with central

opacifications.opacifications.


Periapical Cemento-osseous Periapical Cemento-osseous Dysplasia (cont.)Dysplasia (cont.)



(pgs. 277-278)(pgs. 277-278) Diagnosis and treatmentDiagnosis and treatment

A biopsy may be necessary in cases where A biopsy may be necessary in cases where characteristic radiographic features are not evident.characteristic radiographic features are not evident.

Histologic examination reveals a fibro-osseous lesion Histologic examination reveals a fibro-osseous lesion composed of fibrous tissue and calcifications.composed of fibrous tissue and calcifications.

Early lesions consist of mainly fibrous tissue, where Early lesions consist of mainly fibrous tissue, where older lesions contain numerous calcifications.older lesions contain numerous calcifications.

TreatmentTreatment NoneNone


Focal Cemento-osseous Dysplasia Focal Cemento-osseous Dysplasia (cont.)(cont.)

(pgs. 277-278)(pgs. 277-278) An asymptomatic fibro-osseous lesionAn asymptomatic fibro-osseous lesion

The histologic features are similar to periapical The histologic features are similar to periapical cemento-osseous dysplasia and florid cemento-osseous dysplasia and florid cemento-osseous dysplasia, but it has unique cemento-osseous dysplasia, but it has unique clinical and radiographic features.clinical and radiographic features.


Focal Cemento-osseous Dysplasia Focal Cemento-osseous Dysplasia (cont.)(cont.)

Clinical and radiographic featuresClinical and radiographic features Usually occurs in women between 30 and 50 Usually occurs in women between 30 and 50

years of ageyears of age More common in white than in black individualsMore common in white than in black individuals Typically arises in the posterior mandibleTypically arises in the posterior mandible Appears as an isolated, well-delineated Appears as an isolated, well-delineated

radiolucent to radiopaque lesion less than 1.5 radiolucent to radiopaque lesion less than 1.5 cmcm


Focal Cemento-osseous Dysplasia Focal Cemento-osseous Dysplasia (cont.) (cont.)

Diagnosis and TreatmentDiagnosis and Treatment Biopsy and histologic examination are usually Biopsy and histologic examination are usually

necessary to establish a diagnosis,necessary to establish a diagnosis, A surgical feature is that it is composed of A surgical feature is that it is composed of

numerous gritty pieces of soft and hard tissue.numerous gritty pieces of soft and hard tissue.


Florid Cemento-osseous DysplasiaFlorid Cemento-osseous Dysplasia

(pgs. 278-279)(pgs. 278-279) A condition of disordered cementum and A condition of disordered cementum and

bone developmentbone development Characteristically involves multiple quadrants Characteristically involves multiple quadrants

in the maxilla and mandible. in the maxilla and mandible.


Florid Cemento-osseous Dysplasia Florid Cemento-osseous Dysplasia (cont.)(cont.)

(pgs. 278-279)(pgs. 278-279) Clinical and Radiographic FeaturesClinical and Radiographic Features

Occurs most often in middle-aged black Occurs most often in middle-aged black women who are older than 49women who are older than 49

It typically affects more than one quadrant of It typically affects more than one quadrant of the maxilla and mandible, often in posterior the maxilla and mandible, often in posterior areas.areas.

Masses of irregular opacification are noted that Masses of irregular opacification are noted that are composed of dense, sclerotic bone, are composed of dense, sclerotic bone, cementum, or both.cementum, or both.



Diagnosis and TreatmentDiagnosis and Treatment Often diagnosed based on characteristic Often diagnosed based on characteristic

clinical presentation and radiographic clinical presentation and radiographic appearanceappearance

In an edentulous patient, the sclerotic masses In an edentulous patient, the sclerotic masses may perforate the mucosa.may perforate the mucosa.

This may lead to osteomyelitis, requiring This may lead to osteomyelitis, requiring surgery and antibiotics.surgery and antibiotics.


Fibrous DysplasiaFibrous Dysplasia

(pg. 279)(pg. 279) A disease characterized by replacement of bone A disease characterized by replacement of bone

with abnormal fibrous connective tissue with abnormal fibrous connective tissue interspersed with varying amounts of calcificationinterspersed with varying amounts of calcification

The cause is unknown.The cause is unknown. One theory is it may be due to abnormal mesenchymal One theory is it may be due to abnormal mesenchymal

cell function.cell function. Histologically, it is a benign fibro-osseous lesion, Histologically, it is a benign fibro-osseous lesion,

with vascularized, cellular fibrous connective with vascularized, cellular fibrous connective tissue interspersed with irregular trabeculae of tissue interspersed with irregular trabeculae of bone.bone.


Types of Fibrous DysplasiaTypes of Fibrous Dysplasia

Monostotic fibrous dysplasiaMonostotic fibrous dysplasia Polyostotic fibrous dysplasiaPolyostotic fibrous dysplasia


Monostotic Fibrous DysplasiaMonostotic Fibrous Dysplasia

(pg. 279)(pg. 279) Characterized by involvement of a single Characterized by involvement of a single

bonebone The maxilla is more frequently involved than The maxilla is more frequently involved than

the mandible.the mandible. Most commonly diagnosed in children and Most commonly diagnosed in children and

young adults with no sex predilectionyoung adults with no sex predilection Clinical examination reveals a painless Clinical examination reveals a painless

swelling or bulging of the buccal plate.swelling or bulging of the buccal plate.


Polyostotic Fibrous DysplasiaPolyostotic Fibrous Dysplasia

(pgs. 279-280)(pgs. 279-280) Characterized by involvement of more Characterized by involvement of more

than one bonethan one bone Typically occurs in children with a female Typically occurs in children with a female

predilectionpredilection When long bones are involved, they may When long bones are involved, they may

exhibit bowing and an associated dull aching exhibit bowing and an associated dull aching pain.pain.

Patients may have skin lesions appearing as Patients may have skin lesions appearing as light-brown macules called café au lait spots.light-brown macules called café au lait spots.


Polyostotic Fibrous Dysplasia Polyostotic Fibrous Dysplasia (cont.)(cont.)

There are several typesThere are several types Craniofacial fibrous dysplasiaCraniofacial fibrous dysplasia

• Involves the maxilla with extension into the sinuses Involves the maxilla with extension into the sinuses and adjacent zygoma, sphenoid, and occipital bonesand adjacent zygoma, sphenoid, and occipital bones

Jaffe typeJaffe type• Involves multiple bones along with café au lait Involves multiple bones along with café au lait

macules on the skinmacules on the skin Albright syndromeAlbright syndrome

• Characterized by endocrine abnormalities, precocious Characterized by endocrine abnormalities, precocious puberty in females, stunting or deformity of skeletal puberty in females, stunting or deformity of skeletal growth in both sexes as a result of premature closing growth in both sexes as a result of premature closing of the epiphyseal plates café au lait spotsof the epiphyseal plates café au lait spots



(pgs. 279-280)(pgs. 279-280) Clinical and radiographic featuresClinical and radiographic features

A painless enlargement of affected bone or A painless enlargement of affected bone or bonesbones

Typically, a painless, progressive, unilateral Typically, a painless, progressive, unilateral enlargement of the mandible or maxilla.enlargement of the mandible or maxilla.

The classic radiographic appearance is a The classic radiographic appearance is a diffuse radiopacity looking like “ground glass.”diffuse radiopacity looking like “ground glass.”



(pgs. 279-280)(pgs. 279-280) Diagnosis and treatmentDiagnosis and treatment

Characterized by cellular fibrous connective Characterized by cellular fibrous connective tissue interspersed with irregularly shaped tissue interspersed with irregularly shaped bony trabeculaebony trabeculae

In fibrous dysplasia, radiographic changes In fibrous dysplasia, radiographic changes blend into the surrounding normal bone.blend into the surrounding normal bone.

TreatmentTreatment Surgical recontouring of bone for cosmetic Surgical recontouring of bone for cosmetic

reasonsreasons


Paget Disease of Bone Paget Disease of Bone (Osteitis deformans)(Osteitis deformans)

(pgs. 280-281)(pgs. 280-281) A chronic metabolic bone diseaseA chronic metabolic bone disease

Characterized by resorption, osteoblastic Characterized by resorption, osteoblastic repair, and remineralization of involved bonerepair, and remineralization of involved bone

Unknown cause – may be due to a virusUnknown cause – may be due to a virus Most commonly occurs in men over age 50Most commonly occurs in men over age 50 The maxilla is more commonly affected than The maxilla is more commonly affected than

the mandible.the mandible.


Paget Disease of BonePaget Disease of Bone

(pgs. 280-281)(pgs. 280-281) Clinical and radiographic featuresClinical and radiographic features

Enlargement is common; the patient often Enlargement is common; the patient often complains of pain.complains of pain.

Spaces may increase between teeth as bone Spaces may increase between teeth as bone enlarges.enlarges.

RadiographicRadiographic A patchy radiolucency and radiopacity, “cotton A patchy radiolucency and radiopacity, “cotton

wool”wool” Hypercementosis, loss of lamina dura, and Hypercementosis, loss of lamina dura, and

obliteration of the periodontal ligament may obliteration of the periodontal ligament may occur.occur.


Paget Disease of Bone (cont.)Paget Disease of Bone (cont.)



(pgs. 280-281) (pgs. 280-281) Diagnosis and TreatmentDiagnosis and Treatment

The serum alkaline phosphatase level is The serum alkaline phosphatase level is significantly elevated in active disease.significantly elevated in active disease.

Histologic examination reveals bony trabeculae Histologic examination reveals bony trabeculae surfaced with numerous osteoclasts and surfaced with numerous osteoclasts and osteoblasts.osteoblasts.

Prominent reversal lines may create a pattern Prominent reversal lines may create a pattern known as mosaic bone.known as mosaic bone.

TreatmentTreatment Experimental; the disease is slowly progressiveExperimental; the disease is slowly progressive


Central Giant Cell Granuloma(Central Central Giant Cell Granuloma(Central Giant Cell Lesion)Giant Cell Lesion)

((pgs. 281-282)pgs. 281-282) Composed of well-vascularized connective Composed of well-vascularized connective

tissue containing many multinucleated giant tissue containing many multinucleated giant cellscells Occurs within boneOccurs within bone

A disease of bone that develops over a long A disease of bone that develops over a long period of timeperiod of time The result of calcium deficiencyThe result of calcium deficiency In young children, it is usually caused by a In young children, it is usually caused by a

deficiency of vitamin D.deficiency of vitamin D. In adults, it may be related to various health In adults, it may be related to various health

problems.problems.


Central Giant Cell Granuloma(Central Central Giant Cell Granuloma(Central Giant Cell Lesion) (cont.)Giant Cell Lesion) (cont.)


OsteomalaciaOsteomalacia

Clinical and radiographic featuresClinical and radiographic features May be associated with delayed tooth eruption May be associated with delayed tooth eruption

and periodontal diseaseand periodontal disease TreatmentTreatment

Based on identification of the causeBased on identification of the cause


Discussion Questions Discussion Questions

With what disease are “ground glass” and With what disease are “ground glass” and “fingerprint pattern” associated?“fingerprint pattern” associated?

What is Paget disease?What is Paget disease? What are the signs of osteomalacia?What are the signs of osteomalacia?

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