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Diseases of Gnathic bones and TMJ

Laura Gennaro Oral Path NDBE English 107 cards

Diseases of Gnathic bones and TMJ

Cards in this deck (107)

  1. 1Idiopathic Osteosclerosis (Enostosis, dense bone island)-Asymptomatic focus of increased bone production
    -Considered a variation of normal
    -Tend to arise in 1st-2nd decade
    -May remain static or enlarge until skeletal maturity
    -Seen in tooth, or non-tooth bearing areas of the jaws
    -Associated dentition vital
    -Diagnosed clinically/radiographically w/ sequential radiographs as needed
    -Root resorption seen rarely
  2. 2Reported prevelance of idiopathic osteosclerosis5-10%
  3. 3Condensing/sclerosing osteitis-Identical radiographic appearance to idiopathic osteosclerosis
    -Seen exclusively at apex of non-vital tooth
    -represents reactive bone formation in response to pulpal/periapical inflammation
  4. 4Cherubismpainless, self-limiting disorder characterized by:
    -symmetric, bilateral expansion of the mandible (& maxilla)
    -bone is replaced by fibro-osseous tissue w/ giant cells
    -swollen, rounded cheeks
    -interference of normal tooth eruption; impacted teeth
    -gnathic expansion causes downward stretching of the skin, exposing the white sclera beneath the iris
    -jaw enlargement continues throughout childhood; stabilizes during puberty and changes regress by early adulthood as normal bone remodeling occurs
  5. 5Hypophosphatasia-rare metabolic bone disease characterized by ALPL mutations
    -alkaline phosphatase levels in serum and bone low
    -low enzyme levels results in impaired bone mineralization
    -variable disease severity
    >>perinatal lethal
    >>infantile (50% die)
    >>adult (mild phenotype)
    >>odontophosphatasia
  6. 6Odontophosphatasia-premature exfoliation of incisors only sign of disease
    -most mild presentation of disease
  7. 7Clinical features of hypophosphatasia-osteomalacia (bone pain/tenderness; fractures)
    -Periodontal disease
    -Premature exfoliation of dentition (cementum does not form, PDL non-functional)
  8. 8Nasopalatine duct cyst (incisive canal cyst)-Most common non-odontogenic cyst of the gnathic bones
    -most common in 4th-5th decade
    -Symmetric radiolucency between vital maxillary central incisors
    >>may appear heart-shaped due to superimposition of the Ant. nasal spine
    >>may cause root divergence    Nasopalatine duct cyst (incisive canal cyst)
  9. 9Paired incisive canals open into a single incisive foramen & transmit...-nasopalatine nerve (innervates palatal mucosa of incisors)
    -terminal end of greater palatine artery (supplies nasal cavity)
    -degenerated remnants of nasopalatine duct
  10. 10Nasopalatine duct cyst arieses from...-epithelial rests of degenerated nasopalatine duct
  11. 11Nasaopalatine duct cyst differential diagnosis-radicular cyst/granuloma
    -keratocystic odontogenic tumor
    -large incisive foramen
  12. 12Nasopalatine duct cyst management-conservative surgical removal
    -recurrence rare
  13. 13Cyst of the incisive papilla-soft tissue counterpart of nasopalatine duct cyst (very rare, no radiograph abnormalities)
    -Arises from remnants of nasopalatine duct located within the incisive papilla
    -conservative removal, recurrence rare
  14. 14Surgical ciliated cyst-uncommon consequence of surgical entry into maxillary sinus
    -sinus epithelium iatrogenically implanted in bone by surgeon (pseudostratified ciliated respiratory epithelium)
    -posterior maxilla most common site
    -conservative removal (recurrence rare)
  15. 15Simple bone cyst (traumatic bone cyst, idiopathic bone cavity)-Hollow cavity within bone
    -Etiology unknown
    -Treated by vigorous curettage of cavity walls (induces bleeding, wound healing)
    -20% recurrence rate    Simple bone cyst (traumatic bone cyst, idiopathic bone cavity)
  16. 16Epidemiology of Simple bone cysts-Metaphysis of humerus or femur most common location
    -2:1 male predilection
    -Most common in 1st-2nd decade
  17. 17Gnathic Simple Bone Cyst-75% occur in posterior mandible, typically unilocular
    -asymptomatic, associated teeth are vital
    -Scalloping between roots characteristic but not universal
    -Rarely bilateral
  18. 18Differential diagnosis of Gnathic simple bone cyst-Keratocystic odontogenic tumor (both have tendency to scallop around roots of teeth)
  19. 19Central Giant Cell Granuloma (CGCG)-Likely neoplastic lesion exclusive to gnathic bones
    -associated w/ PDL of teeth
    -75% of cases are unilocular/multilocular radiolucency of the mandible (anterior or body most common)
    -Most common in 1st-3rd decades
    -Female predilection
  20. 20Aggressive CGCGs characterized by...-pain
    -paresthesia
    -size >5cm
    -root resorption
    -rapid growth
    -cortical perforation
    -recurrence
  21. 21Management & Prognosis of CGCG-surgical excision w/ vigorous curettage
    -variable recurrence rate (depending on biologic potential of lesion)
  22. 22Recurrent CGCG lesions-En bloc resection
    -intralesional injection (steroid, denosumab, IFN-alpha)
  23. 23Aneurysmal bone cyst-benign neoplasm characterized by recurrent USP6 abnormalities
    -Aneurysmal= referring to blowout distension of contour of affected bone
    -Cyst= consists primarily of blood-filled (cyst-like) cavities    Aneurysmal bone cystAneurysmal bone cyst
  24. 24Epidemiology of Aneurysmal Bone Cyst (ABC)-80% occur in 1st-2nd decade
    -20% occur in craniofacial bones
    -Approx. 50% of ABCs occur secondary to a pre-existing lesion (osteoblatoma, CGCGs, fibrous dysplasia, osteosarcoma in craniofacial bones)
  25. 25Gnathic ABC-most commonly occur in posterior mandible
    -multilocular, eccentric radiolucency with paper-thin shell of subperiostea bone
    -rapid growth, tooth displacement, root resorption common
    -patient may complain of pain, tenderness
    -finger in balloon sign    Gnathic ABC
  26. 26ABC clinical differential diagnosis Management & Prognosis-CGCG
    -Aggressive curettage w/ bone grafting (high recurrence rate (20-70%))
    -En bloc resection (most effective treatment; may require significant reconstruction)
  27. 27Hematopoietic bone marrow defect-focus of hyperplastic hematopoietic marrow
    -considered a variation of normal
    -no reported cases outside of gnathic bones
    -no treatment required
    -biopsy usually necessary for diagnosis
    -Post. mandible most common site
    -well-demarcated or diffuse radiolucency
    -may or may not be corticated
    -asymptomatic
  28. 28Myospherulosis-increasingly uncommon iatrogenically caused condition
    -gauze impregnated w/ petrolatum/antibiotics placed following:
    >>dental extractions
    >>surgical procedures involving paranasal sinuses
    >>subcutaneous intramuscular injections
  29. 29Cause of Myospherulosis Presentation Treatment-lipids in petrolatum or linolatum based antibiotic ointments undergo non-degradable emulsification w/ RBCs
    -Non-descript radiolucency; usually in the area of a previously extracted tooth
    -Curettage curative
  30. 30Osteonecrosis (avascular necrosis)-infarction of bone & marrow
    -associated w/ a variety of conditions:
    >>fracture
    >>corticosteroid administration (femoral head common site)
    >>antiresorptive therapy (bisphosphonates, denosumab; jawbones common site)
    >>infection, radiation
    >>sickle cell crisis
  31. 31Medication related osteonecrosis of teh jaws (MRONJ)-uncommon but serious side effect of certain medications
    >>bisphosphonates (majority of cases)
    >>denosumab
    >>antiangiogenic cancer therapies (rarely)
    -rarely extragnathic bones involved
    -mechanism of action incompletely understood
  32. 32What are bisphosphonates?Inhibitors of osteoclastic bone resorption
    -attach to hydroxyapatite crystals in bone
    -ingested by osteoclasts during bone resorption
    -osteoclasts rendered non-functional
    -half-life in bone ~10yr
  33. 33When are bisphosphonates administered?-Cancer therapy (multiple myeloma, metastatic cancer to bone [breast, prostate, lung]; inc. quality of life by decreasing skeletal events)
    -Osteoporosis/osteopenia (reduced risk of osteoporotic bone fracture)
    -Any condition w/ excessive bone resorption (osteogenesis imperfecta, Paget disease)
  34. 34IV bisphosphonates every 3-4 weeks for bone metastases (zoledronate/zometa; pamidronate/aredia)0.5-1% develop osteonecrosis
  35. 35IV bisphosphonates once yearly for osteoporosis (zoledronate/reclast)0.02-0.04% develop osteonecrosis
  36. 36Oral bisphosphonates taken daily/weekly/monthly for osteoporosis (alendronate/fosamax; risedronate/actonel; ibandronate/bonvia)0.1-0.2% develop osteonecrosis
  37. 37What is denosumab?inhibitor of osteoclastic bone resorption
    -binds RANK ligand so it cannot bind RANK (binding is necessary to continue maturation)
    -osteoclasts cannot develop from precursor cells
    -does not bind bone
    -half-life ~6months
  38. 38When is denosumab administered?-Osteoporosis/osteopenia (reduce risk of osteoporotic bone fracture)
    -Cancer therapy (metastatic cancer to bone; increase quality of life by decreasing skeletal-related events)
  39. 39Subcutaneous administration of denosumab every 6months for osteoporosis (Prolia)0.5-1% develop osteonecrosis
  40. 40Subcutaneous administration of denosumab every 4 weeks for bone metastases (Xgeva)0.02-0.04% develop osteonecrosis
  41. 41MRONJ Risk Factors: site73% Mandible
    22.5% Maxilla
    4.5% Both jaws
  42. 42MRONJ Risk Factors: Duration of dose-IV= 9-30 months median onset
    -PO= 4yr median onset
  43. 43MRONJ Risk Factors: Age-no children have developed ONJ
  44. 44MRONJ: Other risk factors-Dentoalveolar surgery?
    -Pre-existing inflammatory dental disease?
  45. 45Diagnosis of MRONJ3 diagnostic criteria must be met:
    1) Current or previous treatment with anti-resorptive/anti-angiogenic agents
    2) Exposed bone or bone that can be probed (intraorally or extraorally) through a fistula
    (Present for at least 8 weeks)
    3No history of radiation therapy to jaws or metastatic disease to jaws
  46. 46Stage 0 MRONJNo clinical evidence of necrotic bone
    Non-specific clinical/radiographic symptoms:
    -Dull/aching bone or sinus pain
    -Odontalgia, loosening of teeth
    -Alveolar bone loss, changes in trabecular pattern of bone
    -Intraoral fistula (does not probe to bone)
  47. 47S-Exposed necrotic bone or fistula that probes to bone
    -No evidence of infection
    -Asymptomatic
  48. 48Stage 2 MRONJ-Exposed necrotic bone or fistula that probes to bone
    -Evidence of infection (swelling, erythema)
    -Typically symptomatic
  49. 49Stage 3 MRONJ-Exposed necrotic bone or fistula that probes to bone
    -Evidence of infection (swelling, erythema)
    -One of the following:
    >>Extensive exposed bone
    >>Pathologic fracture
    >>Extra-oral fistula
    >>Oro-antral/oro-nasal communication
  50. 50Treatment of MRONJ-Conservative management of caries, periodontal disease
    -Close monitoring for progression to higher stage
    -Mobile bony sequestra should always be removed to facilitate soft tissue healing, when possible
    -Chlorhexidine 0.12% (antimicrobial mouth rinse)
    -Oral antibiotics (penicillin best) and/or pain control
    -Surgical resection, debridement
  51. 51MRONJ & dental considerationsPrior to beginning therapy with anti-resorptives
    -Optimize dental health
    If dental work needed during therapy
    -Wait until 2 months after bisphosphonate administration (lowest levels in serum)
    -Bisphosphonate ‘drug holiday’ suggested but efficacy unproven
    If patient has exposed bone
    -Instruct to gently brush area with toothbrush (so plaque doesn’t build up)
  52. 52Osteoradionecrosis-Exposed, irradiated bone in the absence of residual or recurrent tumor
    -Complication of radiotherapy= vascular obliteration leads to tissue hypoxia
  53. 53Osteoradionecrosis of the jaws-Occurs in 5-7% of locally radiated patients
    -Mandible involved in >90% of cases
    (Exposed to high doses of radiation in majority of radiated patients (oropharyngeal cancer, oral cancer)
    Maxillary osteoradionecrosis rare)
  54. 54Majority of Osteoradionecrosis of the Jaws occur...-At radiation doses >60Gy
    -Following dentoalveolar surgery
    -4-36months after completion of radiation therapy
  55. 55Management of Osteoradionecrosis of the jawsComplex
    -Conservative debridement, antibiotics
    -Resection
    -Hyperbaric oxygen
  56. 56Prevention represents best course of action (Osteoradionecrosis)-Extraction of unrestorable teeth
    -Extraction of teeth w/ advanced periodontitis
    -Elimination of oral foci of infection
    -Excellent oral hygiene
  57. 57Spontaneous sequestration (osteonecrosis)-Occurs nearly exclusively along the mylohyoid ridge (<1cm in diameter)
    -Etiology unknown
    -Patient management:
    >>gently brush area (avoids plaque build-up)
    >>once mobile, can be removed
  58. 58Other causes of osteonecrosis-Mechanical trauma
    -Chemical trauma
    -Infection
    -Secondary to disease states causing hypovascular bone
  59. 59Fibrous dysplasia-anomaly of bone-forming mesenchymal tissue
    -characterized by inability of bone-forming tissue to produce mature lamellar bone
    >>Maturation arrested at level of woven bone
    >>abnormal bone produced in increased amounts
  60. 60Fibrous dysplasia manifestation-usually during 1st-3rd decades
    -asymptomatic bony swelling or deformity
    -mild/moderate pain occasionally
    -growth typically arrests by early 20s (foci go away entirely on their own once growth is arrested due to normal remodeling)
  61. 61Fibrous dysplasia variable phenotypic expressions Monostotic FD (85-90%)-one bone involved
    -craniofacial bones, ribs, femur commonly involved
  62. 62Fibrous dysplasia variable phenotypic expressions Polyostotic FD (10-15%)-Multiple bones affected
    -craniofacial involvement in ~50% of cases
    -Mazabraud syndrome: polyostotic FD w/ soft tissue myxomas
  63. 63Fibrous dysplasia variable phenotypic expressions McCune-Albright Syndrome (<5%)-Polyostotic FD
    -Irregular Cafe-au-lait skin pigmentation (coast of Maine borders)
    -precocious puberty
  64. 64Extent of disease (FD) correlates wonset of disease-causing GNAS mutation
    -always post-zygotic (never inherited)
    -Earlier occuring mutations in osteoblast precursors during embryologic development results in greater proportion of functional osteoblasts w/ GNAS mutation (greater amounts of abnormal bone production)
  65. 65Radiographic appearance of FD-normal bone trabeculation characteristically replaced by 'ground glass' appearing bone
    -borders often poorly discernable and blend into normal bone    Radiographic appearance of FD
  66. 66Craniofacial fibrous dysplasiarefers to a solitary lesion affecting multiple contiguous craniofacial bones
  67. 67Fibrous dysplasia Diagnosis & Management-Diagnosed based on clinico-radiologic features (biopsy usually unnecessary)
    -Management depends on the presence of symptoms:
    >>Asymptomatic= observation w/ periodic radiographs
    >>Symptomatic= surgical recontouring (high rate of recurrence until natural cessation of growth of lesion)
  68. 68Cemento-ossifying fibroma-benign odontogenic neoplasm exclusive to tooth-bearing regions of gnathic bones
    -most common in 3rd-4th decades
    -60-70% occur in body of mandible
    -Typically treated by conservative removal
    -Rare patients may have hyperparathyroidism-jaw tumor syndrome
  69. 69Cemento-ossifying fibroma Radiographic appearance-well-demarcated radiolucency w/ variable radiopacitites
    -expansion, root resorption occasionally noted    Cemento-ossifying fibroma Radiographic appearance
  70. 70Aggressive (juvenile) ossifying fibromas -Trabecular ossifying fibroma-mean age range 8.5-12yr
    -Maxilla/mandible most common sites of occurence (rarely extragnathic craniofacial sites)
    -Progressive/rapid expansion of affected area
  71. 71Aggressive (juvenile) ossifying fibromas -Psammomatoid ossifying fibroma-Most common in 2nd-3rd decades
    -Extragnathic craniofacial sites most commonly involved (rarely gnathic bones)
    -Progressive/rapid expansion of affected area
  72. 72Gigantiform cementoma-very rare
    -multifocal development of ossifying fibroma-like lesions
    -arises in childhood & progressively expand to cause facial deformity
    -familial inheritance in some cases    Gigantiform cementoma
  73. 73Cemento-osseous dysplasia-idiopathic bone condition in which bone is replaced by varying amounts of fibrous tissue and cemento-osseous tissue
    -unique to tooth-bearing regions of gnathic bones
    -Most common fibro-osseous lesion encountered
    -May persist following or develop in response to dental extraction
  74. 74Cemento-osseous dysplasia Takes months/years to develop & radiographic appearance depends on maturity of lesion-Early= radiolucent (fibrous tissue)
    -Intermediate= mixed radiolucent/radiopaque
    -Late= radiopaque (cemnto-osseous tissue)    Cemento-osseous dysplasia Takes months/years to develop &amp; radiographic appearance depends on maturity of lesion
  75. 75Cemento-osseous dysplasia most frequently occurs in...African American females in 4th-5th decades
    -asymptomatic & discovered on routine radiographs
    -no bony expansion
    -associated dentition vital
  76. 76Periapical COD-(most?) common presentation of COD
    -affects apices of one or more vital mandibular anterior teeth    Periapical COD
  77. 77Focal CODCOD also known to present unifocally in posterior jawsFocal COD
  78. 78Multifocal CODinvolving more than one siteMultifocal COD
  79. 79Florid CODFlorid COD
  80. 80Management of COD-Can be diagnosed confidently on panoramic or periapical films
    (Biopsy not needed; Should be avoided because hypovascular bone prone to infection (osteomyetlitis))
    -Do not do a root canal if the teeth are vital!!
    -Patient can be followed with serial imaging
    -Osteomyelitis may rarely develop
  81. 81Osteoma-benign, slow-growing, bone-forming tumor
    -Limited almost exclusively to craniofacial bones (gnathic bones less commonly)
    -Most commonly diagnosed in 4th-5th decades
    -Asymptomatic
    -Firm, painless expansion
  82. 82Osteoma Diagnosis-radiographic imaging or biopsy
    -radiographic appearance of gnathic osteomas resembles that of parosteal osteosarcoma and typically requires biopsy
  83. 83Bones/areas affected by Osteoma-Paranasal sinuses, cranial vault, nasal cavity, orbit
    -Inferior or lingual border of mandible
    -Condylar or coronoid regions
  84. 84Osteoid osteoma & osteoblastoma-Microscopically identical neoplasms with predilection for 1st-3rd decades
    -May appear radiolucent, radiopaque, or mixed depending on amount of osteoid is produced
  85. 85Osteoid Osteoma-Less than 1.5-2 cm in diameter
    -50% of cases involve femur or tibia
    -Presents with tenderness, severe nocturnal pain relieved by aspirin
    -10-12% of all bone tumors
    (Uncommon in gnathic bones)
    -Treated by surgical resection
    -Recurrences uncommon
  86. 86Osteoblastoma-Larger than 1.5-2 cm in diameter
    -Frequently involves vertebral column
    -Pain not distinctly nocturnal and unresponsive to aspirin
    -Less than 1% of bone tumors
    -Common in craniofacial bones
    -Treated by surgical resection
    -25% recurrence rate
  87. 87Osteosarcoma-malignant neoplasm of bone
    -most common primary bone malignancy
    -second most common malignancy to metastases
    -75% occur in 1st-2nd decades of life
    -Usually arises in long bones of extremities (50% in area of knee; 6-10% occur in craniofacial bones)
    -Typically presents as painful, progressively enlarging masses; pathologic fracture may be first symptom
  88. 88Osteosarcoma survival-Historically 85-90% of patients developed metastases and died of disease
    -Most patients have subclinical metastatic disease at time of surgery
    -Introduction of neoadjuvant chemotherapy has markedly improved & predicted survival
    >>Responders (>90% tumor necrosis)= long-term survival in 90% of cases
    >>Non-responders= 5yr survival rate of <15%
  89. 89Osteosarcoma of Gnathic bones-tends to affect skeletally mature patients (3rd-5th decades most common)
    -local pain/paresthesia & swelling most consistent complaints
    -Local recurrence most important reason for therapeutic failure
    -metastases occur in 30% of patients (average survival rate <1yr)
  90. 90What percent of mandibular and maxillary osteosarcomas recur-50% of mandibular osteosarcomas
    -80% of maxillary osteosarcomas
  91. 91Radiographic appearance of Gnathic Osteosarcoma-radiolucent, radiopaque, or mixed depending on ratio of bone destruction/formation
    -widening of PDL, loosening of teeth, and supracrestal bone formation may all be seen    Radiographic appearance of Gnathic Osteosarcoma
  92. 92Osteosarcoma, Codman triangle, & 'sunburst' appearance-when breaking through the cortex, lifts off normal periosteum, inducing reactive bone formationOsteosarcoma, Codman triangle, &amp; 'sunburst' appearance
  93. 93Surface osteosarcomas-most osteosarcomas arise within medullary cavity of bone; some originate in periosteal or cortical region w/ little to no medullary involvement
  94. 94Periosteal osteosarcoma-better prognosis than conventional osteosarcomaPeriosteal osteosarcoma
  95. 95Parosteal osteosarcoma-excellent prognosisParosteal osteosarcoma
  96. 96Chondrosarcoma-Malignant neoplasm of cartilage
    -Peak incidence after 5th decade of life
    -<10% occur in craniofacial bones
    -local pain/paresthesia & swelling most consistent complaints
  97. 97Chondrosarcoma statistics-3rd most common primary bone malignancy following osteosarcoma & multiple myeloma
    -Approx. 1/2 as common as osteosarcoma
    -90% are low/intermediate grade tumors (grade I & II)
    -10% are high-grade (grade III, other rare variants)
  98. 98Chondrosarcoma Precursor lesions-Osteochondroma, enchondroma (<1%)
    -Ollier disease, Mafucci syndrome
  99. 99Low/intermediate grade Chondrosarcoma-Slow growing w/ low metastatic potential
    -Relatively refractory to chemotherapy, radiation
    -Treated by surgical resection
  100. 100High-grade chondrosarcoma-high metastatic potential
    -surgical resection remains best chance for cure but some indications for chemotherapy, radiation
  101. 101Mesenchymal chondrosarcoma-<5% of all chondrosarcomas
    -gnathic bones most common site of involvement
    -significant minority occur extraskeletally
    -Most common in 2nd-3rd decades
    -Aggressive= 10yr overall survival ranges from 10-54%
  102. 102Metastases to gnathic bones-comprise 1% of all oral/maxillofacial malignancies
    -gnathic bones & mouth uncommon sites
    -Gnathic bones 2x as commonly involved as oral soft tissues
    -Typically evidence of widespread disease
    -Average survival rate 7months
    -First evidence of disease in up to 25% of patients
    -Local pain/paresthesia & swelling most consistent complaints
    -Bon preferred site of metastasis of several neoplasms (breast, prostate, thyroid, kidney, lungs)
  103. 103Radiographic appearance of metastatic disease-poorly circumscribed radiolucency most common appearance
    -breast and prostate cancer may appear radiopaque
  104. 104Synovial Chondromatosis-benign disorder (likely neoplastic) or synovium
    -Nodules of cartilage produced from synovial membrane
    >>become detached from synovial membrane, float in the joint; may ossify
    -Self-limiting or indolent course
    -Rarely may transform to synovial chondrosarcoma
  105. 105Synoviuimspecialized connective tissue which maintains synovial fluid within synovial cavity of synovial joints
  106. 106Treatment of Synovial chondromatosis-surgical removal of loose bodies & synovial membrane as needed
  107. 107Synovial Chondromatosis characteristics-typically monoarticular
    -affects majority weight-bearing joints
    -TMJ uncommonly affected
    -Pain, swelling, or limitation of function
    -Male predilection
    -TMJ involvement present with non-specific signs and symptoms (pain, swelling, restricted movement, clicking/popping, crepitus, malocclusion)

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NDBE Oral Path Flashcards on Diseases of Gnathic bones and TMJ, created by Laura Gennaro on 21/01/2018.
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Laura Gennaro
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