FOLs seminar Dr. Abd El Azeem Mostafa

1. Fibro osseous
lesions
Dr/ Abd El Azeem Mostafa

2. Definition :
• intraosseous lesions in which there is
replacement of normal bone by tissue
composed of collagen , fibers & fibroblasts
that contain varying amounts of
mineralized substances , which may be
osseous or cementum-like in appearance .

3. • These are essentially
benign lesions

4. Classification of FOLs
A- developmental B- reactive / reparative
1- solitary bone cyst 1- aneurysmal bone cyst
2- Gigantiform cementoma 2- central giant cell
3- cherubism granuloma
3- Garre's osteomylitis
4- osseous dysplasia
- florid osseous dysplasia
-Periapical ( cemental )
osseous dysplasia
- focal osseous dysplasia
( sclerosing osteomylitis )
5- osseous keloid
6- traumatic periostitis

5. Classification of FOLs cont..
C- neoplasm D- endocrinal / metabolic
1- benign brown tumor of
cementoblastoma hyperparathyroidism
2- ossifying fibroma
3- osteoid osteoma
4-Osteoblastoma
E- idiopathic
1- fibrous dysplasia
2- pagets disease

6. A- developmental

7. 1- solitary bone cyst
• The traumatic bone cyst (TBC) is an uncommon nonepithelial
lined cavity of the jaws.
• The lesion is mainly diagnosed in young patients most
frequently during the second decade of life.
• The majority of TBCs are located in the mandibular body
between the canine and the third molar.
• Clinically, the lesion is asymptomatic in the majority of cases
and is often accidentally discovered on routine radiological
examination usually as an unilocular radiolucent area with a
"scalloping effect".
• The definite diagnosis of traumatic cyst is invariably
achieved at surgery. Since material for histologic examination
may be scant or non-existent, it is very often difficult for a
definite histologic diagnosis to be achieved..

8. Preoperative panoramic X-ray showing the left lower semi-impacted
3rd molar.
Panoramic X ray taken four years later showing a unilocular radiolucent
area in the left ramus.

9. CT scans showed a cyst like low density area in the left ramus region.
CT scans showed a cyst like low density area in the left ramus region.

10. Normal appearing bone spicules with parts of vascular connective tissue
(haematoxylin-eosin, original magnification × 40).
Higher magnification (haematoxylin-eosin × 160).

11. 2- Gigantiform cementoma
• Gigantiform cementoma is a rare, benign
fibro-cemento-osseous disease of the
jaws, seen most frequently in young girls.
• Radiographically, it typically presents as
multiquadrant, expansile, mixed
radiolucent-opaque lesions that cross the
midlines of the jaws.
• Although cases with a familial pattern are
noted in a few publications, sporadic
cases have been reported without a
family history.

13. (a) Massive mixed radiolucent/radioopaque expansile lesions in both jaws.
(b) Fibro-osseous pattern with cementicles and boney trabecuae,
the former often appearing much larger that
those seen in cemento-ossifying fibroma

14. 3- cherubism
• It is a autosomal dominant fibro-osseous
• *benign hereditary condition which
affects only the jaw bones and it is
• characterized by “bilaterally symmetrical
enlargement” of mandible sometimes
maxilla

17. Cherubism is a hereditary disease
which is histologically similar to
Central Giant cell granuloma

18. B- reactive / reparative

19. 1- aneurysmal bone cyst
• Aneurysmal bone cyst (ABC) is an uncommon non-
neoplastic lesion of the bones, usually affecting the long
bones and spine.
• The rare jaw lesions are encountered in the body and ramus
of the mandible.
• Commonly reported in the second and third decades of life,
• ABC's are characterized by a rapid growth pattern with
resultant bony expansion and facial asymmetry.
• Surgical management usually consists of surgical curettage
or resection.
• The treatment of aneurysmal bone cyst is complete surgical
excision of the lesion.
• Sometimes, the lesion regresses even after incomplete
removal. Prognosis is excellent and recurrences are rare.

20. Aneurysmal bone cyst.
Expansile multilocular "soap bubble"-like osteolysis with soft tissue
extension transversed by intralesional bony septa.
Although barely visible, the extraosseous component is well-delineated.
Root resorption of included teeth.

21. Prominent osteoblastic activity is seen along anastomosing bony trabeculae

22. 2- central giant cell granuloma
• (CGCG) is a benign lesion of the jaws with
an unknown etiology.
• Clinically and radiologically, a differentiation between
aggressive and non-aggressive lesions can be made.
• The incidence in the general population is very low
and patients are generally younger than 30 years.
• Histologically identical lesions occur in patients with
known genetic defects such as cherubism, Noonan
syndrome, or neurofibromatosis type 1.
• Surgical curettage or, in aggressive lesions, resection,
Is the most common therapy.

27. 3- Garre's osteomylitis
• Inflammatory periosteal hyperplasia
• -Periosteal reaction to inflammation:
forms several rows of reactive vital bone
parallel to each other.
• -Primarily in children and young adults
(avg~13 yrs)
• -Most frequent cause: caries w/ assoc
Periapical disease

31. 4- osseous dysplasia
• periapical OD/COD: dysplastic lesions occurring in
the anterior mandible and involving only a few
adjacent teeth
• focal OD/COD: similar to periapical OD/COD, but
with the limited number of lesions occurring in a
posterior jaw quadrant (rather than in the anterior
mandible)
• florid OD/COD and familial gigantiform cementoma:
more extensive forms, occurring bilaterally in the
mandible or in all jaw quadrants

32. periapical OD/COD

33. focal OD/COD

34. florid OD/COD

35. Hematoxylin and eosin stained section of the maxillary right quadrant
showing cemental masses
fusing with the trabeculae of the bone (10×)

36. traumatic periostitis

37. C- neoplasm

38. 1- benign cementoblastoma
• The benign cementoblastoma is a relatively rare
odontogenic neoplasm of the jaws
• The lesion is considered as the only true neoplasm of
cementum origin
• generally occurs in young persons, comprises less than 1%
to 6.2% of all odontogenic tumours
• characterized as being attached to the roots, most
frequently tends to be associated with an erupted
permanent tooth, most often the first molar or second
premolar in the lower jaw: only rarely has an association
with an impacted or partially impacted tooth been reported
• The recommended treatment is complete enuclation of the
tumor mass with extraction of the involved tooth

42. 2- ossifying fibroma
• Ossifying fibroma develops from the multipotential mesenchymal
cells of periodontal origin which are able to form both bone and
cementum. Although the precise pathogenesis is still unknown, it
has been suggested that trauma induced stimulation may play a
role.
• Juvenile ossifying fibroma is a fibro-osseous neoplasm that
arises within the craniofacial region in young individuals below 15
years of age.
• It is described in the World Health Oraganisation histological
typing of odontogenic tumours as an actively growing lesion
consisting of a cell rich fibrous stroma, containing bands of
cellular osteoid without osteoblastic lining, together with
trabeculae of more typical woven bone. Small foci of giant cells
may also be present.
• The lesion is non – encapsulated but well demarcated from
surrounding bone

46. 3- osteoid osteoma
• Osteomas are benign, slow-growing osteogenic
tumours rarely occurring in the craniofacial bones.
• Osteomas are characterised by the proliferation
of compact and/or cancellous bone.
• It can be of a central, peripheral, or extra skeletal
type.
• The peripheral type arises from the periosteum
and is rarely seen in the mandible.
• The lingual surface and lower border of the body
are the most common locations of these lesions.
• They are usually asymptomatic and can be
discovered in routine clinical and radiographic
examination.

49. - Limited growth pattern (1.5- 2.0 cm).
- Sharp circumscription near cortical surface (forming nidus).
- Composed of anastomosing bony trabeculae with variable mineralization.
- Bony trabecules lined by plump osteoblast.
- Vascularized connective tissue: surrounded by sclerotic bone.
- Benign giant cells may be present.

50. 4-Osteoblastoma
• Benign osteoblastoma is an uncommon, solitary, osteoid and
bone-producing tumor which is characterized by prevalent
active osteoblasts and rich vascularized delicate fibrous
stroma, previously regarded as malignant.
• The term benign osteoblastoma was recently proposed by
different authors to separate this lesion from other solitary
benign bone tumors.
• It most often involves long bones and vertebral column and
other bones, and also occurs in jaw bones.
• There is a close histopathologic similarity between benign
osteoblastoma and osteoid osteoma; consequently, much
debate about them exists.
• Benign osteoblastoma has a good prognosis and is best
treated by curettage or conservative surgical excision.
Recurrence is rare.

51. Cellular connective tissue containing delicate collagen fibres and
irregular bone-like trabeculae.
Plump osteoblasts and multinucleated osteoclasts are present on
the trabeculae.

52. Radiolucent lesion with small calcifications and irregular,
indistinct margins in the 33-46 area.

53. D- endocrinal / metabolic

54. brown tumor of
hyperparathyroidism
• excess secretion of parathyroid hormone due to
parathyroid hyperplasia compensating for a metabolic
disorder that has resulted in retention of phosphate or
depletion of the serum calcium level.
• The radiologic features of both forms of
hyperparathyroidism are similar. These include generalized
osteoporosis, unilocular or multilocular cystic
radiolucencies in bone (Brown tumor), attenuation or loss
of lamina dura surrounding the teeth, and calcifications in
muscles and subcutaneous tissues.
• It is often considered that histopathologic study of a biopsy
specimen is the basis for diagnosis of "cystic" lesions of
the jaws
• . Unfortunately, the Brown tumor provides no definitive
histologic answer. Nuclear medicine or serologic
confirmation is usually needed.

56. E- idiopathic

57. fibrous dysplasia
• non-neoplastic, primary disorder of
bone in which normal medullary bone is
replaced by a variable amount of
structurally weak fibrous and osseous
tissue.

62. Paget's disease
• a chronic progressive disease of the bone characterized by
abnormal bone resorption and deposition affecting either single
bone (monostotic) or many bones (polyostotic) with uncertain
etiology.
• Clinical symptoms include pain, deformity, and may lead to fracture
of the affected bone, even though the initial course of the disease
may be asymptomatic.
• The enlarged and deformed bones may compress surrounding
nerves and vessels causing neurological symptoms like hearing
loss; inexplicably, it is quite unusual in the facial bones.
• Facial disfigurement may be consequence of enlargement of the
maxilla and/or mandible
• Therapeutic agents commonly used include calcitonin,
bisphosphonate, and mithramycin. A recent clinical trial suggested
that second and third generation bisphosphonate, such as
pamidronate and alendronate, were more effective than calcitonin
and editronate, the first generation bisphosphonate.

63. Extra oral view shows large mandible

64. Large size partially edentulous mandible

65. OPG shows hypercementosis of the teeth roots.

66. 3D scan shows thickened mandibular cortical plate

67. (a) Irregular reversal line, (b) mosaic bone pattern histologically

68. Biochemical report

69. GOOD LUCK