NON ODONTOGENIC

TUMOURS OF JAW

PRESENTED BY-
MUSKAN ARORA
MDS 1ST YEAR
DEPTT. OF ORAL AND MAXILLOFACIAL SURGERY
 CONTENTS
1) Neoplasm
2) Tumour
3) Non odontogenic tumour
4)

NEOPLASM
  It can be defined as an abnormal mass of tissue, the growth of which exceeds and is
uncoordinated with that of the normal tissues and persists in the same excessive
manner after cessation of the stimuli which has evoked the change.
- (Willis 1952).
 Tumor or neoplasm is an abnormal new, uncoordinated growth in the body, which
results from excessive, autonomous, purposeless proliferation of cells, which
continues its growth, even after cessation of stimuli
-Malik 4th edition
TUMOR
 The word TUMOR – Means swelling .
 An abnormal benign or malignant new growth of tissue that possesses no
physiological function and arises from uncontrolled usually rapid cellular
proliferation – called also neoplasm
BY NCI DICTIONARY OF CANCER TERMS

NON ODONTOGENIC TUMOUR

The benign jaw tumors are divided into two broad categories:
1. Odontogenic tumors
2. Non-odontogenic tumors

ODONTOGENIC TUMORS:
A group of neoplasm or tumor like malformations arising from cells of odontogenic
apparatus or their remnants. The abnormal tissue in each of these tumors often can be
correlated with similar tissue in normal odontogenesis.

NON ODONTOGENIC TUMORS-

Develop from epithelium/mesenchyme of wide variety of tissues in the body, often originate
in non-tooth bearing facial bones.
WHO CLASSIFICATION OF NON ODONTOGENIC JAW TUMORS 1992-

I. Osteogenic Neoplasms
Cemento- ossifying fibroma
II. Non neoplastic bone lesion
1. Fibrous dysplasia of jaws
2. Cemento-osseous dysplasias
a. Periapical cemento-osseous dysplasia
b. Focal cemento osseous dysplasia
c. Florid cemento-osseous dysplasia (gigantiform)
III. Other Cemento-Osseous Dysplasias
a) cherubism
b) Central giant cell granuloma

Source- Kramer IR, Pindborg JJ, Shear M

The WHO histological Typing of Odontogenic Tumours. A commentary on the Second
Edition. Cancer. 1992;70(12):2988-94.

WHO CLASSIFICATION 2005

1) BENIGN

-Ossifying Fibroma
-Osteoma
-Osteoid osteoma
-Osteo-blastoma
-Chondroma
-Chondromyxoid fibroma
-Melanotic neuro ectodermal tumour of infancy

2) Malignant tumors
A) Osteosarcoma
B) Fibrosarcoma
C) Ewing’s sarcoma
D) Chondrosarcoma
E) Kaposi sarcoma
F) Hodgkin’s lymphoma
G) Non-Hodgkin’s lymphoma

3) FIBROOSSEOUS LESIONS
a) Fibrous dysplasia
b) Cemento-ossoeus dysplasia:
- periapical cemental dysplasia
- florid cemento-osseous dysplasia
- focal cemento-osseous dysplasia
c) Cherubism
d) Central giant cell granuloma
e) tori, exostosis

CLASSIFICATION ACC TO ORIGIN-

A. Giant cell lesion
 • Giant cell reparative granuloma
• Brown tumour of hyperparathyroidism
• Cherubism
B. Vascular
• Vascular tumour
• Vascular malformation
C. Hematopoietic reticulo-endothelial
• Eosinophilic granuloma
• Hand- schuller-Christian disease
• Letterer-siwe disease
D. Neurogenic
• Neurofibroma
• Schwannoma

NON-ODONTOGENIC TUMOURS AND FIBRO OSSEOUS LESIONS OF

JAW BONES

A. Non- odontogenic tumours

1. central fibroma
2. Myxofibroma
3. Ossifying fibroma
4. Osteoma
5. Osteoid osteoma
6. Benign osteoblastoma
7. Chondroma
8. Giant cell granuloma
9. Central hemangioma
10. Benign tumours of nerve tissue.
B. Fibro-osseous lesions
1. Fibrous dysplasia of bone
2. Cherubism
3. Ossifying fibroma
4. Central giant cell granuloma

-Malik 4th edition

OSSIFYING FIBROMA

 The lesion previously termed as cementifying fibroma was considered earlier as

odontogenic tumour .
 Montgomery 1927
Origin: Ossifying fibroma is a benign lesion arising from undifferentiated cells of the
periodontal ligament
Age: Third and fourth decades of life
Sex: A definite female predominance with female to male ratio—5:1
Site: Mandible is the most common site—premolar molar area. Maxilla— common site—
posterior maxilla
Signs and symptoms:
 Small lesions are symptomless and detected on radiological examination.
 Larger lesions are painless, slow, but persistently growing swelling of the involved
bone, often causing facial asymmetry
 Gradual expansion and thinning of the buccal and lingual cortical plates is seen
 Clinically, it presents as a slowly enlarging and progressive swelling
Radiologically:
 Well circumscribed lesion with sharply defined border between the lesion and
adjacent normal bone.
 Most often it shows unilocular radiolucency, but varying degrees of radiopacity can
be seen.
 As the lesion enlarges, it may displace the adjacent teeth and less commonly, cause
resorption of the roots.
 Large ossifying fibroma of the mandible, often may demonstrate a typical
downwards bowing of the inferior cortex of the mandible.

Histopathology:
 It may show a fibrous capsule surrounding a tumor
 The tumor consists of a collagenous stroma, containing variable numbers of uniform
spindled on stellate cells.
 The feature which distinguishes ossifying fibroma from fibrous dysplasia is the focal
presence of osteoblasts along the surface of the bone deposits.

Two types of calcifications are commonly seen—

(1) In the form of trabeculae of osteoid and bone
(2) basophilic ovoid calcifications that resemble cementum like material.

Management:
 As the lesion is well demarcated from the surrounding bone, it permits relatively
easy separation in one piece or in several large pieces.
 Intraoral approach by enucleation is the preferred method.
 More extensive lesion may require resection and bone grafting.
 Recurrence is not seen.
Types
1) Ossifying / cementifying fibroma
2) Juvenile ossifying fibroma
3) Trabecular juvenile ossifying fibroma
4) Psammatoid juvenile ossifying fibroma
5) Gigantiform cementoma

JUVENILE OSSIFYING FIBROMA

- It is described in the literature under various terms as juvenile active ossifying fibroma,
aggressive psammomatoid ossifying fibroma.
-The World Health Organization defines juvenile aggressive ossifying fibroma as “an
actively growing lesion mainly affecting individuals below the age of 15 years, which is
composed of a cell-rich fibrous tissue containing bands of cellular osteoid without
osteoblastic rimming together with trabeculae of more typical woven bone. Small foci of
giant cells may be present, and in some parts there may be abundant osteoclasts related to
the woven bone.

-It is distinguished from the standard ossifying fibroma on the basis of occurrence in a
younger age group, tendency to occur in different anatomic sites and aggressive clinical
behaviour

 Age: Most commonly seen below the age of 15 years

 Site: Orbital, frontal and ethmoid bones are most frequently involved. The maxilla,
paranasal sinuses are more frequently involved than mandible
 Signs and symptoms: Some tumors show rapid progressive growth and enlargement
with expansion and thinning of the adjacent cortical bone and invasion of adjacent
tissue.
 Common clinical symptoms include proptosis, exophthalmos, visual disturbances,
nasal obstruction and facial asymmetry

Radiographically:

 Variable features, depending on the location and the amount of calcified tissue.
 A destructive, expansile lesion often with well demarcated
borders, but it may demonstrate invasion and erosion of the surrounding
bone.
 Varying degrees of radiolucency and opacity may be seen depending on the degree
of mineralization.

Treatment and prognosis:

 Recurrence rate is reported as 30–58%.
 Complete surgical excision is mandatory.
 Small accessible lesions are treated with enucleation or peripheral osteotomy.
 Large lesions require en bloc resection.

OSTEOMA
 Osteomas are benign tumors composed of mature compact or cancellous bone.
 These are essentially restricted to cranio-facial skeleton and rarely are diagnosed in
other bones.
 TYPES-
1) Peripheral osteoma- sessile mass
2) Endosteal osteoma – within medullary bone
 AGE- Detected in young adults. 2nd to 5th decades
 -Signs and symptoms:
 Periosteal osteoma presents as a slow growing, asymptomatic bony hard masses.
 The lesion may arise in the maxilla or mandible, especially at the angle of the
mandible and lingual aspect of the mandible in premolar/molar area.
 An osteoma involving the mandibular condyle may cause a slow progressive shift in
the patient’s occlusion with deviation of the midline of the chin towards the
unaffected side.
 Small endosteal osteomas are asymptomatic, but large lesions cause progressive
enlargement of the affected area.
 Lesions within the paranasal sinuses may develop symptoms like sinusitis,
headaches, ophthalmological problems

 Radiographically
 well circumscribed, densely sclerotic, radiopaque masses.
 Periosteal osteoma may show a uniform sclerotic pattern at the periphery with a
central trabecular pattern

Histopathologically:
 Two varieties are seen.
(1) Compact osteoma— composed of dense, compact bone with sparse marrow
tissue. The bone is mature
and lamellar with osteomas and haversian canals;
(2) Cancellous osteomas— composed of lamellar trabeculae of cancellous bone and
fibro fatty marrow.
Osteoblastic activity may be fairly prominent

Treatment:
 Conservative surgical excision is done.
 larger osteomas of the mandibular body causing symptoms or cosmetic deformity
are treated by conservative surgical excision.
 Small asymptomatic osteomas particularly those located endosteally probably do not
need to be treated but should be observed periodically.
 Because of the frequency of associated symptoms osteomas arising in the condyle
are usually removed surgically.
 Large lesions mandate condylectomy whereas peripheral osteomas are treated by
local resection.
 Osteomas are completely benign and patients do not experience malignant change
or recurrences after excision
 Osteotome may be used to separate the periosteal osteoma from the attachment of
the underlying bone.

Gardner syndrome and osteoma-

 Autosomal dominant disorder .

 The most common clinical manifestations
are—
o multiple adenomatous polyps of the colon and rectum
o multiple osteomas,
o dermal and mesenteric fibrous tumors (fibroma)
o multiple odontomas
o Epidermal and trichilemmal cysts
o dermoid fibrous tumors of skin.
- The responsible gene has been mapped to chromosome 5.
 The presence of mutiple osteomas of the facial bones is an important early marker
for this syndrome.
 Dental abnormalities such as impacted permanent and supernumerary teeth and
odontomas may be present in addition to osteomas
 The most important feature of the Gardner’s syndrome is the association of multiple
colonic polyps with sebaceous cysts and jaw osteomas

OSTEOBLASTOMA

 First described under the name “giant osteoid osteoma” by Dahlin and
Johnson 1954
 Presently accepted term “benign osteoblastoma” -> Jaffe and Lichtenstein
1956.
 Osteoblastoma is a benign neoplasm of bone that arises from osteoblasts.
 The features of this tumor closely resemble those present in the
cementoblastoma.
 The osteoblastoma-
 grows rapidly
 Predominant clinical feature -pain which is generally localized to the lesion
itself.
 AGE-second decade (rarely occur after 30 years).
 SEX-Males appear to be affected more commonly than females.
 SITE-mandible most common in head and neck
 SIZE- greater than 2 cm in diameter
 Clinically swelling with or without cortical expansion is noticed, may be of few
weeks duration or few years duration. Associated teeth may be mobile
Radiographically-
 Mixed radiolucency and radiopacity
 The designation osteoblastoma is normally reserved for lesions > 2 cm in diameter.
 They are well circumscribed radiographically with a thin radiolucency surrounding
the variably calcified contents.
 A sunray pattern of new bone formation – Intramedullary lesion

 Histologically-
 Irregular trabeculae of osteoid and immature bone within a predominantly vascular
stromal network.
 various degrees of calcification present.
 Small and slender Stromal cells
  Differentiatial Diagnosis-
I. ossifying fibroma
II. fibrous dysplasia
III. osteosarcoma.

 Treatment-
 Conservative surgical excision either with curettage or local excision.
 Recurrences are rare but If occurs , need to go for more aggressive treatment - en
bloc resection.

OSTEOID OSTEOMA

 First described by Henry Jaffe 1925

 It represents a smaller version of the osteoblastoma
 It is normally < 2 cm in diameter clinically and radiographically.
 AGE- second and third decades of life
 SEX-male predominance.
 C/F-Pain is the major clinical feature.
 NATURE -Classically, the pain is worse at night and is relieved by acetylsalicylic acid
 Radiographically the lesion again shows a welldefined mixed
radiolucency/radiopacity with a small radiolucent rim around the lesion, which is
walled by sclerotic bone.
 Histologically it resembles the osteoblastoma with a rich vascular stroma with
trabeculae of osteoid and immature bone.
 The bone is rimmed by layers of active osteoblasts.
 Treatment - conservative surgical excision. Spontaneous regression has also been
reported clinically.

JAFFE’S CRETERIA FOR OSTEOID OSTEOMA

 The lesion is a benign neoplasm

 It forms large amounts of osteoid which became calcified.
 There was little evidence to suggest that the lesion was an inflammatory process
 Lesion most frequently seen in young adults
 There were characteristic x ray changes- focal rarefaction, reactive bone
 Pain is an outstanding feature
 Complete removal is treatment of choice
-Journal of Oral And Maxillofacial Pathology volume issue 2, 2008.

PAIN IN OSTEOID OSTEOMA –

• SHERMAN ET AL demonstrated nerve fibres in fibrous zone around nidus and
implicated them as mediators of pain
• GOLDING believed that the marked vascular elements were responsible for both
pain and osseous reaction
• JAFFE regarded the curious pain seen in osteoid osteoma as being attributable to
the arteriolar blood supply to the lesion
 -Journal of Oral And Maxillofacial pathology volume 3 issue 2, July
2007

CHONDROMA

 It is a benign tumor of mature cartilage.

 They presents as a painless slowly progressive swelling, which may result in mucosal
ulceration.
 No gender predilection
 AGE – mainly in 50 years.
 Radiographically-
o they present as irregular radiolucent lesions
o Resorption of tooth roots
 Histologically-
o The lesions contain well defined lobules of mature hyaline cartilage.
 Treatment-
o Localized- conservative surgical excision is normally recommended

OSTEOCHONDROMA
 Also known as osteo-cartilagenous exostosis
 Regarded as the most common benign tumor of bones in the body (1/3 of benign
bony tumors).
 Rarely, it occur in jaws
 It is not a true neoplasm, but thought to represent developmental or
hemartomatous process of bone.
 It forms as an exophytic growth from the surface of the affected bone.
 In the jaw bone mandibular condyle, coronoid process, symphysis, zygomatic arch,
posterior
 maxilla may be involved.
 Asymptomatic, bony hard swelling.
 Involvement of the mandibular condyle may produce unilateral posterior open bite,
chin deviation away from the
 affected side with facial asymmetry or bowing of ramus.
Radiographs:
 Show a sessile or pedunculated lesion that is continuous with the adjacent cortex
and underlying medullary bone.
 The bony portion of the lesion shows a central trabecular pattern with well-defined
radiopacity.
 The cartilaginous superficial aspect is less well mineralized.
Histopathology:
 The surface is composed of a moderately cellular, hyaline cartilage cap covered by a
thin, fibrous
perichondrium.
 The deep layer of cartilage exhibits endochondral ossification with deposition of
woven
bone on mineralized cartilage.
 Treatment:
 Complete conservative surgical excision is done.
 Recurrence is not reported.

CHONDROMYXOID FIBROMA
 The chondromyxoid fibroma is an uncommon benign tumor
of cartilage derivation first described as an entity in 1946 by
Jaffe and Lichtenstein.
Clinical Features.
 This central bone tumor has a predilection for occurrence in young persons,
approximately 75% of patients being under the age of 25 years.
 There is no definite gender predilection.
 The majority of cases occur in long bones
 Pain is the outstanding clinical characteristics of the lesion.
 Evident swelling is uncommon but does occur.
Histologic Features.
 This tumor characteristically exhibits lobulated myxomatous areas, fibrous areas and
areas having a chondroid appearance, i.e. cells resembling chondroblasts and
chondrocytes in lacunae in a chondroid matrix.
 In addition, foci of calcification are sometimes found.
Treatment.
 Conservative surgical excision is the preferred treatment for this benign tumor.
 However, recurrence of this tumor in other bones is not uncommon, particularly in
young patients in whom the lesions appear to act somewhat more aggressively.

OSTEOSARCOMA
 Osteosarcoma is the third most common cancer in adolescence
 It is thought to arise from a primitive Mesenchymal bone-forming cell and is
characterized by production of osteoid.
 Clinical Features-
 Can occur in any bone.
 It most commonly occurs in the long bones of the extremities near metaphyseal
growth plates.
 SITE- skull or jaw 8%
 SEX- Males : females (1.25: 1)
 AGE-chiefly in young persons(10–25 years )
 Swelling and pain, particularly with activity of the involved bone, are the early
features of the neoplasm.
 Patients may complain of a sprain, arthritis, or so-called grawing pain

FEATURES-
 Three classic features of osteosarcoma are:
1) Small streaks of bone radiate outward from approximately 25% of these tumors. This
produces a sunray (sunburst) pattern.
2) This tumor may grow within the periodontal membrane space causing resorption of
the adjacent bone resulting in uniform widening of the space.
  Widening of the periodontal membrane space may also be seen in other conditions
such as chondrosarcoma and scleroderma, and so it is not pathognomonic.
3) In the long bones affected with osteosarcoma, the periosteum is elevated over the
expanding tumor mass in a tentlike fashion.
 At the point on the bone where the periosteum begins to merge (edge of the tent),
an acute angle between the bone surface and the periosteum is created.
 This is called Codman’s triangle and is highly suspicious for osteosarcoma.
RADIOGRAPHIC FEATURES
The radiographic appearance is variable and depends on the amount of tumor bone
synthesized by the malignant osteoblasts.
 In those tumors with little tumor bone, the radiographic appearance will be
radiolucent; whereas those tumors with much tumor bone will be radiodense.
 Mixed lucent-dense lesions indicate an intermediate degree of tumor bone
formation.
 Cumulus cloud densities form within the intramedullary and soft tissue components
caused by mineralizing tumor osteoid

TREATMENT
 Long bone involvement-> amputation is a prime requisite.
 Neoplasms in jaws->radical resection, but, here it is difficult to perform adequate
and complete excision.
 Neoadjuvant (preoperative) chemotherapy has been found to facilitate subsequent
surgical
removal by shrinking the tumor.
 More recently, adjuvant chemotherapy in combination with surgery, including
resection
of pulmonary metastases, has appeared to offer promise of increased survival from
this disease.
 The prognosis depends considerably upon the condition of the patient and the
duration of the lesion
when treatment is instituted.

FIBRO-OSSEOUS LESIONS
 Fibro-osseous lesions refer to as collection of non-neoplastic intra-osseous lesions
that replace normal bone consist of cellular fibrous connective tissue within which
non functional osseous structure form.
- EVERSOLE
  Fibro-osseous lesions are diverse group of processes that are characterised by
replacement of normal bone by fibrous tissue containing a newly formed mineralised
product.
-NEVIELLE
WALDRON MODIFIED CLASSIFICATION OF FIBROOSSEOUS LESION OF JAW
1) Fibrous dysplasia
2) Cement-osseous dysplasia
a) Periapical cemento osseous dysplasia
b) Focal cemento osseous dysplasia
c) Florid cemento osseous dysplasia
3) Fibro-osseous Neoplasm
a) Cementifying fibroma
b) Ossifying fibroma
c) Cemento ossifying fibroma
WHO CLASSIFICATION OF FIBROOSSEOUS LESION OF JAW 2005
1) Ossifying fibroma
2) Fibrous dysplasia
3)Osseous dysplasia
a) Periapical osseous dysplasia
b) Focal osseous dysplasia
c) Florid osseous dysplasia
d) Familial giagantiform cementoma
4)Central giant cell granuloma
5) Cherubism
6) Aneurysmal bone cyst
7) Solitary bone cyst

PAUL M.SPEIGHT AND ROMAN CARLOS CLASSIFICATION 2006

1) Fibrous dysplasia
 a) Monostotic fibrous dysplasia
b) Polyostotic fibrous dysplasia
c) Craniofacial fibrous dysplasia
2) Osseous dysplasia
a) Periapical osseous dysplasia
b) Focal osseous dysplasia
c) Florid osseous dyplasia
d) Familial gigantiform cementoma
3) Ossifying fibroma
a) Conventional ossifying fibroma
b) Juvenile trabecular ossifying fibroma

c) Juvenile psammomatoid ossifying fibroma

FIBROUS DYSPLASIA
 first described by Von Recklinghausen in 1891
 1938, Lichtenstein introduced the term fibrous dysplasia.
 Fibrous dysplasia is a skeletal developmental anomaly of the bone-forming
mesenchyme that manifests as a defect in osteoblastic differentiation and
maturation.
 It is a nonhereditary disorder of unknown cause.
PATHOPHYSIOLOGY
 Developmental tumour like lesion characterized by repalcemnet of normal bone by
an excessive proliferation of cellular fibrous connective tissue mixed with irregular
bone trabeculae.
 FD is a condition that results from a mutation in GNAS1 gene.
 The clinical severity of this condition depends upon the time of GNAS1 mutation
occurrence during foetal or postnatal life.
TYPES-
The following three disease patterns are recognized:
1. Monostotic form
2. Polyostotic form
3. Craniofacial form.
MONOSTOTIC FIBROUS DYSPLASIA-

 About 70% to 85% of patients with fibrous dysplasia have disease limited to a single
bone
 Monostotic fibrous dysplasia is diagnosed most often during the second and third
decades of life.
 Males and females are affected with about equal frequency.
 Commonly involved sites include the craniofacial bones, ribs, femur, and tibia.
 Among cases involving the jaws, the maxilla is affected more often than the
mandible.
 There is a predilection for the posterior region.
 Although mandibular lesions are truly monostotic, maxillary lesions often extend to
involve adjacent bones (e.g., zygoma, sphenoid, ethmoid, frontal bone, temporal
bone, occiput)—in which case the term craniofacial fibrous dysplasia is appropriate.
 Painless, unilateral swelling is the most common clinical finding
 Adjacent teeth may be displaced by the bony mass but usually remain firm.
RADIOGRAPHIC FINDING-
 The classic radiographic finding is a fine “ground-glass” opacification with poorly
defined margins
 However, some lesions may appear radiolucent or mixed radiolucent-radiopaque.
 Mandibular lesions often exhibit buccolingual expansion and bulging of the inferior
border.
 There may be superior displacement of the inferior alveolar canal.

POLYOSTOTIC FIBROUS DYSPLASIA

 Involvement of two or more bones.
 Most of the patients are diagnosed before 10 years of age
 Female predilection
 A small subset of patients may exhibit polyostotic fibrous dysplasia in association
with the following syndromes:
• Jaffe-Lichtenstein syndrome, characterized by Polyostotic fibrous dysplasia and café au
lait (coffee with milk) pigmentation
• McCune-Albright syndrome, characterized by Polyostotic fibrous dysplasia, café au lait
pigmentation, and multiple endocrinopathies
• Mazabraud syndrome, characterized by fibrous dysplasia and intramuscular myxomas
TREATMENT
 Fibrous dysplasia tends to stabilize upon skeletal maturation,
and spontaneous regression even has been reported in a few cases. Therefore, conservative
management is preferred.
 The risk for severe deformity and complications is particularly elevated among
patients with widespread polyostotic fibrous dysplasia—especially in the Setting of
McCune-Albright syndrome with uncontrolled growth hormone excess.
 Combined orthodontic treatment and orthognathic surgery may be performed to
correct malocclusion.
 Radiation therapy is contraindicated because of the risk for postirradiation bone
sarcoma
 CEMENTO OSSEOUS DYSPLASIA
 It occurs in the tooth-bearing areas of the jaws and is probably the most common
fibro-osseous lesion encountered in clinical practice.
 Because the histopathologic features share many similarities with fibrous dysplasia
and ossifying fibroma, correct diagnosis can be problematic but is critical for
appropriate management.
 Based on clinical and radiographic features, cementoosseous dysplasia includes the
following variants:
(1) focal
(2) periapical
(3) florid.
FOCAL CEMENTO OSSEOUS DYSPLASIA
 It involves a single site.
 occur in females, with an approximate mean age of 41 years and a predilection for
the third to sixth decades.
 The disease typically is asymptomatic and is detected incidentally by radiographic
examination.
 Most lesions are smaller than 1.5 cm in diameter.
 Radiographically, the lesion varies from completely radiolucent to densely
radiopaque with a thin peripheral radiolucent rim.
 Most commonly, however, there is mixed radiolucent and radiopaque pattern
PERIAPICAL CEMENTO OSSEOUS DYSPLASIA
 Asymptomatic set of lesions tht form around the apex of mostly mandibular, vital
anterior teeth
 SEX- black women of African heritage
 AGE- mostly around 40 years
 Usually an incidental radiographic finding because these lesiions do notinduce tooth
mobility or bony expansion
 Radiolucent to mixed radiolucent –radiopaque to completely radiopaque without a
change in root structure or tooth vitality
FLORID CEMENTO OSSEOUS DYSPLASIA

 It exhibits multifocal involvement not limited to the anterior mandible.

 Although many cases affect only the posterior portions of the
jaws, synchronous involvement of the anterior mandible may be observed as well
 predominantly affects black females
 Asymptomatic dysmorphic bone-cementum complexes.
 It refers to as set of radiolucent- radiopaque periapical and interradicular lesions
involving the mandible bilaterally and sometimes the maxilla

CHERUBISM
  Cherubism is a rare developmental jaw condition that can be inherited as an
autosomal dominant trait with variable expressivity.
 Most cases are caused by gain-of-function mutations in the SH3BP2 gene on
chromosome 4p16.
 The name cherubism was applied to this condition because the facial appearance is
similar to that of the plump cheeked little angels (cherubs) depicted in Renaissance
paintings.
 Although cherubism also has been called familial fibrous dysplasia, this term should
be avoided because cherubism has no relationship to fibrous dysplasia of bone.

CLINICAL FEATURES-
 AGE- 2 to 5 years of age
 The clinical alterations typically progress until puberty, then stabilize and slowly
regress.
 The plump, cherub-like cheeks result from painless, bilaterally symmetric expansion
of the posterior mandible
 In severe cases, involvement of the inferior and/or lateral orbital walls may tilt the
eyeballs upward and retract the lower eyelid, thereby exposing the sclera below the
iris to produce an “eyes upturned to heaven” appearance.

JAW INVOLVEMENT-

 In the mandible, lesions frequently develop in the angles, ascending rami, and
coronoid processes, but the condyles usually are spared.
 In severe cases, most of the mandible is affected.
 Involvement of the maxillary tuberosities or entire maxilla also is possible, and there
may be a V-shaped palatal arch.
 Extensive jaw involvement causes marked widening and distortion of the alveolar
ridges.
 In addition to aesthetic compromise, the lesions may cause tooth displacement,
tooth mobility, failure of tooth eruption, impaired mastication, speech difficulties,
upper airway obstruction, and vision or hearing loss.

RADIOGRAPHIC FEATURES-
 Typically shows bilateral, multilocular, expansile radiolucencies
 Less commonly, the lesions may appear unilocular.
 Resorption of adjacent tooth roots and thinning or perforation of the cortical bone.

TREATMENT-
 In most instances, the lesions regress spontaneously after puberty.
 By the fourth decade, the facial features of most patients approach normalcy
 Because most cases regress over time, a conservative treatment approach generally
is preferred.
 Mild cases may require only observation.
 However, treatment typically is indicated for patients with aggressive lesions, severe
functional impairment, or marked facial deformity.
  Surgical intervention may consist of curettage, recontouring, partial resection, or
complete resection. The surgical defects may be filled with autogenous cancellous
bone and bone marrow grafts.
 Generally, it is preferable to delay surgery until the disease has become quiescent,
although severe aesthetic and functional compromise may demand earlier
intervention
 Dental management may include extraction or orthodontic extrusion of impacted
teeth; orthodontics for malocclusion; and prostheses for missing teeth.
 Placement of dental implants and auto transplantation of teeth also have been
reported in a few cases

CENTRAL GIANT CELL GRANULOMA

 Central giant cell granuloma is a condition of unknown aetiology.
 It has been suggested that it could be a reaction to some form of haemodynamic
disturbance in bone marrow perhaps associated with trauma and haemorrhage.
 According to World Health Organization classification, CGCG is defined as “an
intraosseous lesion consisting of more or less fibrous tissue containing multiple foci
of hemorrhage, aggregates of multinucleated giant cells, some amount of trabeculae
of woven bone forming within the septa of more mature fibrous tissue that may
traverse the lesion.”
 This condition may occur at any age but presents most frequently in the second and
third decades.
 There is a female predominance.
 Involves the mandible more frequently than the maxilla and
most arise in the anterior part of the jaws.
 The lesion clinically presents as a swelling of the bone, and growth may sometimes
be rapid.
 Radiographically, the lesion appears as a well-defined radiolucent area with thinning,
expansion, and, occasionally, perforation of the cortex.
 Involved teeth may be displaced and their roots may show resorption
 Histological examination shows large numbers of multinucleate,
osteoclast-like giant cells lying in a vascular stroma which is rich in small, spindle-shaped
cells
 The giant cells may be arranged in focal aggregates or be scattered throughout the
lesion
 Foci of extravasated erythrocytes and granules of haemosiderin pigment are
common in stroma.
TREATMENT
 Curettage, segmental resection
 Intralesional steroids –younger patients , very large lesion
 Individualized treatment depending on characteristic and tumor location
 TORUS PALATINUS

 The torus palatinus is a common exostosis that occurs in the midline of the vault of
the hard palate.
 presents as a bony hard mass that arises along the midline suture of the hard palate
CLASSIFIED according to their morphologic appearance:
-The flat torus has a broad base and a slightly convex, smooth surface. It extends
symmetrically onto both sides, of the midline raphe.
-The spindle torus has a midline ridge along the palatal raphe. A median groove is
sometimes present.
-The nodular torus arises as multiple protuberances, each with an individual base. These
protuberances may coalesce, forming grooves between them.
-The lobular torus is also a multilobulated mass, but it rises from a single base. Lobular tori
can be either sessile or pedunculated.

 The torus palatinus usually does not appear on routine dental radiographs. Rarely, it
may be seen as a radiopacity on periapical films if the film is placed behind the torus
when the radiograph is taken.
TREATMENT
 Most palatal tori can be diagnosed clinically based on their characteristic
appearance; therefore biopsy rarely is necessary.
 In edentulous patients, the torus may need to be removed surgically to
accommodate a denture base.
 Surgical removal also may be indicated for palatal tori that repeatedly become
ulcerated or that interfere with oral function.

TORUS MANDIBULARIS
The torus mandibularis is a common exostosis that develops along the lingual aspect of the
mandible.
 The mandibular torus presents as a bony protuberance along the lingual aspect of
the mandible above the mylohyoid Line in the region of the premolars
 Bilateral involvement occurs in more than 90% of cases.
 Most mandibular tori occur as single nodules, although multiple lobules paralleling
the teeth are not unusual.
 Patients often are unaware of their presence unless the overlying mucosa becomes
ulcerated secondary to trauma.
 A large mandibular torus may appear on periapical radiographs as a radiopacity
superimposed on the roots of the teeth
 Mandibular tori are easily visualized on occlusal radiographs.
TREATMENT
Most mandibular tori are easily diagnosed clinically, and no treatment is necessary.
However, surgical removal may be required to accommodate a lower full or partial denture.
Occasionally, tori may recur if teeth are still present in the area
 EXOSTOSES
 Exostoses are localized bony protuberances that arise from the cortical plate.
 These benign growths frequently affect the jaws and may be related to stresses
placed on the bone from the function of teeth.
 Exostoses are discovered most often in adults.
 Buccal exostoses occur as a bilateral row of bony hard nodules along the facial
aspect of the maxillary and/or mandibular alveolar ridge. They usually are
asymptomatic, unless the thin overlying mucosa becomes ulcerated from trauma.
 Palatal exostoses (palatal tubercles) are similar bony protuberances that develop
from the lingual aspect of the maxillary tuberosities. These lesions usually are
bilateral but may affect only one side They are more common in males
 Many patients with buccal or palatal exostoses also will have palatal or mandibular
tori
 Less commonly, solitary exostoses may occur, possibly in response to local irritation.
Such lesions may develop from the alveolar bone beneath free gingival grafts and
skin grafts. Presumably placement of the graft acts as a stimulant to the periosteum
to form new bone.
 Another uncommon variant is the reactive subpontine exostosis (subpontic osseous
proliferation, subpontic osseous hyperplasia), which may develop from the alveolar
crestal bone beneath the pontic of a posterior bridge
 If enough excess bone is present, exostoses may exhibit a relative radiopacity on
dental radiographs. In rare instances exostosis may become so large that it is difficult
to distinguishing it from a tumor
 If the diagnosis is uncertain, biopsy should be performed to rule out other bony
pathosis.
 Reactive subpontine exostoses may need to be removed if they interfere with oral
hygiene or are associated with adjacent periodontal disease.

BIBLIOGRAPHY
1) Textbook of oral pathology- Shafer’s
2) Textbook of oral and Maxillofacial Pathology- Nevielle 4th edition
3) Differential diagnosis of oral and maxillofacial lesions- Norman K Wood and Paul W.
Goaz
4) Cawson essential of oral pathology and oral medicine- R.A. Cawson 7 th edition
5) Textbook of oral and maxillofacial pathology- Neelima Anil Malik 4 th edition
6) Textbook of oral and maxillofacial surgery – Rajiv M Borle
7) Textbook of oral pathology- J.V.Soames
8) Textbook of oral and Maxillofacial Surgery – Raymond J Fonseca volume 2
9) Textbook of Oral And Maxillofacial Surgery – SM Balaji
10)Kramer IRH, Pindborg JJ, Shear M. Histological typing of Odontogenic tumors. 2nd edition.
New York : Springer-Verlag;1992
11)Adarsh Kudva, K.M. Cariappa, Vasantha, Monica Solomon: Central giant cell granuloma: An
Uncommon presentation oral and maxillofacial surgery cases , 4(4), 135-140