Jaw bone disaese

Jaw bone DiseaseJaw bone DiseaseMazen Abood Bin ThabitMazen Abood Bin Thabit

MD.FICPathMD.FICPath Associate Prof .of PathologyAssociate Prof .of Pathology ..

Senior lecturer of Oral pathologySenior lecturer of Oral pathology and and oral histologyoral histology. .

Classification of bone Classification of bone diseasedisease

1.1. Inflammatory bone disease.Inflammatory bone disease.

2.2. Hereditary bone disease .Hereditary bone disease .

3.3. Metabolic bone disease . Metabolic bone disease .

4.4. Disease of unknown etiology .Disease of unknown etiology .

a. Paget’s disease .a. Paget’s disease .

b. Fibro-osseous disease b. Fibro-osseous disease

5.5. Bone tumors . Bone tumors .

Normal bone histologyNormal bone histology

Haversian system

Inflammatory disease of Inflammatory disease of jaw bonejaw bone

Bone infection Bone infection ( Oteomyelitis) can be ( Oteomyelitis) can be classified into : classified into :

1.1.Suppurative : Suppurative :

Acute osteomyelitis Acute osteomyelitis

Chronic Chronic osteomyelitis .osteomyelitis .

2.2.Granulomatous Granulomatous

3.3.Non suppurative Non suppurative

Chronic sclerosing O Chronic sclerosing O

a. Focal a. Focal

b. Diffuse b. Diffuse

Chronic osteomyelitis Chronic osteomyelitis with proliferative with proliferative periostitis ( Garr’s periostitis ( Garr’s disease) disease)

Alveolar ostitis .Alveolar ostitis .

Special types Special types

a Osteoradionecrosis .a Osteoradionecrosis .

b. Chemical b. Chemical osteomyelitis osteomyelitis

c. Osteomyelitis of c. Osteomyelitis of newborn and infant newborn and infant ( Neonatal maxillitis) ( Neonatal maxillitis)

d. Chronic periostitisd. Chronic periostitis

OsteomyelitisOsteomyelitis

• Is an inflammation of the medullary Is an inflammation of the medullary portion of the jaw bone which extends portion of the jaw bone which extends to involve the periosteum of the to involve the periosteum of the affected areaaffected area

Acute osteomyelitisAcute osteomyelitis

• Rare disease .Rare disease .• An infection of bone follow an infection An infection of bone follow an infection

associated with teeth associated with teeth • The potential source of infection is The potential source of infection is

1. Periapical infection .1. Periapical infection .

2. Periodontal pocket’s .2. Periodontal pocket’s .

3. Acute gingivitis .3. Acute gingivitis .

4. Penetrating and contaminated injuries4. Penetrating and contaminated injuries

5. Tooth extraction .5. Tooth extraction .


Predisposing factors : Predisposing factors :

Local: Local:

1.1.Fracture .Fracture .

2.2.Radiation Radiation

3.3.Paget’s disease Paget’s disease

4.4.Osteoporosis .Osteoporosis .

5.5.Vascular disease Vascular disease


Systemic:Systemic:

1.1.Immunodeficiency .Immunodeficiency .

2.2.Immunosuppressant .Immunosuppressant .

3.3.Malignancy .Malignancy .

4.4.Poorly controlled D.MPoorly controlled D.M

5.5.Chronic alcoholism and malnutrition Chronic alcoholism and malnutrition


• Clinical feature: Clinical feature: • More common in adult with More common in adult with

mnadibular infection mnadibular infection • Osteomyelitis of Maxilla more Osteomyelitis of Maxilla more

common in neonate .common in neonate .• Sever throbbing pain , deeply Sever throbbing pain , deeply

sited pain .sited pain .• Swelling ,malaise and pyrexia Swelling ,malaise and pyrexia • Gingiva red swollen and Gingiva red swollen and

tender tender • Involved teeth tender and Involved teeth tender and

mobile .mobile .• Intra and extra-oral pus Intra and extra-oral pus

discharge discharge • Regional L.N enlargement Regional L.N enlargement • Paresthesia of lower lips .Paresthesia of lower lips .• Trismus Trismus


Radiography: Radiography:

1.1.Normal in early Normal in early stages.stages.

2.2.In 10-14 days, In 10-14 days, sufficient bone sufficient bone resorption occurs to resorption occurs to produce irregular, produce irregular, moth-eaten areas of moth-eaten areas of radiolucency.radiolucency.

3.3.Sequestra may be Sequestra may be seen.seen.

osteomyelitis

EtiopathogensisEtiopathogensis

Micro-organism Micro-organism

1.1.Aerobic bacteria: Aerobic bacteria: . Staphylococcus aureus .. Staphylococcus aureus .

. Haemolytic . Haemolytic streptococcus .streptococcus .

2.2.Anaerobic Anaerobic bacteria : bacteria :

..Pigmented bacteroids Pigmented bacteroids

.Anaerobic streptococcus ..Anaerobic streptococcus .

.Perphyromonas .Perphyromonas

. Pervotella . Pervotella

• Pathogenesis : Pathogenesis :


• Histopathology:Histopathology:• Acute inflammatory changes Acute inflammatory changes • Bone trabeculae shows Bone trabeculae shows

scalloping.scalloping.• Bone necrosis with Bone necrosis with

degeneration of osteoblast degeneration of osteoblast and osteocytes .and osteocytes .

• Sequestrum. Sequestrum.

Chronic suppurative Chronic suppurative osteomyelitisosteomyelitis

Low grade Low grade inflammation with inflammation with associated with bone associated with bone destruction , granulation destruction , granulation tissue formation with tissue formation with little suppuration little suppuration

• Causes : Causes : 1.1. Inadequate treatment of Inadequate treatment of

acute osteomyelitisacute osteomyelitis..2.2. Infection by weak Infection by weak

bacteria .bacteria .

3.3. Infection of avscular Infection of avscular bone .bone .

4.4. Irradiation .Irradiation .

Chronic suppurative Chronic suppurative osteomyelitisosteomyelitis

Clinical feature:Clinical feature:• Molar area mostly Molar area mostly

affected .affected .• Mild dull pain . Mild dull pain . • Jaw swelling .Jaw swelling .• Sinus tract formation , Sinus tract formation ,

pus discharge and pus discharge and shedding of squestra shedding of squestra

• Sequestra can be felt by Sequestra can be felt by probe . probe .

Radiography: Radiography: • Mouth eating radiolucent Mouth eating radiolucent

area area • Multiple radio-opaque Multiple radio-opaque

area represent sequstra .area represent sequstra .

Alveolar ostitis ( Dry Alveolar ostitis ( Dry socket)socket)

• Localized inflammation Localized inflammation of bone following of bone following either failure of blood either failure of blood clot to form in socket, clot to form in socket, or premature loss or or premature loss or disintegration of clotdisintegration of clot..

Unpredictable complication of tooth extraction (~1-3%).

Improper healing


• Etiology: Etiology: 1.1.Failure of blood clot Failure of blood clot

formation due to formation due to Poor blood supply as Poor blood supply as in: in:

. Paget’s disease.. Paget’s disease.

. Osteopetrosis.. Osteopetrosis.

. Following . Following radiotherapy.radiotherapy.

. Excessive use of . Excessive use of vasoconstrictor vasoconstrictor

in local anesthesiain local anesthesia..

2.2. Premature loss of Premature loss of blood clot may be blood clot may be due to:due to:

. . Excessive mouth Excessive mouth rinsing.rinsing.

. Fibrinolysis . Fibrinolysis byproteolytic byproteolytic

bacteriabacteria..


Clinical picture Clinical picture : : 1.1. Intense pain .Intense pain .

2.2. Most frequently seen in :Most frequently seen in :

. 3. 3rdrd molar extraction molar extraction

. Difficult extraction with . Difficult extraction with traumatrauma

. Smoker .. Smoker .

3.3. tooth socket appears empty and tooth socket appears empty and drydry

4.4. jaw bone is visible in the tooth jaw bone is visible in the tooth socketsocket

5.5. Bad breath and Unpleasant taste Bad breath and Unpleasant taste ..

6.6. Swollen of regional lymph node .Swollen of regional lymph node .


• Histopathology: Histopathology: Histological section Histological section

of socket wall reveal of socket wall reveal formation of necrotic formation of necrotic bone containing bone containing empty lacunae empty lacunae

Chronic osteomyelitis with Chronic osteomyelitis with proliferative periostitisproliferative periostitis

• Represent areactive Represent areactive sub-periosteal new sub-periosteal new bone formation in bone formation in response to low response to low grade periapical grade periapical infection , infection , perifolliculitis or perifolliculitis or trauma trauma

Garr’s disease Periostitis

Chronic osteomyelitis Chronic osteomyelitis with proliferative with proliferative

periostitisperiostitis• Clinical feature:Clinical feature: 1.1.Young adult of both Young adult of both

sexes.sexes.

2.2.Exclusively lower 1Exclusively lower 1stst permanent molar permanent molar

3.3.Mild pain .Mild pain .

4.4.Non tender , smooth Non tender , smooth and hard bony and hard bony swelling .swelling .

X-Ray: Smooth , focal subperiosteal bony growth on the outer surface of cortex

Chronic osteomyelitis with Chronic osteomyelitis with proliferative periostitisproliferative periostitis

• Histopathology:Histopathology: Fibro-osseous Fibro-osseous

microscopic feature microscopic feature

Chronic sclerosing Chronic sclerosing osteomyelitisosteomyelitis

I.I. Chronic focal Chronic focal Sclerosing OSclerosing O : :

Uncommon nonsuppurative Uncommon nonsuppurative inflammation with bone reaction inflammation with bone reaction

( Osteosclerosis) around the ( Osteosclerosis) around the root apex of nonvital tooth. root apex of nonvital tooth.

It is a local repose to low grade pulpal inflammation or high tissue resistance to infection

• Clinical feature:Clinical feature:1.1. Young adult .Young adult .

2.2. Commonly related to Commonly related to permanent mandibular permanent mandibular 11stst molar molar

3.3. Rare mandibular 2Rare mandibular 2ndnd molar or premolar molar or premolar

4.4. Asymptomatic Asymptomatic

5.5. Some time dull painSome time dull pain

6.6. Large carious lesion , Large carious lesion , non vital pulp non vital pulp

7.7. Rare may associated Rare may associated with non vital tooth with non vital tooth

• Radiography:Radiography: well defined radio-well defined radio-

opaque up to 3 cm opaque up to 3 cm below the apex with below the apex with intact lamina dura intact lamina dura

Focal sclerosing osteomyelitis

Histopathology

Chronic diffuse sclerosing Chronic diffuse sclerosing osteomyelitisosteomyelitis

• Represent a proliferative bone Represent a proliferative bone reaction ( Osteosclerosis) of reaction ( Osteosclerosis) of the jaw bone to low grade the jaw bone to low grade inflammation , the source of inflammation , the source of infection here is through the infection here is through the PDLPDL

1.Propionibacterium Acnes

2.Peptostreptoccocus

Chronic diffuse sclerosing Chronic diffuse sclerosing osteomyelitisosteomyelitis

• Clinical Feature: Clinical Feature: 1.1. Black Elderly .Black Elderly .

2.2. More in female.More in female.

3.3. Mandible and edentulous Mandible and edentulous ..

4.4. Usually asymptomatic .Usually asymptomatic .

5.5. Vague dull pain .Vague dull pain .

6.6. Exacerbation may occur Exacerbation may occur with mild pain , with mild pain , suppuration and fistula suppuration and fistula

Diffuse or nodular sclerosis resembling cotton wool

Histopathology: Pagetoid ( Mosaic) pattern

Radiation osteomyelitis Radiation osteomyelitis

( Osteoradionecrosis( Osteoradionecrosis)) • Bone necrosis follow Bone necrosis follow

irradiation of oral irradiation of oral malignancy malignancy

Endarteritis obliterans and thrombosis of inferior dental artery

Bone sterile and more susceptible for infection

Osteo-radionecrosis

Specific osteomyelitisSpecific osteomyelitis

• Neonatal Neonatal MaxillatitisMaxillatitis

• Rare type of Rare type of osteomyelitis osteomyelitis

• Infection during Infection during delivery or breast delivery or breast feeding .feeding .

• Red , swollen , Red , swollen , painfull maxilla with painfull maxilla with multiple sinus .multiple sinus .

• Sequestration of Sequestration of developing teeth developing teeth

• Chemical Chemical osteomyelitisosteomyelitis

• Rare condition .Rare condition .• Incorrect use of Incorrect use of

medicaments .medicaments .• Paraformaldehyde Paraformaldehyde • Phosphorus or Phosphorus or

mercury mercury

Fibro-osseous disease Fibro-osseous disease • Group of disorder Group of disorder

characterized characterized histologically by histologically by replacement of the normal replacement of the normal bone by fibrous tissue bone by fibrous tissue within which trabeculae of within which trabeculae of nonfunctional osseous nonfunctional osseous structure or metaplastic structure or metaplastic bone bone

• Classification :Classification :1.1.Fibrous dysplasia Fibrous dysplasia : : a. a. Monostatic .Monostatic .

b. Polystatic .b. Polystatic .

2.2.Cemento-osseous Cemento-osseous dysplasia.dysplasia.

a. a. Periapical –cemental Periapical –cemental dysplasia dysplasia

b. Focal cemento-osseous dys b. Focal cemento-osseous dys

c. Florid cemento –osseous c. Florid cemento –osseous dysp.dysp.

3.3.Fibro-osseous neoplasm.Fibro-osseous neoplasm.

4.4.Cherubism Cherubism

Fibrous dysplasiaFibrous dysplasia

• A self limiting disease A self limiting disease characterized by characterized by fibrous replacement fibrous replacement of medullary bone by of medullary bone by metaplastic woven metaplastic woven bone that eventually bone that eventually replaced by dense replaced by dense lamellar bonelamellar bone

1. Monostatic 2. Polystatic


• Monostatic : Monostatic : 1.1. More common 70%.More common 70%.

2.2. Any bone affected Any bone affected

3.3. In the Jaw bone maxilla is In the Jaw bone maxilla is more affected more affected

4.4. Start in childhood .Start in childhood .

5.5. Slow growing painless, Slow growing painless, smooth , rounded bony smooth , rounded bony swelling with facial swelling with facial asymmetry .asymmetry .

6.6. Enlarge to make dysfunction Enlarge to make dysfunction with malocclusion and with malocclusion and displacing teeth and some displacing teeth and some time prevent it’s eruption time prevent it’s eruption

Monostatic fibrous dysplasia


7.7. No pain on palpation No pain on palpation

8.8. Maxillary lesion may Maxillary lesion may cause exophthalmos , cause exophthalmos , proptosis and nasal proptosis and nasal obstruction .obstruction .

9.9. Mandibular lesion Mandibular lesion occur in molar and occur in molar and premolar region premolar region

10.10. Protuberance and Protuberance and increase the depth of increase the depth of jaw jaw


• Polystatic: Polystatic: 1.1. Rare . Rare .

2.2. Several bone .Several bone .

3.3. More common in female.More common in female.

4.4. 5% in the head and neck .5% in the head and neck .

5.5. ( Albright syndrome) ( Albright syndrome) Patchy pigmentation Patchy pigmentation Café au lait Café au lait with with precocious puberty and precocious puberty and oth endocrine oth endocrine dysfunction.dysfunction.

6.6. Jaffe syndrome when Jaffe syndrome when these is absence of these is absence of endocrine abnormalitisendocrine abnormalitis

Café au lait


• Histopathology:Histopathology: 1.1. Normal bone replaced by Normal bone replaced by

loose cellular fibrous loose cellular fibrous tissue .tissue .

2.2. Newly formed bony Newly formed bony trabeculae are delicate and trabeculae are delicate and irregular (likened to irregular (likened to Chinese characters).Chinese characters).

3.3. Spherical areas of Spherical areas of calcification resembling calcification resembling cemetum may be present.cemetum may be present.

4.4. At the margins, lesional At the margins, lesional bone fuses with normal bone fuses with normal bone bone ..

5.5. With age fibrous tissue With age fibrous tissue decrease and bone formation decrease and bone formation increase with remodeling to increase with remodeling to lamellar bonelamellar bone

Fibrous stroma with metaplastic

bone


• Radiography:Radiography: . . Radiolucent area Radiolucent area

with fine orange peal with fine orange peal textures textures

. Borders are difficult . Borders are difficult to define because of to define because of gradual transition to gradual transition to normalnormal..

. . Initially resemble Initially resemble cyst-like radiolucencies cyst-like radiolucencies containing faint bony containing faint bony trabeculaetrabeculae

1. The disease is self limiting

2. Large lesion surgical ecountring

Cemento-osseous Cemento-osseous dysplasiadysplasia

• A disease of jaw bone A disease of jaw bone of unknown etiology of unknown etiology with reactive and with reactive and dysplastic process dysplastic process characterized characterized microscopically by the microscopically by the replacement of normal replacement of normal bone with a bone with a collagenous matrix collagenous matrix containing trabeculae containing trabeculae of immature bone and, of immature bone and, in some in some instances,cementum-instances,cementum-like materlike mater

• Cemento-osseous Cemento-osseous dysplasia of three typesdysplasia of three types: :

1.1. Periapical Periapical Cemento-osseous Cemento-osseous dysplasia .dysplasia .

2.2. Focal Cemento-osseous Focal Cemento-osseous dysplasia .dysplasia .

3.3. Florid Cemento-osseous Florid Cemento-osseous dysplasia dysplasia


• Periapical Cemento-Periapical Cemento-osseous dysplasia osseous dysplasia ..

1.1. Mandibular incisor Mandibular incisor

2.2. More than one teeth is More than one teeth is affected .affected .

3.3. Tooth vital Tooth vital

4.4. More common in black More common in black female .female .

5.5. Middle age ( around 40) Middle age ( around 40) and rare before 20 .and rare before 20 .

6.6. Asymptomatic , typical Asymptomatic , typical discovered on routine discovered on routine radiographic examination radiographic examination

A mixture of benign fibrous tissue , trabeculae of bone and cemnentum like material

Periapical Cemento-osseous Periapical Cemento-osseous

dysplasiadysplasia ..

• Radiography:Radiography:1.1.Early lesion appears Early lesion appears

as rounded as rounded radiolucent area radiolucent area related to the apex related to the apex and continue with and continue with PDL.PDL.

2.2.Later produce solid Later produce solid radio-opaque massradio-opaque mass

Early Late

When not associated with a tooth apex called as focal cementoosseous, dysplasia


• Florid cemento-Florid cemento-osseous dysplasia:osseous dysplasia:

1.1. Gigantiform cementomaGigantiform cementoma

2.2. Less common .Less common .

3.3. Represent an exuberant Represent an exuberant and sever form of and sever form of periapical type periapical type

4.4. Middle age black Middle age black women women

5.5. Typically symmetrical Typically symmetrical and bilateral .and bilateral .

6.6. Some time all four Some time all four quadrant evolved quadrant evolved

Radio-opaque masses with radiolucent porder at the root

CherubimCherubim

• Benign and self-Benign and self-limited hereditary limited hereditary autosomal autosomal dominant disease dominant disease of the jaw bone of the jaw bone

Symmetrical jaw bone swelling

Chromosome 4pl6.3, which encodes the SH3-binding protein, SH3 BP2.

CherubimCherubim

• Clinical featureClinical feature: : 1.1. Young children 2-5 years Young children 2-5 years

2.2. More common in male .More common in male .

3.3. Familial .Familial .

4.4. At birth patient appears At birth patient appears normal .normal .

5.5. Later develop bilateral , Later develop bilateral , painless , symmetrical swelling painless , symmetrical swelling at the angles of mandible .at the angles of mandible .

6.6. The swelling grow rapidly for The swelling grow rapidly for few years then slow regression few years then slow regression untill childhood and become untill childhood and become static at puberty static at puberty

7.7. In sever cases maxilla In sever cases maxilla involved and give Chubby involved and give Chubby face.face.

CherubimCherubim

8.8. Exhibit fullness of cheek with Exhibit fullness of cheek with widening of alveolar ridges widening of alveolar ridges and flat palatal vaultand flat palatal vault

9.9. Premature exfoliation of Premature exfoliation of deciduous teeth deciduous teeth

10.10. Malocclusion .Malocclusion .

11.11. Difficulty in mastication , Difficulty in mastication , swallowing and speech swallowing and speech

12.12. Sever maxillary lesion Sever maxillary lesion produce pressure at the produce pressure at the orbit floor result in upward orbit floor result in upward turn of the pupils turn of the pupils ( Heavenward look) with an ( Heavenward look) with an angelic appearance .angelic appearance .

13.13. Enlargement of Enlargement of submandibular L.Ns may submandibular L.Ns may occur .occur .

CherubimCherubim

• Radiography:Radiography:1.1.Well defined Well defined

multilocular cyst like multilocular cyst like radiolucent areas radiolucent areas

2.2.Expansion and Expansion and thinning of the thinning of the cortical plates cortical plates

Multilocular cyst like radiolucent

CherubimCherubim

• HistopathologyHistopathology1.1. Highly cellular and Highly cellular and

vascular connective tissue vascular connective tissue arrange in whorls.arrange in whorls.

2.2. Large number of Large number of multinucleated giant cells multinucleated giant cells ..

3.3. Eosinophilic peri-vascular Eosinophilic peri-vascular cuffing of collagen fibers .cuffing of collagen fibers .

4.4. Extravassated RBCsExtravassated RBCs

5.5. Variable amount of Variable amount of metaplastic bone metaplastic bone trabeculaetrabeculae

Ossifying fibromaOssifying fibroma

Jaw bone disaese

Health & Medicine