1. 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
The Maxillofacial Center for Education & Research Dr. J. E. Bouquot, Director
Directions
Copyright
Dedication
The Tissue
3,150,000 hits annually
The Author
Index of All Modules
Additional Resources
Main Index of Disease Changes

2. 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

3. 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

4. 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

5. © 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

6. 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-
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, 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 or $10 US for shipping and handling is requested but not required.
Index of Cortical Bony Masses

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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