Troubled Bones: Cortical Bony Masses Module 9 Troubled Bones: Cortical Bony Masses A Part of the Hyperlinked Atlas of Ischemic & Inflammatory Jawbone Disease With more than 1,000 Copyright-Free Photos Version 13.7.1 The Maxillofacial Center for Education & Research Dr. J. E. Bouquot, Director bouquot@oralpath.com bouquot@aol.com Directions Copyright Dedication The Tissue www.maxillofacialcenter.com; 3,150,000 hits annually The Author Index of All Modules Additional Resources Main Index of Disease Changes

Troubled Bones Index of Modules (Topic-Related Sections) ©Photo(s): Dr. J.E. Bouquot, MFCenter for Education & Research Troubled Bones Index of Modules (Topic-Related Sections) Modules: Normal bone and marrow Ischemic marrow, Part I: vascular changes Ischemic marrow, Part II: nonvascular changes Ischemic bone, Part I: cavitated bone Ischemic bone, Part II: noncavitated bone changes Ischemic bone, Part III: osteopenic changes Ischemic bone, Part IV: imaging and clinical features Osteomyelitis, acute & chronic Tori and exostoses Pulp disease Classification of bone disorders References & definitions Typical lesion: a pseudo-biker Index of Cortical Bony Masses

About the Tissue Samples All tissue in these photomicrographs was hand-curetted from the marrow spaces, placed immediately in 10% buffered formalin and shipped by mail or FedEx to the laboratory. In the lab, the tissue was gently decalcified with a formic acid/formalin solution and cut at 7-8 microns in order to prevent destruction of osteocytes as well as to preserve tissue architecture. All non-tumor bone in this lab is treated in a manor designed to provide optimal assessment of viability and minimal artifactual change. Since most cases had a varied microscopic appearance, the photomicrographs are representative only and do not reflect all the different changes seen microscopically. The representative regions, however, are considered to be the most diagnostic regions. Views from Bouquot’s new office: front porch of his home in West Virginia Index of Cortical Bony Masses

Troubled Bones Presentation created by Dr. J.E. Bouquot ©Photo(s): Dr. J.E. Bouquot, The MFCenter; Morgantown, West Virginia Troubled Bones Presentation created by Dr. J.E. Bouquot Please note: This is not a routine Power Point presentation. It is a reference atlas with hyperlinks. This atlas does not function like a scrolling presentation, rather, it works like a web site with hyperlinks allowing you to navigate to various topics within the document. This was created with Power Point 2010. Directions: This is a self-learning module designed to provide very basic information about ischemic and inflammatory bone disorders, bone hyperplasias and pulpal diseases Purpose: to familiarize the student with enough knowledge to recognize basic jawbone and pulpal ischemic and inflammatory diseases and their distinction from other bone diseases To use a hyperlink handout: click on buttons to jump between topics, or the buttons in the lower right corner to go backwards or forwards. Use the button to return to the last slide viewed. Use the button to go to the first slide. Features for each disease appearance are briefly reviewed, primarily microscopic, but some clinical and radiographic features are also presented One module is dedicated to references and definitions, while another to classification Index of Cortical Bony Masses

© The Maxillofacial Center for Education & Research Troubled Bones This presentation created by Dr. J. E. Bouquot © Copyright Notice This presentation is intended for students and colleagues of the author, but is available for general distribution to the health professions. Designated owners of the photographic images retain the copyrights for those images but have agreed to allow their photos to be used for teaching and learning.* You are welcome to use this presentation or portions thereof for your own teaching without permission from the Maxillofacial Center or its contributors, but permission is not given for the publication of these photos in electronic or other formats except for classroom teaching (including online) and handouts of various forms for that teaching. You are welcome to give this presentation free to other health professionals. * Special thanks to photo and idea contributors © The Maxillofacial Center for Education & Research Disclaimer: The author is an adjunct faculty member of the University of Texas School of Dentistry at Houston and the West Virginia University School of Dentistry. The information and opinions provided herein are, however, his own and do not represent official opinion or policy of either university. Index of Cortical Bony Masses

Page 1 of 2 The BTG (Bouquot-To-Go) disk A resource with 3,000+ copyright free photos This disk is literally full of copyright-free clinical and microscopic photos relating to topics in oral pathology and oral medicine. Altogether, there are more than 3,000 photos In Power Point (PP) format, continuously updated and ready for you to use for study, diagnosis or in your own talks. These “hyperlink handouts” have become very popular, with many thousands in use worldwide. Examples of Power Point presentations on the disk: The 53 Most Common Oral Lesions. Hyperlink handout; 500+ clinical photos; first version: 2004; updated 2011 The Must-Know Oral Lesions. Hyperlink handout 0f differential diagnosis; 1,150+ clinical photos; first version: 2009 The CD Johnson Collection – A potpourri of Oral Lesions from the Urgent Care Clinic. Hyperlink handout of various oral lesions, especially those related to drug use; 500+ clinical photos; first version: 2009 The Beginnings of Oral Pathology/Oral Medicine, 1805- 1899. PP presentation depicting the earliest books, articles, drawings of oral lesions; 90+ photos; first version: 2002 The Dreizen Collection – Oral Lesions from the University of Texas, Houston, 1978. One of the first popular collections of oral clinical lesions, from a previous University of Texas faculty member; 90+ clinical photos; first PP version: 2009 Troubled Bones: Ischemic Jawbone Disease. Hyperlink handout providing detailed information about ischemic and inflammatory jaw disorders; 1,000+ photomics and clinical photos; first version: 2006 Review of NICO. PP of a popular lecture; 150+ photos; first version: 2003 The Little Book of Lists. Hyperlink handout of important lists of oral lesions/ effects associated with drugs, syndromes, systemic disorders, etc.; first version: 2009 Order by contacting Dr. Bouquot at Jerry.Bouquot@uth.tmc.edu or bouquot@aol.com; $10 US for shipping and handling is requested but not required. Index of Cortical Bony Masses

Oralpath.com the Oral Pathology Home Page Page 2 of 2 Oralpath.com the Oral Pathology Home Page Web-based information pertaining to diseases of the oral & maxillofacial region is relatively sparse, scattered in small fragments throughout the internet and often lacking in real and evidence-based content. The oralpath.com portal is designed to be not only a reliable source for such information but also a guide to other sites with reliable information. Initiated in 1998, it improved for 6 years, at which time Dr. Bouquot, its webmaster, moved to Texas and was unable to continuously update it. Upon his retirement in 2012 the update began anew. The most popular oral pathology website, worldwide; 1,694,000 hits in 2012; webmaster: Dr. J.E. Bouquot Index of Cortical Bony Masses

Dr. Bouquot, Oral Cancer, Precancer Jerry Bouquot, DDS, MSD, DABOMP, FAAOMP, FICD, FACD, FADI, FRSM Director of Research, The Maxillofacial Center for Education & Research Adjunct Professor, West Virginia University & University of Texas at Houston Page 1 of 2 Born & raised: St. Paul, Minnesota (just another Swede) St. Olaf College, Minnesota (BA, psychology, biology) University of Minnesota (DDS, MSD in oral pathology) Bone Pathology Fellowship, Mayo Clinic Oral Pathology Fellowship, Royal College of Dentistry, Copenhagen, Denmark Chair (18 yrs), Oral & Maxillofacial Pathology, WVU -- Youngest oral path chair in U.S. history Chair (8 yrs), Diagnostic & Biomedical Sciences, Univ. Texas Senior Visiting Scientist, Mayo Clinic, Rochester, MN Dental Director, West Virginia Bureau for Public Health Consultant, Pittsburgh Children’s Hospital Consultant, New York Eye and Ear Infirmary Osteonecrosis Scientific Advisory Board, Novartis Pharm. Board of Directors (national), American Cancer Society Executive Council, Amer. Academy of Oral & Maxillofac. Path. President, American Board of Oral & Maxillofacial. Pathology President, Eastern Society of Teachers of Oral Pathology President, Western Society of Teachers of Oral Pathology President, Organization of Teachers of Oral Diagnosis President (multiple times), American Cancer Society, WV Div. President, 3 regional dental associations Career Development Award, American Cancer Society Outstanding Teacher Award, WVU (8 times) Heebink Award for Service to Humanity, WVU Scholar’s Walk (Two bronze plaques), WVU St. George National Award, American Cancer Society W. Robert Biddington Distinguished Lecturer, WV Robert B. Bridgeman Distinguished Dentist Award, WVDA Fleming & Davenport Award for Original Research, Univ. TX Distinguished Alumnus Award, University of Minnesota 1973 Jamie, Jerry 1980 2002 Jerry (left) and James (right) * 1973 Click to see Bouquot age Index of Cortical Bony Masses

Dr. Bouquot, Oral Cancer, Precancer J.E. Bouquot, DDS, MSD, FAAOMP, Diplomate-ABOMP, FICD, FACD, FADI, FRSM Page 2 of 2 JB 1945 1946 1947 1949 1954 With brothers Dave, Randy, Den With father Elmer With sisters Jan, Marlene With mother Marion With brother Dave 1963 1967 1969 2000 2009, with Geritol 2011 High school grad, Caldwell, New Jersey College grad. Northfield, Minnesota With mother Marion, at Univ. Minnesota Director of Research, MFCenter, WV This is what 44 years in dentistry will do to you Click x2 to see Bouquot age Index of Cortical Bony Masses

This Atlas is dedicated to Dr This Atlas is dedicated to Dr. Robert McMahon, oral surgeon in Merrilville, Indiana, for his constant questioning, skillful therapies and remarkable observational insights. Index of Cortical Bony Masses

Subpontic Osseous Hyperplasia Module 9 Tori and Exostoses Torus Mandibularis, Torus Palatinus Buccal Exostosis Reactive Exostosis Subpontic Osseous Hyperplasia

Mandibular & Palatal Tori Basic Facts Page 1 of 6 Tori are masses growing from the cortical surface and may become massive Mandibular tori develop on the lingual surface of the mandible in the premolar/first molar Palatal tori develop in the hard palate midline Traumatic ulcers on the surface of a torus often takes many weeks, or months, to heal Tori are especially susceptible to bisphosphonate-associated osteonecrosis Tori may be all cortical/lamellar bone or may be filled with marrow spaces Tori often show focal evidence of ischemia, i.e. focal loss of osteocytes, bone marrow edema Dark focus of subcortical infarction and cavitation in mandibular torus Index of Cortical Bony Masses

Mandibular Torus Page 2 of 6 Below & Right: Dense mass of lamellar bone many have few, if any, spaces filled with fibrovascular tissue. In this field, none are present. Left: Clinical view of torus. Index of Cortical Bony Masses

Mandibular Torus Page 3 of 6 All photos: This torus is filled with osteopenic bone. The fatty marrow shows signs of granular fat necrosis (arrows) and congestion (dilated capillary) Index of Cortical Bony Masses

Mandibular Torus Page 4 of 6 Right: Many empty, sometimes enlarged lacunae (white arrow) and a layer of new bone formed over the dead bone, separated by a thick cement line (yellow arrow). Below: Almost completely solid torus has largely empty “marrow” spaces or spaces filled with greatly dilated capillaries. Index of Cortical Bony Masses

Torus Palatinus Page 5 of 6 Below: Solid mass of lamellar/cortical bone has only small spaces filled with fibrofatty tissue. Occasional microcracks are seen (arrows). Above: Arrow points to midline bony mass. Index of Cortical Bony Masses

Torus Palatinus Page 6 of 6 Right: Mature lamellar bone has many empty lacunae (sign of nonviable bone) Below: Mass of bone with empty spaces indicative of chronic ischemic damage. Overlying palatal mucosa has several minor salivary glands. Index of Cortical Bony Masses

End of this Subunit Next: Buccal Exostosis Index of Cortical Bony Masses

Buccal Exostosis Basic Facts Page 1 of 4 Buccal exostoses develop on the facial surfaces of the maxillary and mandibular alveoli Presumed to result from chronic clenching or grinding of the teeth May be solid lamellar bone or filled with fatty or hematopoietic marrow May show regions of nonviable bone or ischemic marrow damage Index of Cortical Bony Masses

Buccal Exostoses Page 2 of 4 Below: Fatty marrow in an exostosis shows extensive ischemic damage, with myelofibrosis, plasmostasis, fatty microvesicles and scattered lymphocytes. The bone remains viable. Above: Classic bony masses of the facial surface of the maxillary alveolus. Photo: Dr. Robert Gorlin, University of Minnesota Index of Cortical Bony Masses

Buccal Exostosis Page 3 of 4 All photos: Exostosis shows diffuse reticular fatty degeneration with coalesced fat cells (arrows; indicates necrosis) and a few chronic inflammatory cells. Index of Cortical Bony Masses

Buccal Exostosis Page 4 of 4 Below: Fibrofatty “marrow” fills numerous spaces within intertwining sheets of mature lamellar bone. Above: Lower left bone has many empty lacunae, indicated focal bone death (the ischemic pattern), while greatly dilated marrow capillaries (arrow) indicate increased backup pressures, i.e. intramedullary hypertension. Some vessels (to left) are empty, indication stagnation as well. Index of Cortical Bony Masses

End of this Subunit Next: Reactive Exostosis Index of Cortical Bony Masses

Reactive Exostosis Basic Facts Page 1 of 4 This is a cortical mass developing after injury (patient may not remember) Located in areas NOT associated with tori -- Usually hard palate May be blunt or pointed May be painful in early stages May show erythematous mucosal covering -- Usually not May be solid lamellar bone or filled with cancellous bone In early stages: new bone formation in the heart of the lesion, perhaps on the surface May show osteomyelitis or ischemic damage in central or subcortical zones Last indefinitely, usually, but some will completely disappear Index of Cortical Bony Masses

Reactive Exostosis Page 2 of 4 All photos Beneath cortical bone of lesion is a focus of fibrosing chronic inflammation (yellow arrow; chronic fibrosing osteomyelitis). Abundant new/reactive bone (white arrows) fills cancellous spaces. Index of Cortical Bony Masses

Reactive Exostosis Page 3 of 4 Below: Bony hard, sessile, asymptomatic mass of the left hard palate (yellow arrow) was not radiographically visible. Right: Dilated capillaries (white arrows; marrow edema) are seen in spaces within dense sheets of mature lamellar bone. Left: higher power view of photomic. above Index of Cortical Bony Masses

Reactive Exostosis Page 4 of 4 Below: Marrow in exostosis shows greatly dilated marrow capillary (yellow arrows) lies adjacent to region of dead fat cells with granular cytoplasm (circle). Above: Above: Nonviable adipocytes become filled with a granular pale material (arrows), partially consisting of serous ooze. Index of Cortical Bony Masses

End of this Subunit Next: Subpontic Hyperplasia Index of Cortical Bony Masses

Subpontic Osseous Hyperplasia Basic Facts Page 1 of 3 Presumably from altered periosteal electrical charge (piezo phenomenon) created by slight lateral forces of abutment teeth once bridge is placed Bony mass found immediately beneath abutment May be all lamellar or may have cancellous bone inside May show chronic inflammation or ischemic marrow damage Bone itself usually remains viable Occasionally is painful May remain even if bridge is removed Index of Cortical Bony Masses

Subpontic Osseous Hyperplasia Page 2 of 3 Below: C Viable lamellar bone has small spaces filled with loose fibrovascular connective tissue; in this case, without inflammation or ischemia. Above: Sessile bony mass beneath pontic (arrow) is somewhat less dense than rest of mandible. Microscopically is showed ischemic bone disease and was clinically very painful for a number of years. Index of Cortical Bony Masses

Subpontic Osseous Hyperplasia Page 3 of 3 Below: Microcracks (yellow arrows) found beneath a pontic have very smooth edges compared to routine microtome knife tears (white arrow) . They represent defective growth or remodeling of bone. Above: Microcrack (yellow arrow); excess prominent cement lines (parallel to top of photo), focal loss & pyknosis of osteocytes (oval) are all signs of chronic ischemic change. Index of Cortical Bony Masses

Texas Medical Center in Houston; largest medical center in the world End of this Module Texas Medical Center in Houston; largest medical center in the world Index of Cortical Bony Masses