A Note on Bone Swellings in Jaw Bones

Bone Swellings

Bone swellings are lesions that characteristically present as asymptomatic hard lumps, covered by normal epithelium. Developmental disorders, benign and malignant tumors are included in this group of lesions.

•        Torus mandibularis
•        Torus palatinus
•        Multiple exostoses
•        Osteoma
•        Osteosarcoma
•         Chondrosarcoma
•         Burkitt lymphoma
•         Multiple myeloma
•         Paget disease
•       Odontogenic tumors

Torus Mandibularis

Definition and etiology Torus mandibularis is a developmental malformation of unknown etiology.

Clinical features It presents as an asymptomatic bony swelling, covered by normal mucosa. The lesion displays slow growth during the second and third decades of life. Characteristically, the lesions appear bilaterally on the lingual surface of the mandible, usually in the area adjacent to the bicuspids. The diagnosis is based on clinical criteria.

Torus mandibularis

Treatment Unnecessary unless full denture construction is required.

Torus Palatinus

Torus palatinus at the midline of the hard palate

Definition and etiology Torus palatinus is a developmental malformation of unknown etiology.

Clinical features It presents as a slow-growing, nodular, lobular or spindled, asymptomatic bony swelling covered by normal mucosa. Characteristically, the lesion appears along the midline of the hard palate.It occurs more often in women, and usually appears during the third decade of life. The diagnosis is based on the clinical findings.

Treatment Unnecessary unless full denture construction is required.

Multiple Exostoses

Multiple exostoses may occur on the buccal surface of the maxilla, and rarely on the mandible. Clinically, the lesions appear as multiple asymptomatic bony swellings. The diagnosis is based on the clinical findings.

Multiple exostoses on the maxilla.

Treatment Unnecessary unless full denture preparation is required.

Osteoma

Definition Osteoma is a benign neoplasm that consists of mature compact or cancellous bone.

Etiology Unknown.

Clinical features

It presents as an asymptomatic, slow-growing bony swelling of the jaws. The size ranges from a few millimeters to several centimeters. Multiple jaw osteomas are a common feature of Gardner syndrome.

Gardner syndrome: osteoma of the mandible.

Laboratory tests Histopathological examination, radiography.

Differential diagnosis Exostoses, osteosarcoma.

Treatment Surgical excision.

Osteosarcoma

Definition Osteosarcoma is the most common primary malignant neoplasm of bone.

Etiology Unknown.

Clinical features

The jaws are affected in 6–7% of cases, and usually during the third decade of life. Both jaws are affected equally and it is more common in men. Clinically, the lesion presents as a rapidly growing hard swelling that progressively produces facial deformity. Pain, paresthesia, tooth loosening, and nasal obstruction may also occur.

Osteosarcoma of the upper jaw, presenting as a hard swelling.

Laboratory tests Histopathological examination, radiography, CT scans.

Differential diagnosis Chondrosarcoma, Ewing sarcoma, metastatic tumors, odontogenic tumors and cysts, giant-cell tumor.

Treatment Surgical excision and supplementary radiotherapy and chemotherapy.

Chondrosarcoma

Chondrosarcoma  is more common in men than in women, between 30 and 60 years of age. Clinically, it appears as a painless hard swelling that progressively enlarges, causing extensive bone destruction with pain and loosening of the teeth.

Burkitt Lymphoma

Definition Burkitt lymphoma is a high-grade malignant B-lymphocyte lymphoma.

Etiology Epstein–Barr virus is closely associated.

Clinical features

The malignancy is prevalent in central Africa (the endemic form), and usually affects children 2–12 years of age. Cases have also been observed in other countries (the nonendemic form), and recently in patients with AIDS. The jaws are the most common site of lymphoma (60–70%). Clinically, it presents as a rapidly growing hard swelling that causes bone destruction, tooth loss, and facial deformity.Pain, paresthesia and large ulcerating or nonulcerating masses may also be seen.

Burkitt lymphoma, facial deformity.

Burkitt lymphoma, gingival mass

Burkitt lymphoma on the gingiva in a young patient with AIDS

Laboratory tests Histopathological examination, radiography.

Differential diagnosis Central giant-cell granuloma, ossifying fibroma, other non-Hodgkin lymphomas, and odontogenic tumors.

Treatment Chemotherapy, radiotherapy.

Multiple Myeloma

Definition Multiplemyeloma is a relatively rare malignant plasma-cell disorder.

Etiology Unknown.

Clinical features The malignancy is more common in men over 50 years of age, and the jaws are affected in about 30% of cases. Clinically, it presents with bone swelling, tooth mobility, pain, and paresthesia. A painless soft swelling, usually on the alveolar mucosa and gingiva, may develop as part of the overall disease spectrum.

Multiple myeloma, swelling on the gingiva

Laboratory tests Bone-marrow biopsy, radiography, serum and urine protein electrophoresis.

Differential diagnosis Plasmacytoma, non-Hodgkin lymphoma, Ewing sarcoma, leukemia, Langerhans cell histiocytosis.

Treatment Chemotherapy, radiotherapy.

Paget Disease

Definition Paget disease, or osteitis deformans, is a chronic, relatively common disorder characterized by uncoordinated bone resorption and deposition.

Etiology Unknown.

Clinical features Clinically, the signs and symptoms develop gradually and are characterized by bone pain, headache, deafness, visual disorders, dizziness, and progressive bone enlargement. Progressive expansion of the maxilla and the mandible lead to symmetrical thickening of the alveolar ridges.

Paget disease, enlarged maxilla

Edentulous patients may complain that their dentures do not fit due to alveolar enlargement.

Paget disease, alveolar enlargement

Delayed wound healing, bleeding, and osteomyelitis after tooth extraction may occur. The maxilla is more frequently affected than the mandible. Malesare more often affected than females. Two major forms of the disease are recognized: (a) the monostotic, and (b) the polyostotic. The clinical diagnosis should be confirmed by a histopathological and radiographic examination. Elevations of serum alkaline phosphatase and urinary hydroxyproline levels are common findings.

Differential diagnosis Fibrous dysplasia, osteosarcoma, multiple exostoses, fibro-osseous lesions.

Treatment Most cases require no treatment. Calcitonin and bisphosphonates may slow the pathological process.

Odontogenic Tumors

Definition Odontogenic tumors are a group of lesions that originate from odontogenic epithelium and ectomesenchyme.

Etiology Unknown. Some are neoplasms and others hamartomas.

Classification On the basis of the tissue of origin, three major varieties are recognized: (a) tumors of odontogenic epithelium, (b) tumors of odontogenic ectomesenchyme, and (c) mixedod ontogenic tumors.

Clinical features Most odontogenic tumors are usually asymptomatic for long time and are discovered only during a routine radiographic examination. However, with time they may form a usually painless slow-growing swelling or expansion of the mandible or the maxilla.

Odontogenic myxoma, expansion of the retromolar area

Extraosseous calcifying epithelial odontogenic tumor presenting as a gingival mass

The clinical signs and symptoms are not diagnostic and the final diagnosis should be made by radiographic and histopathological examinations.

Differential diagnosis Different varieties of odontogenic tumors, odontogenic cysts, osteosarcomas, chondrosarcomas, multiplemyeloma.

Treatment Surgical excision.