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Disorders of bone 2
Last time we start talking about fibro-osseous lesion we define it
histologically as replacement of normal bone by fibrous tissue with
woven bone deposition and island of a cellular mineralized tissue,
which is a generalized term of 3 different lesions
O histopathological appearance :(mainly the normal bone is
replaced with fibrous tissue)





1- Collagen fibers
2- Nucleus of fibroblast (these black dots )
3- Woven bone trabeculae ( irregular shaped ) which not mature
not lamellar but it may mature and be remodeled in lamella later
Classification of the lesions that show fibro-osseous lesions features :
1
3
2
- Fibrous dysplasia
B- Cement-osseous dysplasia
C- Ossifying fibroma or cement-ossifying fibroma

O so we can't differentiate between these lesion only by
histopathological examination we need radio graphical and
clinical information
Both ( B ) are osseous dysplasia
Osseous :bony dysplasia :disorganized form
so its abnormal structure of bone
C is true benign tumor that means it has other features like
continuous growth so it will not stop growing due to something wrong
in cell cycle routine continuous progressively growth but slowly
finaly but dysplasia may have quiescent periods of growing may
mature









Monostatic
Notice slide28
You can see diffuse enlargement (you can't see where it start
and where it ends ) of maxilla which is the most common
llbro osseous dysplasla of bone
olysLaLlc
SegmenLal lnvolvemenL of bone (malnly ln
long bone)
MonosLaLlc
Cne leslon ln one bone (lnvolve one bone)
Much more common
location in the jaws (more than mandible) especially posterior
part
This expansion is anteriorly posteriorly to maxillary sinus or
other bones of skull
O May press on the eye (the orbit)so cause protrusion of it out of
skull in case of quick expansion
O may extend buccaly more than palataly
O Presents in ribs and skull in general
O When it involves the maxilla and other bones of skull it called
Craniofacial fibrous dysplasia

t involves bone adjacent to orgin so it's not restrictedly
monostatic and not separated or segmented so it's not
restrictedly polystatic

Slide29
Expansion of buccal and anterior aspect (would be more
obvious anteriorly )

Slide30
The photo shows clinical examination, on operation time that
will be found, canine fossa (depression) is obliterated, bony
expansion (hard, diffuse, not well demarcated from surrounding
structure)
This operation is carried out for cosmetic, remodeling of bone
but not during period of active bone growth (as in teenagers) so
the treatment delays until growth rate decrease and active
phase slowdown

Slide40
Look at radio opaque area in maxilla or higher relative to the
opposite part (look above roots) maxillary sinus is obliterated in
one side (the affected) and not in the other

O Fibrous dysplasia dose not cross suture ( differentiating
feature) although it may involve several bones
O f mandible is involved (less common ) jaw width and depth will
increase and teeth in that quadrant may fail to erupt
O Radiougraphicly appearance is variable :
Fibrous predominate radiolucent
Woven bone start to form mixed
Woven bone is predominate radio opaque

Distinctive feature is ill defined fusion (due to continuous
expansion to surrounding structure or tissue

O With increasing trabuclation it will be mottled and eventually
opaque depending on amount of the structure
O More common in females

Polystatic
O More than one lesion separated or fragmented in long bones
O Found in several bones may be bilateral or unilateral(mainly)
O More in female may associated with syndrome (McCune-
lbright syndrome)its main features:
a- Caf au-lat spot skin pigmentation
b- Polystotic fibrous dysplasia
c- Precocious puberty and other hormone related changes
d- Oral ventilation pigmentation mainly in females

How to diagnose child come with pathological fractures,
multiple lesion ,
Monostatic diagnose not early until it reach certain size
(expansion of buccal aspect) it will stop then t may start
growing again
n radiographs you can see mottled continuous gradually fusion
with surrounding bone give orange peel pattern or ground
glass appearance
1- Normal bone
2- ffected bone






Normal bone have radiolucent area represent normal bone
marrow but in case of the lesion it will have woven bone fibrous
tissue
Histologically a lot of trabeculae , fibrous tissue, and woven
bone

n book >> there is difference of appearance of fibro osseous
lesion in jaw and from that present in other bones

Trabecule is larger and longer in jaws and maybe surrounded
by osetoplast (responsible for bone deposition) when become
incorporated with bone and stop deposition of bone it called
osetosite
Here you can see several osetosits in their lacunae in the
woven bone rarely seen rimming cells (cells removing particles)
in other bones

Typical picture:
n jaw active osteoplast elongate woven bone trabecule is
thicker blunter or spherical area
1
2
n other bone short small delicate Chinese characters irregular
appearance

n book in addition there is a cellular mineralized structure
thought to be cementum-like (will talk about later)
O With time amount of bone calcified tissue increase become
more opaque may associated with other bony lesion
aneuryismal bone cyst

#0202-07
neuryismal bone cyst may be primary due to trauma or
hemorrhage theory or secondary associated with other lesions

Etiology:
Developmental and mutation in GNS code for stimulatory protein
Time of occurrence of mutation affect number of lesions :
O Fetal polystatic
O Postnatal monostatic

Malignant transformation of cell reminant high mitotic activity
due to radiotherapy

ppearance of osetosarcoma have these features with
hyberkromatic ugly lesion
t was used to use radiotherapy to reduce the growth of the
lesion but it was discovered that it could induce
transformation to fibrosarcoma so it's not used now as
treatment ,instead surgery is used to reduce the size and
deformity


Cement- osseous dysplasia

occur only in the jaws not other bone (skull or long bones)
contains particles that looks like cementum(where the name
came)
There are 3 different types that differs clinically (features,
location and behavior) but the same histopathologically:
1- Periapical cemental dysplasia because it locates periapical
area of roots especially lower anterior region

2- Focal cemmento-ossouse dysplasia slightly bigger than
periapical but still focal


3- Florid cemmento-osseouse dysplasia bigger and more in
number may involve one quadrant (lower left part may be
obliterated)
Clinical considerations:
O Radiographically like fibroossouse radiolucent if it contains
lot of fibrous tissue, opaque if it's mainly bone , mix if it contains
moderate amount of bone
O More in common in women more in30s
O Mainly in mandible
Slide48
Periapical cemental dysplasia
Radiographs is important to distinguish it from fibroosseouse lesion
it's well defined
Slid49
Focal larger lesion radio opaque tissue separated from surrounding
tissue (well-defined)
Some times in focal or florid the separations not well seen (not
mostly)
Here it's focal not periapical its larger separated from the root by
radiolucent zone
What the significances:
O Dose not cause any problem to the patient may not enlarge
stay in the same size no pain
O Sometimes it enlarges cause bone expansion (not mostly )
O Bone is dense relatively avascular not many blood vessels
decrease blood supply prone to infections (any bacteria reach
cause osseomyelitis inflammation or infection of bone marrow
which serious problem -)
Take care
1- Treat caris
2- n extraction :don't allow entry of bacteria , bone is also prone
to fracture
Slide 50
cellular particles (like cement)
Radiougraphically opaque area separated from roots (if it was fused it
could be: hypercementosis rounded, plunted roots- , bony scar ,
condensing osteosclerosis, or kind of tumor)


Ossifying fibroma
True benign tumor will keep growing , increasing in size for ever if
untreated will cause bone expansion
Well demarcated encapsulated
Histopathologicaly:
O Chinese characters (smaller woven bone trabeculae )
O n the jaws more rounded and larger more osetoplasts rimming
the bone
O t's similar to fibrous dysplasia so its distinguished
radiougraphically
Slide54 ts rounded well defined radio opaque (higher amount of
woven bone) cause bone expansion(clinically)
n that histological picture we need radiograph for differential
diagnosis
Continuously enlarging no period of stoppage
O The most common location is sinonasal complex
O More in females
Slid56
Well defined relatively radiolucent encapsulated (removed easily not
in fragmented particles which differs from osseocemental lesions-
both well defined)
Sometimes it contains sand like particles (small mineralized acellular)
when predominate it called Pssmmomatoidoss
Slide 59
You can see oseosite , oseoplast (rimming the bone) but not
multinucleated giant cells (osetoclast)
Sand like mineralized particles may be cement like
Fibroma may be found in young adults here called Juveniles (usually
rapidly growing like osetosarcoma ):
1- Biopsy will show polymorphic (variation in shape)
2- Rich cellular mitotically active have immature woven bone
So take in consideration lesion location and age of patient to
differentiate it from sarcoma
May associated with hereditary hyperparathyroidism
490
Fibroma is in another chapter but doctor include it in the lecture to be
able to compare between fibro-osseous lesions


Cherubism
O nherited disorder in bone mutation in fibroblast growth factor
receptor
O n 2-4 years old child expansion occur of angels of mandible
O Radio graphically well defined multilocular cyst like lesion cause
expansion of angels of mandible spread anteriorly posieriorly
seen clinically in2-4 years old , after 7years old it starts to
mature and stop expansion and may start to decrease in size
especially after surgical operation that may take place for
cosmetic purposes
O Teeth may be loose and lost prematurely and permanent teeth
may not erupt (effect on dentition )
O Well defined cystic lesion may mature and start to deposit
woven bone so look like fibro-osseous lesion (not normal bone
but may become lamellar (mature) later)
O Due to expansion tissue of maxilla will be stretched and white
sclera will be seen below the pupil that called heaven lookup
appearance like angels
O Lymph node may had reactive hyperplasia so adding to the
fullness of the face after maturation cosmetic surgery maybe
done
O thinning of cortices may occur and may perforated
O Cortices compact bone at peripheries surrounded the bone but
bone marrow have spaces
Histopatholgy giant cell lesion (histopatholigical term not confined to
certain lesion)
Slide 69 may be cherubism or other (such as hyperparathyroidism)
O Healing by metaplastic bone deposition


Hyperparathyroidism
Giant cell lesion
ts causes:
Primary (no other stimulation) tumor adenoma- , hyperplasia of the
gland
Secondary
Function of the hormone:
Maintain ca level , increase ca level by : 1-increase absorption in
intestine 2- decrease secretion in renal tubules 3-resorption of
bone to release ca
Osetoclast working Resorption (leaving spaces will occupied
by fibrous tissue)
Pic in slid 75
Multinucleated cells within fibrous stroma that is very vascular you
can see blood vessels and hemosedrine (yellowish to brown so it's
called brown tumor the color- ) caused by RBC destroying

Read slid72
Renal colic's due to stones that caused by deposition of elevated Ca
level . Deposition happen in two ways :
1- Metastic calcification : ca will precipitate everywhere because
its level in the blood is high
2- Dystrophic calcification: not related to elevated ca level happen
in inflammenad tissue
Secondary :Decrease in ca level so body stimulate parathyrodisim to
resorpe more bone and release ca and decrease secretion in the
kidney, if it was excessive later on bone cystic-like lesion may
appear radio graphically
f biopsy taken we will see fibrous tissue bone trabeculae
multinucleated giant cells (like osetoclast ) and small capillaries
Biopsy similar in both Cheurbism and Hyperparathyroidism so note
the age churisum dose not happen in adults so 30years old with that
clinical appearance most likely he have hyperparathyroidism if the
hormone is normal then central giant cell granuloma
Slide 83 contain different diagnosis of giant cell lesion
Giant cell granuloma is well or ill-defined radiolucent area its benign
not tumor may be aggressive (most likely if it was ill-defined, well
defined is usually not aggressive) or not mainly in mandible in
anterior to molar region
See slide88
More or less ill-defined so it needs more aggressive treatment to
reduce recurrence (remove remnant tissue)
O Slowly or rapid growth or symptomless with no expansion
swilling
Patient came with expansion in the mental area and may perforate
the cortices and high recurrence most lesions is well defined and not
aggressive
O Surround roots so may displaced or resorped

Histopathologically 1- multinucleated giant cell (where the arrow
pointing to) 2- fibrous tissue note fibroblast cell( the small arrow) 3-
blood vessels
Brown tumor is soft tissue giant cell lesion close to peristenum we
need to exclude hyperparathyroidism by level of the hormone before
diagnosis of central giant cell granuloma
Tumor of bone
The Only true rare in jaw in( long bone) , need aggressive treatment
high recurrence could make metastasis in10%of the cases
THE END
Done by :
Mai Jamal lhmouze
ny intelligent fool can make things bigger
,more complex , and more violent but it
takes a touch of genius and a lot of
courage to move in the opposite direction