ossifying fibroma and cemental dysplasia

MALABAR DENTAL COLLEGE
MALABAR ACADEMIC CITY

1. OSSIFYING FIBROMA AND CEMENTAL DYSPLASIA DR SHABIL MOHAMED MUSTAFA ASSOCIATE PROFESSOR MALABAR DENTAL COLLEGE AND RESEARCH CENTRE

2. OSSIFYING FIBROMA Other terms: cemento ossifying fibroma , cementifying fibroma Is a true neoplasm with significant growth potential. It resemble focal cemento -osseous dysplasia radiographically and histopathologically . Ossifying fibromas are relatively rare.

3. Most authorities consider it to be an odontogenic neoplasm. This tumour consist of highly cellular, fibrous tissue that contains varying amount of abnormal bone or cemental like tissue. In the past this lesion was classified as 2 different entities depending on whether bone or cementum was predominant calcified product. When the histologic appearance of most of the calcified tissue was of irregular trabeculae of woven bone, the term ossifying fibroma was used. .

4. When predominant calcified component was cementum term cementifying fibroma was used Since microscopic appearance of an ossifying fibroma and cementifying fibroma can be very similar, these are combined under the name cemento -ossifying fibroma. Juvenile ossifying fibroma is a very aggressive form of cemento -ossifying fibroma that occurs in first 2 decade of life.

5. CLINICAL FEATURES Occurs over a broad age range Peak in third and fourth decade of life. Female predilection. Mandible is involved far more than maxilla. Mandibular premolar and molar area is most common site Maxillary lesion tends to involve antrum Displacement of teeth may be an early clinical feature.

6. Small lesion are often asymptomatic and may be detected by radiographic examination. Larger tumour produce painless jaws swelling and facial asymmetry. Some lesions may become massive and cause considerable deformity. Pain and paraesthesia are rare. .

7. Most lesions are solitary however multiple synchronous lesion have been reported very rarely-either as an isolated finding or as a component of hyperparathyroidism- jaw tumour syndrome

8. RADIGRAPHIC FEATURES LOCATION appears exclusively in facial bones and most commonly mandible,inferior to premolar and molars and superior to inferior alveolar canal. in maxilla –canine fossa and zygomatic arch area

9. PERIPHERY Borders are well defined. A thin radiolucent line representing fibrous capsule may separate it from surrounding bone. Sometimes bone next to lesion develops sclerotic border.

10. INTERNAL STRUCTURE Is a mixed radiolucent- radiopaque density with a pattern that depends on amount and form of manufactured calcified material. In some instance internal structure may appear almost totally radiolucent with a hint of calcified material. In the type that mainly contain abnormal bone the pattern may be similar to that seen in fibrous dysplasia , or a wispy( stretched tuft of cotton) or flocculant pattern(similar to large heavy snowflakes). Lesion that produces a more cementum like material may contain solid amorphous radioopacities ( cementicles )

11. EFFECT ON SURRONDING STRUCTURE Can result in displacement of teeth or inferior alveolar canal and expansion of outer cortical plate of bone. Outer cortical plate is displaced and thinned. Outer cortical plate remains intact. The lamina dura of involved tooth is usually missing and resorption of teeth may occur. The lesion occupy entire maxilla, expands its wall outward however a bony partition always exist between internal aspect of remaining aspect of sinus and tumor .

12. DIFFERENTIAL DIAGNOSIS Fibrous dysplasia Periapical cemental dysplasia Calcifying odontogenic cyst Calcifying epithelial odontogenic ( pindborg tumor ) Adenomatoid odontogenic tumor Osteogenic sarcoma

13. TREATMENT Surgical enucleation or resection. Large lesion that have caused considerable bone destruction surgical resection and bone grafting,. Recurrance after complete removal is uncommon. Good prognosis No apparent potential for malignant transformation

14. CEMENO –OSSEOUS DYSPALSIA(OSSEOUS DYSPLASIA) Most common fibro osseous lesion. Occurs in tooth bearing area of jaws. Based on clinical and radiographic feature following variants are seen: Focal Periapical florid

15. FOCAL CEMENTO-OSSEUOS DYSPLASIA CLINICAL FEATURES Involves single site 90% cases occur in females Mean age 41 years Predilection for third to sixth decade Seen Most often in American-blacks followed by east-Asian and whites It most commonly involves posterior mandible

16. Disease is asymptomatic and detected by radiographic examination Lesion is smaller than 1.5cm in diameter

17. PERIAPICAL CEMENTO-OSSEOUS DYSPLASIA 2 . Predominantly involves periapical region of anterior mandible. Solitary lesion may occur , but multiple foci typically are present. Marked female predilection Female to male ratio 10:1 to 14:1

18. 70% of cases affects blacks. Most patients are diagnosed between 30 and 50 years of age. The associated teeth are usually vital.

19. RADIOGRAPHIC FEATRURES LOCATION Epicentre usually lies at apex of a tooth. In rare cases the epicentre is slightly higher and over the apical third of the tooth. Has predilection for periapical bone of mandibular anterior teeth. Most cases lesion is multiple and bilateral. Occasionally a solitary lesion arises.

20. PERIPHERY AND SHAPE Periphery is well defined . Often a radiolucent border of varying width is present , surrounded by a band of sclerotic bone of varying width. This sclerotic bone represent the reaction of immediate surrounding bone. The lesion may be irregulary shaped or overall round or oval shaped centered over the apex of teeth.

21. EFFECT IN SURROUNDING STRUCTURE Lamina dura of teeth involved is lost , making pdl space either less apparent or giving it a wider appearance. Rarely root resorption my occur. Occasionally hypercementosis occur on the root of a tooth positioned within the lesion. Some lesion stimulate a sclerotic bone reaction from the surounding bone . Small lesion do not cause expansion of jaw. Larger lesion may cause expansion of jaw thin, intact outer cortex.

22. INTERNAL STRUCTURE Varies depending on maturity of the lesion . 3 stages : Early stage Mixed stage Mature stage In early stage normal bone is resorbed and replaced with fibrous tissue that usually is continuous with the pdl ligament Radiographicaly this appears as a radiolucency at the apex of involved tooth

23. In mixed stage radiopaque tissue appear in the radiolucent structure This material usually is amorphous ; has a round , oval or irregular shape and is composed of cementum or abnormal bone this structures are sometimes called cementicles . In mature stage the internal aspect may be totally radiopaque without obvious pattern. Usually a thin, radiolucent margin can be periphery because this lesion matures from center outward.

24. The internal structure may appear radiolucent if cavities resembling simple bone cyst form within the cemental lesion. In some cases this simple bone cyst extent beyond the margin of the cemental lesion.

25. DIFFERENTIAL DIAGNOSIS Periapical rarefying osteitis(in early pcd ) Benign cemento -blastoma(in mixed and late form) odontoma

26. MANAGEMENT Diagnosis is based on radiologic and clinical characteristics. Possible complication of biopsy is secondary infection, which may occur in lesions that have abundant cementum formation and poor vascularity and treatment is not required. If considerable atrophy of alveolar ridge has occurred, the segments of cementum may reach the mucosal surface,which can perforate the mucosa when positioned under denture. If this occur the pieces of cementum have to be removed surgically because they can act as sequestra in osteomylitis

27. 3.FLORID CEMENTO OSSEOUS DYSPLASIA Exhibit multifocal involvement not limited anterior mandible. Predominantly affects black females. Marked predilection for middle age to older adults. Show a tendency for bilateral and fairly symmetrical involvement of mandible .

28. Occasionally extensive involvement in all four quadrants The disease may be asymptomatic. In other cases the patient may have dull pain , alveolar sinus tract and exposure of yellowish avascular bone to oral cavity. Some jaw expansion may be evident. Both dentulous and edentulous area may be affected. Involvement unrelated to presence or absence of teeth

29. RADIOGRAPHIC FEATURES LOCATION Bilateral and present in both jaws. When they are present only in one jaw mandible is most common location. The epicentre is apical to the teeth within the alveolar process and usually posterior to the cuspid . In mandible the lesion occurs above inferior alveolar canal.

30. PERIPHERY It is well defined and has sclerotic border that vary in width. The soft tissue capsule may not be apparent in mature lesions .

31. EFFECT ON SURROUNDING STRUCTURE Large lesion can displace the inferior alveolar nerve canal in inferior direction. FOD can displace the floor of antrum in superior direction and cause enlargement of alveolar bone by displacement of buccal and lingual cortical plate. The associated teeth root may have considerable amount of hypercementosis which may fuse with the abnormal surrounding cemental tissue of the lesion .

32. INTERNAL STRUCTURE It can vary from and equal mixture of radiolucent and radiopaque region to almost complete radio-opacity. The radiopaque region can vary from small oval and circular regions(cotton wool appearance) to large irregular amorphous of calcification. Some prominent radiolucent regions may be present which usually represent development of simple bone cyst. These cyst may enlarge with time or may fill in with abnormal dysplastic cemento -osseous tissue.

33. DIFFERENTIAL DIAGNOSIS Paget’s disease Chronic sclerosing osteomyelitis Secondary osteomyelitis

34. MANGEMENT Under normal circumstances FOD does not require treatment. Because of the propensity to develop secondary infection , the patient should be encourage to maintain an effective oral hygiene. Program to avoid odontogenic infection If the teeth are extracted and severe atrophy of alveolar process occur , cementum masses emerge and the pressure of the overlying denture may cause dehiscence in the mucosa resulting in osteomyelitis which may spread.

35. It may be necessary to remove large areas of cemental tissue leaving very little residual bone for prosthetic treatment

36. THANKYOU