GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY
SEMINAR ON
FIBRO-OSSEOUS LESIONS OF THE JAWS & ITS SURGICAL MANAGEMENT
Presented By:
Dr. Sambhav K Vora
II MDS
1
CONTENTS-
Introduction
Classification
Fibrous dysplasia
Cemento-osseous dysplasia
Periapical cemento-osseous dysplasia
Focal cemento-osseous dysplasia
Florid cemento-osseous dysplasia
Familial gigantiform cementoma
Ossifying fibroma
Juvenile ossifying fibroma
Osteoblastoma & osteoid osteoma
Cementoblastoma
Differential diagnosis
Controversies
Conclusion
References
2
FIBRO-OSSEOUS LESIONS OF THE JAWS
INTRODUCTION:. !e term FibroOsseous lesions "FO#$ !as been used for
many years as a general description for a group of tumors and proliferative
disorders% &!ic! affect t!e 'a&s .!ey comprise a number of specific clinical
entities in &!ic! clinical% radiological and !istological features often overlap
causing confusion to bot! pat!ologist and clinicians in diagnosis and t!erapy
( be&ildering variety of names !ave been given to lesions &it!in t!e FO#
group. !ese include fibrous dysplasia% osteitis fibrosa cystica% fibrous osteoma%
osseous dysplasia% osteofibrosis% periapical cementoma% and osteoid osteoma.
!is multiplicity of names% fre)uently applied to t!e same pat!ological
condition !as created confusion &it! regard to diagnostic criteria and
misunderstanding of individual biological be!avior.
Fibro osseous lesions "FO#$ refer to a diverse process in &!ic! t!e normal bone
arc!itecture is replaced by fibroblast and collagen fibers containing variable
amounts of minerali*ed material
+
.
Fibro osseous lesions of t!e 'a&s as a generic term used to describe a number of
apparently different pat!ologic entities t!at commonly affect t!e ma,illa%
mandible and ot!er facial bones
+
.
FO# is a generic designation given to a group of disorders "ranging from
inflammatory to neoplastic$ t!at microscopically e,!ibit% a connective tissue
matri, and islands - trabeculae of bone. (lt!oug! t!e !istological appearance
3
and fre)uently t!e clinical and radiological features may be similar for many of
t!ese lesions% t!ey demonstrate a &ide range of biological be!aviour
+
.
!e c!aracteristics used to separate t!e clinical entities are t!e symptoms and
t!e radiograp!ic appearance% bot! of &!ic! are e,tremely varied. #esions vary
from small% locali*ed% asymptomatic areas discovered on radiograp!s to &ell-
defined lesions t!at cause e,pansion of t!e single bone to a functionally
disturbing or cosmetically deforming enlargement of one or many bones. !e
radiograp!ic appearance varies from a large% diffuse% dense ground glass pattern
&it! indistinct boundaries% to locali*ed cyst li.e radiolucent lesion to &ell-
defined solitary or multiple radiolucencies &it! varying foci of radiopa)ue areas
+
.
!is presentation is aimed at revie&ing t!e current .no&ledge and literature
of clinical% radiological% !istological features% differential diagnosis% treatment of
fibro-osseous lesions and controversies related to varios lesions and its
management..
CLASSIFICATION
FIBRO OSSEOUS LESIONS OF JAWS
I. Fibrous Dysplasia
II. Cemento-Osseous Dysplasia.
a$ Focal Cemento osseous Dysplasia
b$ Periapical Cemento osseous Dysplasia
c$ Florid Cemento osseous Dysplasia
III. Familial /igantiform Cementoma
4
I0. Ossifying fibroma.
0. Juvenile ossifying fibroma
III. 1iscellaneous
Osteoblastoma%OsteoidOsteoma.Cementoblastoma%
Charle Wal!r"#$ %la&'&%a(&"#:
I. Fibrous Dysplasia
1onostotic
Polyostotic
II. Fibro Osseous "Cemental$ lesions presumbly arising in periodontal ligament.
Periapical Cemental Dysplasia
#ocalised Fibro Osseous Cemental #esions "Probably reactive in nature$
Florid Cemento osseous Dysplasia "/igantiform Cementoma$
Ossifying fibroma and cementifying fibroma.
III. Fibro- Osseous 2eoplasm of 3ncertain or Debatable Relations!ip to
t!ose arising in t!e periodontal ligament.
Cementoblastoma% Osteoblastoma% Osteoid Osteoma.
5
Juvenile active ossifying fibroma and aggressive active
cementifying-ossifyingfibromas
4rannon and Fo&ler classification
5

+.Fibrous dysplasia
(. 1onostotic
4. Craniofacial
C. Polyostotic
D. 1cCune-(lbrig!t syndrome
6. Ossifying fibroma and 'uvenile ossifying fibroma
7. Osseous dysplasia
(. Periapical
4. Focal
C. Florid
D. Familial gigantiform cementoma
CLASSIFICATION OF RADIOLOGICAL PATTERNS OF THE FIBRO-
OSSEOUS LESIONS OF THE JAWS
7
6
Divided into 7 groups-
i. umour
ii. Dysplasia
iii. Inflammation
!ese 7 groups &ere again divided into 8 types based on t!eir radiograp!ic
patterns-
(. Focal
4. arget
C. Radiolucent
D. Calcification
9. 1ulticonfluent
7
The &)*"r(a#%e "' ra!&"l"+, (" (he !&a+#"& "' FOL:
1a,illofacial FO#s are of particular interest to t!e radiologist because t!ey
emp!asi*e t!e central role of t!e radiologist in t!e diagnostic process. !is role
arises because t!e pat!ology for all FO#s is identical% alt!oug! t!ey range
&idely in be!aviour% from dysplasia% !amatoma to benign neoplasia &it!
occasional recurrence. !e late C!arles :aldron &rote ;In absence of good
clinical and radiologic information a pat!ologist can only state t!at a given
biopsy is consistent &it! a FO#. :it! ade)uate clinical and radiologic
information most lesions can be assigned &it! reasonable certainty into one of
several categories< Conversely in t!e absence of suc! information 9isenberg
and 9isenbud stated t!at ;pat!ologists today &ill often rig!tly decline to render
a definitive diagnosis% Instead% t!e pat!ologist &ill resort to t!e noncommittal
designation of benign fibro-osseous lesions =t!eir italics>. !is is t!e only
acceptable approac! considering t!e potential for inappropriate treatment
ot!er&ise.< !erefore t!e identification of t!e ma'ority of FO#s is made upon
clinical and radiological features Radiological assessment of t!e anatomical
location of a bone tumour% its s!ape and si*e% t!e pattern of its matri, and its
destruction% t!e definition of its margins and concomitant softtissue
abnormalities generally correlate &it! its be!aviour "aggressive or benign$.
;Periosteal reaction< an important feature considered by s.eletal radiologists ;is
not a feature of benign fibro-osseous lesions<.
1any FO#s% particularly COD% are symptomless and re)uire no surgery.
!erefore diagnosis of t!e lesions on clinical and radiological features alone
may obviate t!e need for an ot!er&ise unnecessary invasive procedure. !is
avoidance of surgery could benefit t!e patient% because e,aggerated gro&t! of
FD may be stimulated by surgery in young patients
.?
8
Radiological evaluation can be carried out &it! plain radiograp!y " P.( vie&%
lateral vie&% obli)ue vie& or &aters pro'ection$% OP/% Intra oral periapical
radiograp and Occlusal radiograp!. 4ite&ing radiograp! can be useful only in
visuali*ation of supracrestal bone formation% &!ic! if present is suggestive of
malignancy suc! as osteosarcoma or c!ondrosarcoma.
C. scans are also e,cellent for demonstrating many subtle lesions especially
for t!e evaluation of e,pansile and destructive processes and also for t!e
visuali*ation of cortical brea.t!roug! and e,traosseous e,tensions. I.0 contrast
administration en!ances t!e soft tissues. Dentascans can also be useful in
diagnosing fibro-osseous lesions.
1.R.I can be useful in differentiating solid from non-solid masses% for e,-
fibrous dysplasia complicated by t!e presence of (neurysmal bone cyst.
C. scan !as advantage over 1RI In its ability to s!o& t!e matri, of lesion and
&!et!er it contains fibrous% cartilaginous or calcified tissues. @uc! information
is !elpful in t!e formulation of clinical differential diagnosis.
FI4RO3@ DA@P#(@I(B
:.C.O "+556$% defined Fibrous dysplasia "FD$ as a benign lesion% presumably
developmental in nature% c!aracteri*ed by a presence of fibrous connective
tissue &it! a c!aracteristic &!orled pattern and containing trabeculae of
immature bone.
It is a condition in &!ic! normal medullary bone is gradually replaced by an
abnormal fibrous tissue proliferation. !e mesenc!ymal tissue contains variable
amounts of an osseous matri, t!at presumably arises t!roug! metaplasia and
consists of only &oven bone. CI@ DI@9(@9 PROD3C9@ @O#I(RA or
multifocal lesions in &!ic! t!ere is arrest of bone development in t!e &oven
9
bone stage &it! failure to lamellar bone. !e resultant fibro osseous tissue is
poorly formed and structurally in ade)uate.
!e precise etiology remains un.no&n% alt!oug! various t!eories !ave been
proposed. 1any aut!orities accept t!e premise t!at fibrous dysplasia represents
a non neoplastic !amartomatous gro&t! resulting from altered mesenc!ymal
cell activity or defect in t!e control of cell activity.
1ar, and @tern "6DD7$ stated t!at alt!oug! t!e clinical development of FD
becomes apparent bet&een 8 to +8 years of age % it begins in t!e embryo
&it! t!e spontaneous gene mutation or deletion of an intra cytoplasmic
transducer protein responsible for bone maturation .all t!e daug!ter cells of
t!e original aberrant cell &ill produce immature bone% t!erefore t!e earlier
t!is occurs in embryonic development% t!e more t!e &idespread &ill be t!e
FD.
CLINICAL FORMS OF FIBROUS DYSPLASIA -TYPES
Phili et al !"##$% E classified FD in to 1O2O@OIC and
PO#AO@OIC types% &!ere
1onstotic type of FD is furt!er divided in to t!ree subtypesB
Juvenile
Juvenile% aggressive
(dult
Phili et al!"##$% Polyostotic type of FD is divided in to t!ree subtypesB
Craniofacial FD E in &!ic! only t!e bones of craniofacial comple, are
affected including t!e mandible and ma,illa.
10
#ic!lenstein and 'affe type of FD E in &!ic! bones of t!e s.eleton &it!
cafF au lait pigmentation.
(lbrig!t syndrome type of FD- !as a traid of severe polyostotic FD%
cafF au lait pigmentation and various endocrinopat!ies.
MONOSTOTIC FIBROUS DYSPLASIA
1onostotic fibrous dysplasia "1FD$ is a type of Fibrous Dysplasia% &!ic!
involves only one bone.1FD is t!e most common type of regional deformity.
&aldron et al
'
!"##(% classified 1onostotic type of FD in to t!ree subtypesB
Juvenile
Juvenile% aggressive
(dult
JU.ENILE FIBROUS DYSPLASIA
Phili !"##$% In t!e !ead and nec. area% monostotic 'uvenile fibrous
dysplasia is t!e most common type of regional deformity. It is slo& gro&ing
regional distortion t!at enlarges proportionately &it! t!e affected bone. !e
regional over gro&t! continuous until general body gro&t! ceases in t!e late
teens or early t&enties. (n uncommon form .no&n as aggressive 'uvenile
fibrous dysplasia gro&s at an ever faster rate producing ma'or% often
grotes)ue deformity t!at results in loss of function of t!e affected bone
Cl&#&%al Fea(/re:
@een in +
st
and 6
nd
decades of life
Cas e)ual se, predilection
11
1a,illa is effected more t!an mandible.
&ood N.K and )oa* P.& !"#$+% stated t!at t!e e,pansion is smoot! and
covered &it! normal appearing mucosa or s.in. 3lceration overlying t!e bony
enlargement is uncommon but may be seen &!en t!e mass disrupts t!e
occlusion or is traumati*ed during eating.
!e first sign of disease is a gradually increasing painless s&elling%
&!ic! is not &ell circumscribed and causes a gradually increasing facial
asymmetry. !e enlargement is usually smoot!% often fusiform in outline
and is more pronounced buccaly t!an lingually or palatally. :!en
ma,illa is involved t!ere is usually increased prominence of t!e c!ee.
and buccal e,pansion distal to canine% &!ic! may e,tend to involve t!e
tuberosity. 1a,illary lesions commonly e,tend locally to involve t!e
sinus% Gygomatic process% floor of orbit and orbital contents are displaced
in some cases. :!ere t!e gro&t! is rapid and e,tensive t!ere may be
mar.ed s&elling of t!e c!ee. &it! e,opt!almus and proptosis.
1andibular lesions occur most fre)uently in t!e molar and premolar
regions and if t!e lo&er border is involved t!ere may be an obvious
protuberance and increased dept! of t!e 'a&s.
Ra!&"l"+&%al 'ea(/re:
It varies &it! t!e stage of maturity of t!e lesion% in early stages t!e lesion
may be radiolucent becoming radiopa)ue as more bone is formed. !e
mature lesion retains none of t!e normal arc!itecture of trabecular bone%
!aving replaced it &it! abnormal bone t!at produces a ;ground glass< or
;orange peel< pattern on radiograp!s. !ere is no line of demarcation
because t!e lesion blends &it! surrounding bone. 9,pansion of t!e
cortical plates and displacement of toot! roots is common. !e
laminadura is usually obscured and cortical plates are t!inned.
12
Trea()e#(:
reatment is pursued only &!en lesions are cosmetically unacceptable or
interfere &it! sig!t% mastication and speec!% most lesions of t!e normal
form of 'uvenile fibrous Dysplasia do not re)uire treatment until t!e
patient !as reac!ed adult!ood. #esions s!ould not be treated by
radiot!erapy in an attempt to !alt gro&t! because of t!e ris. malignancy
in later life.
ADULT FIBROUS DYSPLASIA:
It is a rare form t!at occurs spontaneously in adults. It resembles
ossifying fibroma in many &ays and must be separated from it because
t!e treatment is very difficult.
Cl&#&%al 'ea(/re:
Are similar to mature 'uvenile FD. !e affected area presents as an
asymptomatic diffuse e,pansion of t!e cortices. @ome movement of teet!
&it! in t!e area may occur.
Ra!&"l"+&%al 'ea(/re:
Phili !"##$% less !omogenous t!an 'uvenile FD% e,!ibits a mi,ed
radiolucent and radiopa)ue ;cotton E ball< pattern. (s &it! ot!er forms
of disease% individual lesions blend &it! t!e surrounding bone .e,pansion
and t!inning of t!e cortical plates is usually evident.
.
Trea()e#(:
Phili !"##$% treatment aspect is different from 'uvenile FD because it is
not self-limiting. In adults% attempts are made to completely remove
13
smaller lesions and !alt t!e progression of larger ones &it! continuous
conservative treatment.
POLYOSTOTIC FIBROUS DYSPLASIA
Phili !"##$% olyostoti, tye o- .D is divided in to three s/btyes:
0ranio-a,ial .D E in &!ic! only t!e bones of craniofacial comple,
are affected including t!e mandible and ma,illa.
1i,hlenstein and 2a--e tye o- .D E in &!ic! multiple bones of t!e
s.eleton &it! cafF au lait pigmentation.
Albri3ht syndrome tye o- .D E !as a traid of severe polyostotic FD%
cafF au lait pigmentation and various endocrinopat!ies.
0lini,al -eat/res4
Seen in atients /nder 56 yrs o- a3e
.emales are ,ommomly a--e,ted than males
1a,illa is commonly affected t!an mandible.
In t!e 'a&s% pain or fracture is rarely present. !e most common
complaint is s&elling% often to&ard t!e buccal side. On e,amination%
t!e tissue overlying t!e s&elling is of normal color. !e teet! usually
are not mobile% alt!oug! in severe cases may be displaced. :it!
involvement of ma,illa% t!e nose may be appear displaced and may
!ave nasal obstruction and e,op!t!almia. In most severe cases of
craniofacial involvement% t!e patients face may appear significantly
14
asymmetric. !e serum laboratory values in FD are usually &it!in
normal limits
Ra!&"+ra*h&% 'ea(/re:
Radiograp!ic appearance of Fibrous Dysplasia is variable% ranging from a
R(DIO#3C92 lesion to a densely radio opa)ue lesion. !e classic
presentation !as been described as a !omogenous radioopacity &it! t!e
numerous trabecular of &oven bone imparting ;/RO32D /#(@@<
appearance. ( 6
nd
possible pattern is a radiolucent lesion &it! patc!y% irregular
opacities resulting in a mottled radiograp!ic appearance similar in Pagets
disease. (n important distinguis!ing feature of Fibrous Dysplasia is POOR#A
D9FI29D clinical & radiograp!ic margins of t!e lesion.
FD commonly displays an abnormal opacification% &!ic! ranges from t!e very
numerous% small and diffusely distributed opacities =;groundglass< and ;peau
dHorange< to sclerosis % classically described as
;cottonE&ool<. Different patterns may not only be present in different parts of
t!e same lesion% but may also depend on &!et!er t!e film used is ;direct
e,posure< or ;fluorescent screen film<.
?
!e e,pansion of FD of t!e mandible is classically spindle "or fusiform$-s!aped
&!en vie&ed on a true "a,ial$ occlusal film$ or on a posterioanterior
pro'ection of t!e mandible.
D&''ere#(&al !&a+#"&-
O&',&#+ '&0r")aB FD is &ell establis!ed at t!e age of 6D years but
ossifying fibroma is seen at an older age. Radiograp!ically OF are &ell
demarcated% sp!erical or egg s!aped% !eterogeneous from t!e normal bone%
also s!o&s e,panded or t!inned residual uninvolved corte, and
displacement of t!e inferior alveolar canal% &!ereas FD are not
15
demarcated% fusifiorm in s!ape an !omogenous. !e radiograp!s and scans
support t!e concept advanced by :ort! t!at OF is a disease &it! in t!e
bone &!ile FD is a disease of t!e bone .
Chr"#&% %ler"&#+ "(e"),el&(& Bresembles FD in its diffuse and poorly
demarcated radiograp!ic appearance. It too may occur in teenagers and
preteens% but it is more in adults. Co&ever% unli.e FD% C!ronic sclerosing
osteomyelitis is usually severely and constantly painfulB t!ere is fre)uently
a !istory of an abscessed toot!% or some ot!er infection and appro=priate
cultures may yield actinomyces and ei.enella corrodens
Pa+e( !&eae Bcan be distinguis!ed by its onset on individuals older t!an
ID years and its incrases al.aline p!osp!ate levels.
O(e"ar%")aB may be difficult to distinguis! from FD radiograp!ically.
In general osteosarcomas do not remodel but resorb t!e corte, and e,pand
out&ard from t!e destroyed corte,.
TREATMENT a#! PROGNOSIS:
Once a 'a& lesion is determined to represent fibrous dysplasia% t!e e,tent of
s.eletal involvement s!ould be investigated lesions of F.D. c!aracteristically
e,!ibit a period of slo&ly progressive% persistent gro&t! stabili*ation or
considerable s!o&ing of gro&t! after t!e onset of puberty often follo&s.
#esions t!at result in functional or cosmetic disability may be treated by
osseous recontouring via a transoral approac!. !is procedure is generally
initiated follo&ing t!e active gro&t! stage and during t!e period of stabili*ation
of disease process. For large lesions involving t!e midface :eber- Fergussion
approac! is good alternative for surgical recontouring procedures.
16
!e incidence of 1alignant transformation of e,isting F.D. is regarded as rare J
+K. @ome investigators !ave suggested t!at t!e c!ange of developing a
malignancy is greater in pts. :it! polyostotic form of t!e disease% some Patients
&!o !ave developed malignancy !ad received Radiation t!erapy% suggesting
t!at radiation !ad a sole in t!e transformation process. Rapid enlargement of a
lesion or onset of pain suggests t!e possibility of malignant degeneration. 1ost
@(RCO1(@ arising in Pre e,isting lesions of F.D. are !ig! grade lesions &it!
Poor Prognosis. !ese !ave included Osteosarcomas% fibrosarcomas%
c!ondrosarcomas% malignant fibrous !istiocytomas
CEMENTO 1 OSSEIOUS DYSPLASIAS:
!ese disease process defined by specific clinical and pat!ologic features !ave
been classified as
C9192O O@@9O3@ DA@@#(@I(@B
- Periapical cement osseous dysplasia
- Focal cemento osseous dysplasia.
- Florid cement osseous Dysplasia.
!e precise etiology of t!ese lesions is not .no&n. 1ost investigators suggest
t!at t!e C.O.D are t!e result of disorders in t!e metabolism of cells normally
involved in t!e production of bone and cementum matrices. !e aberrant
17
activity of t!ese tissues may be t!e result of an unusual response to undefined
local factors.
PERIAPICAL CEMENTO OSSEOUS DYSPLASIA:
!is peculiar condition c!aracteristically involves t!e periapical bone at t!e
apices of teet! &it! vital% noninflammed pulps. !e process involves multiple
teet!% usually t!e mandibular anterior teet!. Periapical cemental dysplasia most
commonly affects middle aged blac. &omen.
0lini,al -eat/res:
A3e: 1ost patients are bet&een 7D-8D years.

Site and 1o,ation: 1andible is t!e commonly affected site and anterior
mandible is t!e fre)uently affected location.
Wal!r"#
2
342256 lesions are mostly asymptomatic% discovered &!en
radiograp!s are ta.en for ot!er purposes. @olitary lesions may occur% but
multiple foci are present most fre)uently
eet! associated &it! t!e lesions are almost invariably vital and seldom
!ave restorations%
4one e,pansion is absent and pain is not a feature.
eet! are vital% a feature% &!ic! distinguis!es t!is condition from apical%
cystic and inflammatory process.
Radiolo3i,al -eat/re: !e lesions are usually detected incidentally on routine
radiograp!ic e,aminations% as t!e disease is almost invariably asymptomatic
18
#esions of t!is type typically !ave t!ree distinct stages of development.
"+$ Osteolytic
"6$ Cementoblastic
"7$ 1ature
Osteolyti, sta3e: !e osteolytic stage is c!aracteri*ed by a circular area of
rarefaction at t!e ape, of t!e vital toot!. !e lamina dura is usually absent in
t!e apical region of t!e ad'acent toot!. !e radiolucent area is &ell demarcated
from t!e surrounding alveolar bone and a sclerotic ring may be present%&!ic! is
t!ic.er %more irregular%and more diffuse t!an t!e margin of a cystic lesion. !e
average lesion is appro,imately D.8 to +cm in diameter during t!is stage in rare
instances%t!e lesion may be larger t!an +cm% in &!ic! case it is most li.ely t!at
multiple teet! &ill be involved. !e lesion is usually round &!en it is smaller
t!an +cmLit spreads laterally &!en it enlarges%eventually losing its circular
configuration.
0ementoblasti, sta3e: !e cementoblastic stage is c!aracteri*ed by t!e
appearance of a radiodense cemental mass to&ards t!e centre of t!e lesion.
Initially% a single mass &!ic! develops may be very faint. !e radiolucent
component remains prominent. (n outer rim of sclerotic bone may be
present%especially if active lysis of !ost bone is in progress. !e radiolucent
*one bet&een t!e central mass of sclerotic rim is divided into t!ree
radiologically distinct bands. !e outer band is t!e region in &!ic! calcific
sp!erules of cementum-li.e material are formed. In t!e intermediate band% one
can see individual calcific sp!erules coalescing &it! eac! ot!er form calcific
massules. In t!e inner band%
:!ic! is ad'acent to t!e central mass% invidual massules are seen t!at coalesce
&it! t!e central mass.
19
Mat/re Sta3e: In t!e mature stage a single central mass develops. In some
instances t!e mass develops from t!e ape, of t!e involved toot!% causing it to
!ave a crescent s!ape. !e perip!ery of t!e mass tends to !ave a smoot!
surface% alt!oug! it may be irregular or even lobulated as a result of coalesced
massules. During periods of dormancy% t!e cemental mass is in direct apposition
&it! t!e ad'acent bone and may be mista.en easily for idiopat!ic osteosclerosis.
During active periods% an outer radiolucent fibrocemento osseous band and
radiopa)ue margin of reactive bone reappear. !e radiolucent band is usually
millimeters &ideL !o&ever% it may be as t!in as a normal periodontal ligament
space or as &ide as D.8 cm. in some instances% especially on panoramic
radiograp!s% t!e lingual aspect of t!e radiolucent outer rim may appear to
e,tend up on to t!e root of a toot!L !o&ever% t!is may represent a pro'ection
artifact. !e cemental mass may gro& on eit!er side of t!e root% but it usually
does not attac! to t!e root ape,. !e outer rim of sclerotic bone is a variable
feature.
H&("*a(h"l"+,:
!ese lesions are usually diagnosed on clinical and radiograp!ic features.
:!en biopsied% t!ey usually consist of multiple fragments of moderately
cellular% collagenous tissue investing variable amounts of bone and cementum
matri,. !e relative amount and degree of minerali*ation of t!e matri,
components are variable% largely dependent on t!e lengt! of time t!e lesions
!ave been present and t!erefore t!e stage of prognosis. !e calcified tissue is
associated &it! osteoblasts and cementoblasts along t!e surface and is deposited
in variety of configurations% including trabecular% sp!erules or relatively
irregular masses.
20
Trea()e#( a#! Pr"+#"&B
Re)uires no definitive treatment follo&ing diagnosis only periodic observation
is necessary during &!ic! time one &ould e,pect to see t!e radiograp!ic
c!anges association &it! maturation of t!e lesions.
FOCAL CEMENTO 1 OSSEOUS DYSPLASIA:
It is a recently described entity t!at is t!oug!t to fall bet&een P.C.D. and florid
osseous dysplasia in t!e biologic spectrum of C.O.D.
Clinical featuresB
"+$ 1ost common in females and a !ig!er incidence in &!ites.
"6$ #esions are typically solitary involving t!e bone in PO@9RIOR
1(2DI4#9.
"7$ C!aracteristically asymptomatic and fre)uently discovered during routine
radiograp!ic e,amination.
"I$ 1ost lesions are 1IM9D radiolucent E radio opa)ue areas% alt!oug! t!e
radiograp!ic appearance may very from &ell defined radiolucent lesion to a
densely radio opa)ue area.
"8$ 1ost of lesions J +.8 cm in si*e
"N$ 1any cases involve bone ad'acent to t!e roots of asymptomatic vital teet!.
"?$ @ome cases of F.C.O.D. !ave been associated &it! development of
idiopat!ic bone cavities.
H&("*a(h"l"+,:
21
"+$ C!aracteristic feature of F.O.D. is consistency of tissue removed during
biopsy. !e tissue is often difficult to correct from t!e lesion and is removed as
multiple fragments of gritty tissue t!is feature is especially !elpful in distinction
of Ossifying fibroma &!ic! can be removed - separated easily from ad'acent
normal bone.
"6$ !ese fragments are associated &it! surgical !emorr!age.
"7$ @oft tissue consists of cellular proliferation of fusiform% spindled cells in a
collagenous stroma.
"I$ @mall blood vessels observed.
"8$ Connective tissue consists of small% irregular trabecular of &oven bone and
globular deposits of cementum li.e matri,.
Trea()e#( a#! Pr"+#"&:
(s lesions e,!ibits only limited potential for progressive gro&t!% most lesions
re)uire no additional treatment.
FLORID CEMENTO OSSEOUS DYSPLASIA:
!is disease process represents t!e most clinically e,treme end of t!e spectrum
of disorders classified as cemento E osseous dysplasias.
Cl&#&%al'ea(/re:
1ost patients &!o develop F.O.D. are adult% blac. &omen. !e disease process
c!aracteristically alters !e normal bone pattern in a generali*ed% bilateral
faction.
FOD typically produces mottled% mi,ed radiolucent radioopa)ue lesions
ad'acent to t!e teet! t!roug! out t!e affected portions of t!e 'a&s. (s t!e
22
lesions mature over time% t!ey may consist predominantly of irregular% diffuse%
sclerotic masses. 3ncomplicated lesions of FOD may produce mild cortical
e,pansion but are ot!er&ise complicated. Co&ever% t!e altered bone is
susceptible to t!e development of Osteomyelitis follo&ing traumatic episodes
suc! as e,tractions or biopsies or from mucosal ulcerations suc! as t!ose
resulting from ill fitting removable prost!esis.
Trea()e#( a#! Pr"+#"&:
It is a non-neoplastic% self limited process t!at re)uires no treatment follo&ing
diagnosis. In fact% o&ing to t!e significant alterations in t!e affected bone any
form of trauma% including a biopsy procedure is best avoided.
F(1I#I(# /I/(2IFOR1 C9192O1(B
!is is a disorder of 'a& bones t!at ultimately leads to t!e formation of
massive sclerotic masses of disorgani*ed minerali*ed material.
In t!e past it &as a synonym for florid COD.
It is an uncommon !ereditary disorder t!at demonstrates !ig! penetrance
& variable e,pressivity.
It is different from conventional cemento osseous dysplasia.
Cl&#&%al 'ea(/re
23
Commonly seen in caucasians and african blac.s% no se, predilection.
!e osseous pat!osis appears to be limited to t!e 'a&s but multifocal
involving bot! ma,illa and mandible.
Rapid and e,pansile gro&t! pattern of 'a&s in adolescence results in
facial deformity% impaction% malposition% and malocclusion of t!e
involved dentition.
(nemia% multifocal polypoidal adenomas of t!e uterus may be present E
gynocologic consultation is re)uired.
!e osseous enlargement ceases during fift! decade.
Ra!&"+ra*h&% 'ea(/re
Resemble cemento osseous dysplasias.
Initially t!ey appear as multiple radiolucencies in t!e periapical regions.
!e affected sites e,pand and develop mi,ed radiolucent and radiopa)ue
pattern.
:it! furt!er maturation% t!ey become predominantly radiopa)ue &it! a
t!in radiolucent rim.
H&("*a(h"l"+&% 'ea(/re
It s!o&s same spectrum of c!anges seen in t!e florid cemento oseeous
dysplasia% t!e t&o cannot be distinguis!ed radiograp!ically.
Trea()e#( a#! Pr"+#"&
24
@!ave do&n surgical procedures at t!e earlier stage to improve aest!etics
are not successful due regro&t!.
(t t!e later stage "radiopa)ue$ partial removal of affected bone &ill result
in se)uestration of t!e remaining affectd bone.
9,tensive resection and reconstruction of t!e lesion is recommended at a
later stage if t!ey are causing significant functional & est!etic deformity.
!e e,tent of surgical procedures is greater at a later stage.
O@@IFAI2/ FI4RO1(B
It is considered by most to represent a benign neoplasm arising from
undifferentiated cells of periodontal ligament tissue. !is lesions !as been
referred to as osteofibroma% fibro-osteoma and benign fibro-osseous lesion of
Periodontal ligament origin. In +5?6% t!e :orld Cealt!Organi*ation ":CO$
considered ossifying fibroma to be a tumor of bone origin !is lesion s!ares
identical clinical radiograp!ic and !istopat!ologic features of &it! cementifying
fibroma. 2eoplastic etiology for ossifying fibroma includes persistent% locally
aggressive gro&t! c!aracteristic and finding of recurrence is seen. @ome
investigators regard t!e lesion as e,ample of locali*ed dysplastic process in
&!ic! bone metabolism !as been altered.
Cl&#&%al 'ea(/re:
It is typically a slo& gro&ing% e,pansible lesions t!at replaces normal bone as it
enlarges.
25
1ost lesions are asymptomatic &!en detected &it! rare e,ceptions% lesions arise
in toot! bearing regions of 'a&s% &it! t!e body of mandible being t!e most
common site.
1ost affected patients are adults &it! pea. incidence bet&een 6D and ID years.
( definite female predominance "8B+$.
:!en lesions remains undetected for a period of time% t!e lesion e,!ibits slo&
but persistent progression% in gradual e,pansion and possible t!inning of buccal
and lingual cortical plates.
Firbromas occur as solitary lesions.
In contrast to fibrous dysplasia% t!e most important distinguis!ing feature is &ell
circumscribed s!arply defined border bet&een lesion and ad'acent bone.
9arly lesions present as unilocular or multilocular radiolucencies. It progresses
gradually to a mi,ed radiolucent radiopa)ue stage and matri, material is
deposited and minerali*ed in t!e lesion.
Fully mature% long standing lesions appear as dense% radiopa)ue masses
surrounded by a t!in% &ell defined regular% radiolucent rim.
(s lesions enlarge% t!ey may displace ad'acent teet! and less commonly cause
resorption of toot! roots.
H&("*a(h"l"+,:
!e tumor consists of a collagenous stroma containing variable number of
uniform spindled or stellate cells. Collagen fibers are often arranged
!ap!a*ardly.
!e degree of vascularity is variable some are relatively avascular and fibrotic%
&!ereas ot!ers e,!ibit a &ell vascular stoma.
26
Irregular partially interconnecting trabecular of &oven bone are noted.
Presence of O@9O4#(@@ along t!e surface of bone deposits.
4asop!itic sp!erical calcifications and anastamosing trabecular of cementum
li.e material are also fre)uently present.
Differential diagnosis-
+. Fibrous dysplasia-
@.2o Fibrous dysplasia Ossifying fibroma
+. @ite- common in ma,illa Common in mandible
6. @een at +
st
and 6
nd
decade 7
rd
and I
t!
decade
7. 9)ual se, predilection Females are commonly
affected
I. Radiologically no line of
demarcation bet&een normal
bone and immature bone
#ine of demarcation seen
" encapsulated neoplasm$
8. Fusiform elongation or
e,pansion
Round or oval e,pansion
N. Cistologically only &oven
bone &ill be seen
#amellar bone &ill also be
seen.
6. Osteoid osteoma and osteogenic sarcoma- gives an ill defined aggressive
appearance &it! radiograp!ic signs of malignancy.
7. Condensing osteitis and focal sclerosing osteomyelitis- lac.s t!e
surrounding radiolucent capsule seen in ossifying fibroma and t!us easily
differentiated.
27
I. (meloblastoma E multilocualated% bubbly appearance% clear line of
demarcation present% root resorption may be present. @ometimes even
associated &it! unerupted toot!.
8. (denomatoid odontogenic tumour-
Trea()e#( & Pr"+#"&:
(n intraoral approac! for t!e surgical e,cision of tumor by enucleation is t!e
preferred met!od of management ad'acent normal structures including teet!%
neurovascular elements and bone s!ould be preferred &!enever possible &!en
large lesions are e,cised and potential ris. for postoperative fracture% I1F
s!ould be considered during initial !ealing stages. In e,tensive lesions surgical
resection and bone grafting is indicated.
Cryot!erapy is also indicated in treating ossifying fibroma for conditions &!ic!
are lying ad'acent to t!e bone or lying &it!in t!e bone
.+
J3092I#9 O@@IFAI2/ FI4RO1(B
@ynonymsB 'uvenile aggressive ossifying fibroma% 'uvenile active
ossifying fibroma and aggressive psammomatoid ossifying fibroma.
!e term active 'uvenile ossifying fibroma is considered &!en t!e lesion
be!aves in t!e more aggressive manner & t!e patient is under t!e age of
+8 years. Recurrences rates of around 7D to 8D K are encountered in t!is
type of lesion.
6
!is uncommon lesion is distinguis!ed from standard OF based on
its more clinicaly aggressive biologic be!aviour%
28
occurrence in younger age group%
and tendency to occur in different anatomic sites.
Cl&#&%al 'ea(/re
1ost cases reported before t!e age of +8 yrs.
!e most fre)uent sites of occurrence include t!e orbital %frontal and
et!moid bones% t!e paranasal sinuses% and t!e ma,illa.
In contrast to standard OF mandible is less fre)uently involved.
Common clinical presentation are proptosis% e,op!t!almos% visual
disturbances% nasal obstruction and facial asymmetry.
1any tumors e,!ibit rapid and progressive enlargement.
@ome lesions produce e,pansion and t!inning of corticesL ot!ers may
erode t!e bone and ad'acent soft tissue spaces.
Intra cranial e,tension t!roug! cribriform plate leading to elevation of
frontal lobe and pneumococcal meningitis is also reported.
Ra!&"+ra*h&% 'ea(/re
1ost tumors present as destructive% e,pansile lesion% often &it! fairly
&ell demarcated% even corticated% borders.
Fre)uently t!e lesion e,!ibits a primarily radiolucent )uality &it! varying
amounts of internal radiopacity% reflecting t!e degree of minerali*ation.
29
H&("*a(h"l"+&% 'ea(/re
1icroscopic findings of t!is lesion are controversial.
!e tumor stroma consists of a !ig!ly cellular proliferation of spindled to
stellate cells &it! minimal intervening collagen.
!e cellular stroma invests t!in strands and cords of osteoid% &!ic!
contain many osteocyte li.e cells.
It also contains &oven bone trabeculae &it! osteoblastic rimming.
@ome lesions contain numerous unoiform% round often laminateds
tructures described as ossicles or psammoma li.e bodies.
Ot!er features include Emultinucleated goiant cells% my,oid stromal
altterations &it! areas of degenration% and pseudocyst formation.
Trea()e#( a#! Pr"+#"&
!e approac! to surgical treatment is continually evolving.
Complete surgical e,cision is t!e goal% ta.ing into consideration t!e si*e%
location% and e,tent of t!e tumor.
@mall accessible lesions may be amenable to surgical e,cision &it!
enucleation alone or &it! perip!eral ostectomy.
Reported recurrence rates for t!is tumor is bet&een 7DK and 8OK but no
evidence of metastasis.
#arger% recurrent lesions may necessitate segmental resections and
reconstruction &it! bone grafts.
30
O@9O4#(@O1( (2D O@9OID O@9O1(B
Osteoblastoma and Osteiod Osteoma are recogni*ed neoplasms in t!e
e,tragnat!ic s.eleton and !ave been occasionally been reported in t!e 'a&s.
!ere is &ide agreement t!at Osteoblastoma and Osteoid Osteoma are closely
related lesions and are separated only on t!e basis of t!eir clinical and
radiologic c!aracteristics. @ome aut!orities prefer t!e term Osteoblastoma for
bot! lesions.
!e radiograp!ic findings in Osteoblastoma of t!e 'a&s and t!e remainder of
t!e s.eleton are )uite inconsistent and s!o&ing varying combinations of
radiolucency and calcification t!at sometimes are indistinguis!able from typical
ossifying- cementifying fibromas.
Cistologically% osteoblastomas can s!o& a range of features% but most typically
t!ey !ave a !ig!ly vascularised stroma containing irregular% fre)uently
anastomosing trabecular of Osteoid and immature bones &it! varying decrease
of calcification. !e osteoid trabecular are surrounded by prominent% plump
osteoblasts and similar osteoblast li.e cells are conspicuos in t!e inter trabecular
spaces. 0arying number of multinucleated giant cells may also be present.
(lt!oug! t!e !istologic findings in t!e usual osteoblastoma are fairly
distinctive% t!ey !ave enoug! overlapping features &it! some ossifying
fibromas so t!at t!e designation of a given lesion as an Osteoblastoma or an
ossifying fibroma may be constroversial.
C9192O4#(@O1(B
Cl&#&%al a#! Ra!&"+ra*h&% 'ea(/re:
It is a odontogenic neoplasm of cementoblasts
31
(nd also .no&n as true cementoma.
!ese are rare% less t!an + K of all odontogenic tumors.
!e most common site is posterior mandible t!at too first molar area
"8DK$.
2o se, predilection% rarely affects deciduous teet!.
!e common age group is +D-7D yrs.
Pain and s&elling may be present.
Radiogrp!ically it appears as a radiopa)ue mass t!at is fused to one or
more toot! roots and is surrounded by a t!in radiolucent rim.
!e outline of t!e roots of involved toot! is usually obscured as a result
of root resorption and fusion of tumor &it! t!e toot!.
H&("*a(h"l"+&% 'ea(/re
It resembles osteoblastoma and only difference is fusion of t!e tumor
&it! t!e root.
It consists of s!eets and t!ic. trabeculae of minerali*ed material &it!
irregularly placed lacunae and prominent basop!ilic reversal lines.
Cellular fibrovascular tissue surrounds t!e trabeculae% and giant cells are
often present.
!e perip!ery of t!e lesion corresponding to t!e radiolucent *one seen on
t!e radiograp!% is composed of uncalcified matri,% &!ic! often is
arranged in radiating columns.
32
Trea()e#( a#! Pr"+#"&
@urgical e,traction of t!e toot! toget!er &it! t!e attac!ed calcified mass.
@urgical e,cision of mass &it! root amputation and endodontic treatment
of t!e involved toot! may also be considered.
!e prognosis is e,cellent% tumor does not recur after removal.
Progressive gro&t! of t!e tumor after e,traction of t!e toot! and
incomplete removal of t!e mass !as been documented.
(ccording to 9versole et al% t!e !istopat!ological features

of t!e benign fibro-
osseous process% and radiograp!ic findings%

suc! as evidence of bone cortical
e,pansion and &ell-defined

margins% suggest t!e diagnosis of non-aggressive
OF% type 4.

Co&ever% t!e radiograp!ic features seem to ma.e a modest
contribution

to t!e diagnosis of !ybrid lesions% as indicated by t!e small

number
of cases reported in t!e literature. In addition% Central giant cell granuloma
fundamentally presents radiolucent images% especially in lesions

&it! !uge
dimensions. It is recogni*ed

t!at C/C/ may produce calcified material.
:e emp!asi*e t!at t!e C images revealed t!e locali*ation% nature

and e,tent of
t!e lesion. !e last feature seems to be present

in all t!e cases reported. !e
images led to a diagnosis of

OF% and t!e anatomopat!ological e,amination
confirmed an association

of C/C/ and a fibro-osseous lesion.
?
D&''ere#(&al !&a+#"& "' '&0r"-"e"/ le&"# 1
33
Ra!&"l/%e#( le&"#-
a. 3nicystic radiolucency &it! sclerotic margin-
+. Cyst- radiolucency &ill be smoot!% t!in and s!arply defined. oot!
&ill be vital and aspiration s!o&s positive response.
b. 3nilocular radiolucency &it!out sclerotic margin &it! ill defined margins
s!ould be differentiated &it! malignancies. Root resorption &ill also be
seen in all malignant lesions.
c. 1ultilocular radiolucent lesion-
#ocules of trabeculae mig!t be fe& in number and of poor density li.e
central giant cell granuloma or it may be coarse and t!ic. resembling li.e
ameloblastoma.
C!ronic osteomyelitis s!ould also be considered as differential diagnosis.
M&7e! ra!&"l/%e#( a#! ra!&""*a8/e le&"#-
+. Periapical cement osseous dysplasia- radiolucent lesion surrounds t!e
ape, of t!e toot!% &it! eit!er sclerotic margin or opa)ue masses &it!in
t!e lucent lesion. oot! &ill be vital% absence of pain% no e,pansion of
cortices.
6. 1alignant metaststic lesions li.e osteogenic sarcoma and osteoblastic
carcinoma appears as mi,ed radiolucent E radioopa)ue lesions but t!ey
are usually irregular and ill defined along &it! root resorption &!ic! is
not seen in fibro-osseous lesions.
34
7. Odontoma- it is usually located above t!e cro&n of an unerupted toot!
and seldom it is found in t!e apical region . t!ese are more radioopa)ue
compared to fibroosseous lesions.
I. Fibrous dysplasia- common in ma,illa% seen in +
st
and 6
nd
decade of life.
Cas e)ual predilection for bot! male and female. Ja& e,pansion is seen
&!ic! is of fusiform type. t!ere is noline of demarcation bet&een
normal bone and defective bone.
8. Condensing osteitis- clinically pain% inflammation% drainage% tenderness
on palpation and regional lymp!adenitis &ill be present.
N. Cement-ossifying fibroma- predilection for premolars and molars. @een
under 7D years . (ttains si*e of 6 to I cm% produces discernible
e,pansion.
M&7e! ra!&"l/%e#%&e a#! ra!&""*a%&(&e #"( #e%ear&l, %"#(a%(&#+
(ee(h-
+. Fibrous dysplasia
6. C!ronic osteomyelitis
7. Cement-ossifying fibroma
I. Pagets disease
8. C!ondrosarcoma
Ra!&"-"*a8/e le&"#-
+. Fibrous dysplasia
6. Focal sclerosing osteomyelitis
35
7. Diffuse sclerosing osteomyelitis
I. Focal cement-osseous dysplasia.
CONTRO.ERSIES
Despite t!e many years of dedicated study by numerous investigators% t!e
concepts and parameters of fibro-ossoeus diseases are still in flu,.
(mong t!e ne& t!eories and contentions% t!ere is no& essential agreement t!at
t!e osseous dysplasias represent a single disease process% &!ile t!e so-called
'uvenile active ossifying fibroma and ot!er aggressive% active% psammomatoid
ossifying-cementifying fibromas remain controversial
6
(re fibro-osseous lesions malformations% !amartomas% or neoplasmsP
It is strange t!at fibrous dysplasia% cemento-ossifying fibromas are
considered as fibro-osseous lesions not neoplasms and Osteoid osteoma
36
and osteoblastoma are considered as neoplasms and not fibro-osseous
lesions.
!e debate as to tissue of origin is of little clinical significance% as long as one
differentiates ossifying fibromas from fibrous dysplasia. Camner et al
advocated t!e periodontal origin of ossifying fibroma. !e periodontal ligament
!as been s!o&n to be capable of producing cementum and osteoid% bot! of
&!ic! are c!aracteristically found in ossifying fibromas. Qrausen et al and
@p'ut et al% !o&ever% postulated t!at primitive mesenc!ymal cells in areas suc!
as t!e et!moid bone and long bones may produce cementum at sites distant
from odontogenic tissue. !ey discredited t!e notion t!at t!ese tumors arise
from ectopic periodontal tissue in t!ese locations.
.
37
!e ma'or controversies areB
+. Distinguis!ing various fibro-osseous lesions among t!emselves
and also &it! ot!er neoplastic lesions.
6. @urgical management of t!is lesions also remain controversial as
to treat suc! lesions aggressively initially only or s!ould &ait for
its transformation into malignancy t!en en bloc resections s!ould
be planned. @ome lesions can only be treated by curetting and
enucleating.
7. Identifying and predicting aggressive lesions !istologically
CONCLUSION
FO#s are diverse group of processes and benign in nature.
Diagnosis involves all aspects of t!e disease li.e clinical% radiograp!ic%
and !istopat!ological features.
Cistopat!ology of FO#s is similar% and confusing.
reatment largely depends on e,tent of est!etic and functional deformity.

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6DDILvol7OB no 7
6. (lper @ari% Juvenile ossifying fibromaB report of a case. /a*i 1edical Journal
6DD+L+6BN6-?+
7.. (R(QI 1(@(O Classification of Radiograp!ic Patterns of Fibro-osseous
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Revie& of Current Concepts (dvances in (natomic Pat!ologyB
1ay 6DD+ - 0olume O - Issue 7 - pp +6N-+I7
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Clinical Radiology "6DDI$ 85% ++E68
38
O.D.@ummerlin% Diagnosis of fibro-osseous lesions of t!e 'a& . JO1@ LNI"5$B+
5. Faizan Alawi, DDS, 4enign Fibro-osseous Diseases of t!e 1a,illofacial
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+D. Fibro osseous lesions- Dental clinics of 2ort! (merica
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+6. 2ecdet DOR(2% Fibro-Osseous #esions of t!e Ja&sB
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39
.
+. .
40