20.2 Bone Pathology of the Jaws: Fibro-Osseous Lesions, Giant Cell Lesions, Osteomyelitis and Malignancy
Key Takeaways
Fibrous dysplasia shows a ground-glass radiopacity whose margins blend into normal bone, usually stabilizes after puberty, and with café-au-lait macules and endocrine disease forms McCune-Albright syndrome.
Periapical cemento-osseous dysplasia affects vital mandibular anterior teeth, most often in middle-aged Black women, and needs no treatment; surgery or extraction risks secondary osteomyelitis.
Central giant cell granuloma occurs mostly in the anterior mandible of young females, and the same histology in an older patient calls for parathyroid hormone and calcium tests to exclude a brown tumor.
Symmetrical widening of the periodontal ligament space of a tooth (Garrington sign) and a sunburst pattern are radiographic warning signs of osteosarcoma.
Paget disease of bone enlarges the maxilla more than the mandible, gives a cotton-wool radiographic appearance with hypercementosis, and raises serum alkaline phosphatase with normal calcium.
Bone lesions are described mainly by radiographic pattern (radiolucent, mixed or radiopaque; well or poorly defined), age, sex and site, and tooth vitality. Learn the classic combination for each lesion.
Approach to a Jaw Lesion
- History: age, sex, duration, growth rate, pain, paresthesia, systemic disease (cancer, renal or parathyroid disease, bisphosphonates).
- Examination: expansion, consistency, tooth mobility, displacement, and vitality testing of nearby teeth.
- Radiograph: location relative to teeth and the mandibular canal; size; border (corticated, sclerotic, poorly defined or moth-eaten); internal content (radiolucent, mixed, radiopaque, ground-glass); effects on neighboring structures (root resorption, tooth displacement, cortical expansion or perforation, periosteal reaction).
- Further imaging (CBCT, CT or MRI) for large or aggressive lesions.
- Aspiration and biopsy for a definitive diagnosis, unless the features are diagnostic of a lesion that needs no treatment.
Poorly defined, moth-eaten borders, cortical destruction, a periosteal reaction, root resorption with "spiking" and paresthesia are features of aggressive or malignant disease.
Fibro-Osseous Lesions
| Lesion | Typical patient and site | Radiograph | Management |
|---|---|---|---|
| Fibrous dysplasia | Children and teenagers; maxilla more than mandible; painless unilateral enlargement | Ground-glass opacity with margins blending into normal bone | Usually stabilizes after puberty; cosmetic recontouring after growth stops |
| Cemento-osseous dysplasia (periapical, focal, florid) | Middle-aged women, especially of African descent; periapical form at mandibular incisor apices | Starts radiolucent, becomes mixed, then radiopaque with a thin radiolucent rim | Teeth are vital; no treatment; avoid surgery and extractions because sclerotic bone can become infected (osteomyelitis) |
| Ossifying fibroma | Young adults; mandibular premolar-molar region | Well-demarcated, expansile, may displace roots | Enucleation (true neoplasm) |
McCune-Albright syndrome: polyostotic fibrous dysplasia, café-au-lait macules with irregular "coast of Maine" borders, and endocrine disorders such as precocious puberty. It is caused by a GNAS mutation.
Giant Cell and Cyst-Like Lesions
| Lesion | Key points |
|---|---|
| Central giant cell granuloma | Under 30 years, females; anterior mandible, often crossing the midline; multilocular radiolucency. Histology is the same as the brown tumor of hyperparathyroidism, so check calcium and parathyroid hormone. Treated by curettage, intralesional corticosteroids, calcitonin or denosumab |
| Cherubism | Autosomal dominant (SH3BP2); bilateral painless swelling of the posterior mandible in young children; multilocular radiolucencies; "eyes upturned to heaven" when the maxilla is involved; usually regresses after puberty |
| Simple bone cyst (traumatic bone cyst) | Teenagers; mandible; radiolucency that scallops between the roots of vital teeth; an empty cavity at surgery; surgical exploration often leads to healing |
| Aneurysmal bone cyst | Young patients; rapid expansion; blood-filled spaces |
| Stafne bone defect | Well-defined radiolucency below the mandibular canal near the angle, caused by salivary gland tissue; no treatment |
Osteomyelitis
| Type | Features |
|---|---|
| Acute suppurative | Pain, fever, mobile teeth, pus, lower lip paresthesia; radiographic changes appear only after about 1-2 weeks |
| Chronic suppurative | Sinus tracts, sequestra (dead bone fragments), moth-eaten radiolucency |
| Proliferative periostitis (Garré osteomyelitis) | Children and young adults; often a carious mandibular first molar; onion-skin layers of new periosteal bone at the lower border; treat the source tooth |
| Condensing osteitis | Localized periapical radiopacity at the apex of a tooth with pulpal inflammation or necrosis; resolves after endodontic treatment or extraction in many cases |
| Osteoradionecrosis and MRONJ | Covered in the oncology and medically compromised sections |
Management of osteomyelitis: drainage, removal of the source and sequestra, culture-guided antibiotics (often prolonged), and resection for refractory disease. Risk factors include diabetes, immunosuppression, irradiated bone, Paget disease, osteopetrosis and cemento-osseous dysplasia.
Metabolic and Systemic Bone Disease
- Paget disease of bone: over 50 years; enlarging skull and maxilla (dentures and hats become tight), spacing of teeth, cotton-wool radiopacities, hypercementosis, raised alkaline phosphatase with normal calcium and phosphate, bleeding at surgery early and osteomyelitis later; small risk of osteosarcoma; treated with bisphosphonates (MRONJ risk).
- Hyperparathyroidism: loss of lamina dura, ground-glass bone and brown tumors.
- Osteopetrosis: dense, brittle bone with high osteomyelitis risk after extraction.
Malignant Lesions
| Lesion | Key points |
|---|---|
| Osteosarcoma | Jaw cases peak in the third and fourth decades (later than long-bone cases); pain, swelling, loosening teeth, paresthesia; symmetrical widening of the PDL space (Garrington sign), sunburst periosteal reaction |
| Chondrosarcoma | Anterior maxilla; adults |
| Ewing sarcoma | Children; onion-skin periosteal reaction; pain and fever mimic infection |
| Multiple myeloma | Older adults; punched-out radiolucencies, bone pain, anemia, renal failure, Bence Jones proteinuria, amyloid macroglossia |
| Langerhans cell histiocytosis | Children and young adults; "scooped-out" alveolar bone with teeth "floating in air"; mimics severe periodontitis |
| Metastatic tumors | Posterior mandible; from breast, lung, prostate, kidney, thyroid; may present as numb chin or a non-healing extraction socket |
Common Incidental Radiopacities
- Torus palatinus: midline hard palate. Torus mandibularis: bilateral, lingual to the premolars. Remove only when they interfere with prostheses or are repeatedly traumatized.
- Idiopathic osteosclerosis (dense bone island): no expansion, tooth vital, no treatment.
- Osteomas: multiple jaw osteomas suggest Gardner syndrome (colonic polyposis, needs referral).
Exam Traps
- Ground-glass with blending margins is fibrous dysplasia; a well-demarcated expansile lesion is ossifying fibroma.
- Do not root-canal-treat vital teeth with periapical cemento-osseous dysplasia.
- A non-healing extraction socket with numb chin in a patient with a cancer history needs biopsy for metastasis.
A 42-year-old woman has well-defined mixed radiolucent-radiopaque lesions at the apices of teeth 31, 32 and 41, all of which respond normally to cold testing. There are no symptoms. What is the appropriate management?
Extract the incisors and curette the lesions to prevent malignant change
Prescribe a 3-week course of amoxicillin, because the lesions are an osteomyelitis
Start root canal treatment of all three incisors, then plan apical surgery
No treatment; review periodically, as this is periapical cemento-osseous dysplasia
A 19-year-old woman has a painless multilocular radiolucency of the anterior mandible crossing the midline. Biopsy shows multinucleated giant cells in a vascular fibrous stroma. Which investigation should follow?
Fasting blood glucose, because diabetes produces giant cell lesions in the jaw
Sweat chloride test, because cystic fibrosis causes multilocular jaw lesions
Serum calcium and parathyroid hormone to exclude a brown tumor of hyperparathyroidism
Urine Bence Jones protein, because giant cell lesions are an early form of multiple myeloma
A 30-year-old has a painful, enlarging swelling of the mandibular premolar region. The radiograph shows symmetrical widening of the periodontal ligament space of tooth 44 and a sunburst periosteal reaction. What is the most likely diagnosis?
Simple (traumatic) bone cyst between roots
Osteosarcoma
Torus mandibularis on the lingual surface
Periapical cemento-osseous dysplasia
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