```markdown Bone Diseases DENT 5322 part II Dr Omar Kujan DDS DipOPath MSc PhD MFDS RCPS FHEA 1 ``` #### Course Information **DENT 5322 Part II** #### Instructor Details **Dr. Omar Kujan** - DDS, DipOPath, MSc, PhD - MFDS RCPS, FHEA ```markdown **Benign cemento-osseous lesions:** **Fibrous dysplasia** **Cemento-osseous dysplasias** Subtypes: periapical cemental focal cemento-osseous florid cemento-osseous **Cemento-ossifying fibroma** Subtypes: conventional juvenile active ``` #### Fibrous Dysplasia Fibrous dysplasia represents a category of benign cemento-osseous lesions characterized by the replacement of normal bone with fibrous connective tissue and irregular bone trabeculae. #### Cemento-Osseous Dysplasias These lesions are classified into three distinct clinical and radiographic subtypes: - **Periapical cemental dysplasia**: Typically involves the mandibular anterior teeth. - **Focal cemento-osseous dysplasia**: Usually presents as a single site of involvement. - **Florid cemento-osseous dysplasia**: Characterized by multifocal or symmetric involvement across multiple quadrants of the jaws. #### Cemento-Ossifying Fibroma This group includes neoplastic lesions categorized into two primary subtypes: - **Conventional cemento-ossifying fibroma**: The standard presentation of the neoplasm. - **Juvenile active (ossifying) fibroma**: A more aggressive variant typically seen in younger patients. ```markdown Fibrous Dysplasia ``` Fibrous Dysplasia is a benign, non-neoplastic bone disorder characterized by a developmental defect in bone formation. ```markdown **Fibrous Dysplasia** - Benign disorder of bone - Non-neoplastic tumor-like lesion - Developmental defect in bone formation - Fibrous proliferation - Disorderly malformed woven bone - Enlarged deformed bones - Structurally weak ``` #### Pathological Overview - Benign disorder of bone - Non-neoplastic tumor-like lesion - Developmental defect in bone formation - Fibrous proliferation - Disorderly malformed woven bone - Enlarged deformed bones - Structurally weak # Fibrous Dysplasia - **Sites**: ribs, femur, tibia, pelvis, craniofacial - Age: onset in childhood – adolescence - Single or multiple bony lesions - Slow growing - Painless - Often quiesces at puberty - Genetics: GNAS I gene chromosome 20q13.1-2 #### Clinical Presentation and Genetics - **Common Sites**: Ribs, femur, tibia, pelvis, and craniofacial bones - **Age of Onset**: Typically occurs in childhood through adolescence - **Lesion Characteristics**: - Single or multiple bony lesions - Slow growing - Painless - Often quiesces (stabilizes) at puberty - **Genetics**: Associated with the GNAS I gene located on chromosome 20q13.1-2 # Fibrous Dysplasia - Monostotic - 70% - craniofacial – (25%) - Polyostotic - 25% - craniofacial – (50%) - McCune-Albright Syndrome - 3% - endocrine abnormalities #### Classification Types 1. **Monostotic** - Accounts for 70% of cases - Craniofacial involvement in 25% of cases 2. **Polyostotic** - Accounts for 25% of cases - Craniofacial involvement in 50% of cases 3. **McCune-Albright Syndrome** - Accounts for 3% of cases - Characterized by associated endocrine abnormalities # Fibrous Dysplasia ## Oral & Maxillofacial Manifestations: - Painless swelling - Facial asymmetry - Malocclusion – displaced teeth - Headache - Hearing loss - Clinical labs: elevated alkaline phosphatase #### Clinical Symptoms - Painless swelling - Facial asymmetry - Malocclusion and displaced teeth - Headache - Hearing loss #### Laboratory Findings - Clinical labs may show elevated alkaline phosphatase levels. # Radiographic Features: - “Ground glass” opacification - Diffuse – poorly delineated - Cortical expansion – fusiform enlargement - Narrow periodontal ligament - Obscure lamina dura - Early lesions – radiolucent/mottled #### Imaging Characteristics - **Ground Glass Appearance**: Classic opacification pattern - **Margins**: Diffuse and poorly delineated - **Bone Changes**: Cortical expansion resulting in fusiform enlargement - **Dental Implications**: - Narrow periodontal ligament - Obscured lamina dura - **Early Progression**: Early lesions may appear radiolucent or mottled ```html <table> <tr> <td> <img src="https://i.imgur.com/1.png" alt="X-ray image showing fibrous dysplasia in the jawbone, with visible tooth structures and bone density changes." /> </td> <td> <img src="https://i.imgur.com/2.png" alt="X-ray image showing fibrous dysplasia in the jawbone, with visible tooth structures and bone density changes." /> </td> </tr> </table> ``` Fibrous dysplasia   Radiographic evidence of fibrous dysplasia in the jawbone demonstrates characteristic changes in bone density and effects on the surrounding tooth structures. X-ray image showing fibrous dysplasia in the jawbone, with visible tooth structures and bone density changes, highlighting areas of abnormal bone growth. X-ray image showing fibrous dysplasia in the jawbone, with visible tooth structures and bone density changes, indicating a pattern of bone remodeling. <img src="https://i.imgur.com/5ZjKz6l.png" alt="X-ray image of the skull with a red dot indicating a specific area and the number 10 in the bottom right corner."/>  Skull radiography highlighting specific areas of craniofacial involvement. X-ray image of a skull showing the nasal cavity and surrounding structures, with a red dot indicating a specific area of interest and the number 10 in the bottom right corner. <figure> <img src="https://i.imgur.com/1234567.jpg" alt="Two X-ray images of a foot, showing the bones and joints. The image on the right has a red dot marking a specific area on the heel." /> <figcaption>Two X-ray images of a foot, showing the bones and joints. The image on the right has a red dot marking a specific area on the heel.</figcaption> </figure>   Radiographic imaging of the extremities (foot) showing bone and joint involvement, specifically identifying lesions in the heel area. A black-and-white X-ray image of a foot, showing the bones and joints. The image on the right has a red dot marking a specific area on the heel. A black-and-white X-ray image of a foot, showing the bones and joints. The image on the right has a red dot marking a specific area on the heel. # Histology - Woven bone - Irregular trabeculae “Chinese Characters” - Fibrous stroma - No osteoblastic lining - Blends into normal bone – no capsule - Maturation into lamellar bone #### Microscopic Features - **Bone Structure**: Woven bone with irregular trabeculae often described as resembling "Chinese Characters" - **Stroma**: Fibrous stroma present - **Cellular Features**: Absence of an osteoblastic lining - **Margins**: Blends into normal bone without a capsule - **Progression**: Potential maturation into lamellar bone <img src="https://i.imgur.com/5ZjKqfE.png" alt="Microscopic image of tissue stained with hematoxylin and eosin, showing cellular structures and extracellular matrix. A red circle highlights a specific area of interest. The number '13' is visible in the bottom right corner." />  Microscopic tissue analysis using hematoxylin and eosin staining reveals the cellular structures and extracellular matrix characteristic of the lesion. Microscopic image of tissue stained with hematoxylin and eosin, showing cellular structures and extracellular matrix. A red circle highlights a specific area of interest, and the number '13' is visible in the bottom right corner.  Microscopic image of tissue stained with hematoxylin and eosin, showing cellular structures with purple and pink hues. The image displays various cell types and extracellular matrix components, with some areas containing round white spaces likely representing vacuoles or cysts. A red dot highlights a specific point of interest within the tissue. **Cellular - growing** <img src="https://i.imgur.com/1.png" alt="Microscopic image of cellular tissue with a red marker indicating a specific area." />   #### Growth Phase - **Cellular - growing**: Microscopic view showing active cellular proliferation within the tissue. Microscopic image of cellular tissue with a red marker indicating a specific area, labeled as 'Cellular - growing'. The image shows dense cellular structures with varying shades of purple and pink, typical of histological staining. Another microscopic view of cellular tissue, showing elongated cells and fibrous structures in a purple and pink coloration. A red marker highlights a specific region, possibly indicating a point of interest in the tissue growth. ```html <table> <tr> <td> <img src="https://i.imgur.com/1234567.png" alt="Microscopic image of bone tissue with label 'Late - still woven bone'"/> </td> <td> <p><strong>Late - still woven bone</strong></p> </td> </tr> <tr> <td> <img src="https://i.imgur.com/7654321.png" alt="Microscopic image of bone tissue with a red dot and number '16'"/> </td> <td> <p>16</p> </td> </tr> </table> ```   #### Late Stage Histology - **Late - still woven bone**: Histological evidence showing that even in later stages, the bone often retains its woven architecture. Microscopic image of bone tissue labeled 'Late - still woven bone', showing a purple-stained section with irregular bone structures and scattered cells. Microscopic image of bone tissue with a red dot indicating a specific point of interest, labeled with the number 16, showing woven bone structure. ```html <table> <tr> <td> <img src="https://i.imgur.com/1.png" alt="Old fibrous dysplasia"/> </td> <td> <p><strong>Old fibrous dysplasia</strong></p> </td> </tr> <tr> <td> <p><strong>Reactivated area</strong></p> </td> <td> <img src="https://i.imgur.com/2.png" alt="Reactivated area"/> </td> </tr> </table> ```   #### Tissue Variations - **Old fibrous dysplasia**: Characteristics of long-standing lesions. - **Reactivated area**: Evidence of renewed activity or growth within an established lesion. A histological image showing old fibrous dysplasia with characteristic woven bone and fibrous tissue patterns, stained in purple and pink hues, illustrating the abnormal bone formation. A histological image of a reactivated area in fibrous dysplasia, highlighted by a red dot, showing increased cellular activity and structural changes in the bone tissue. ```markdown # Fibrous Dysplasia - Complications - Debilitating deformities - Esthetic/psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement - Malignant degeneration: - rare (< 1%) - osteosarcoma - avoid radiation therapy ``` #### Clinical Complications - Debilitating deformities - Esthetic and psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement #### Malignant Transformation - Rare occurrence (less than 1%) - Most commonly transforms into osteosarcoma - **Caution**: Radiation therapy should be avoided as it may trigger malignant change. ```markdown **Fibrous Dysplasia - Complications** - Debilitating deformities - Esthetic/psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement - Malignant degeneration: - rare (< 1%) - osteosarcoma - avoid radiation therapy ``` #### Clinical Complications - Debilitating deformities - Esthetic/psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement #### Malignant Degeneration - Rare (< 1%) - Osteosarcoma - Avoid radiation therapy ```markdown Fibrous Dysplasia - Complic - Debilitating deformities - Esthetic/psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement - Malignant degeneration: - rare (< 1%) - osteosarcoma - avoid radiation therapy ```  #### Clinical Complications - Debilitating deformities - Esthetic/psychosocial concerns - Malocclusion - Pathologic fractures - Cranial nerve and orbital involvement #### Malignant Degeneration - Rare (< 1%) - Osteosarcoma - Avoid radiation therapy The image displays a presentation slide titled 'Fibrous Dysplasia - Complications' with a bulleted list of potential complications. The text includes debilitative deformities, esthetic/psychosocial concerns, malocclusion, pathologic fractures, cranial nerve and orbital involvement, and malignant degeneration, which is noted as rare (<1%) and can lead to osteosarcoma, with a recommendation to avoid radiation therapy. The slide has a dark purple background with yellow text and a light-colored menu on the right side. **Fibrous Dysplasia - Management:** - May not require treatment - Conservative management - Stabilizes with skeletal maturity - Diffuse involvement precludes excision - Cosmetic and functional deformity - Surgical recontouring/decompression - Regrowth (25-50% - younger patients) #### Treatment Strategies - Treatment may not be required in all cases. - **Conservative Management**: Often preferred as the condition typically stabilizes with skeletal maturity. - **Surgical Considerations**: - Diffuse involvement often precludes complete excision. - Surgery is indicated for cosmetic and functional deformities. - Procedures include surgical recontouring or decompression. - **Prognosis**: Regrowth occurs in 25-50% of cases, primarily in younger patients. **Periapical Cemento-Osseous Dysplasia** Periapical cemento-osseous dysplasia is a specific form of bone dysplasia that occurs in the periapical region of the jaws. # Periapical Cemento-Osseous Dysplasia ## Clinical: - Benign non-neoplastic dysplastic process - Incidence: relatively common - Age: middle age (30 – 50 years) - Gender: female > male (14:1) - Race: black - Site: mandibular anterior – periapical area - Asymptomatic, vital teeth, non-expansile #### Clinical Presentation Periapical cemento-osseous dysplasia is a benign, non-neoplastic dysplastic process with the following clinical characteristics: - **Incidence:** Relatively common. - **Demographics:** - **Age:** Typically affects middle-aged individuals (30–50 years). - **Gender:** Strong female predilection (14:1 ratio). - **Race:** More frequently observed in Black populations. - **Location:** Primarily involves the mandibular anterior periapical area. - **Symptoms:** The condition is asymptomatic; teeth remain vital, and there is no cortical expansion. # Periapical Cemento-Osseous Dysplasia Radiographic Findings: - Multiple - Circumscribed apical radiolucency - Variable radiopacity - maturation - Size: < 1.0 cm - Non-expansile - Vital teeth  #### Radiographic Characteristics - **Distribution:** Often presents as multiple lesions. - **Appearance:** Circumscribed apical radiolucencies with variable degrees of radiopacity depending on the stage of maturation. - **Size:** Generally less than 1.0 cm in diameter. - **Impact on Structures:** Non-expansile nature; associated teeth remain vital. The image contains a list of radiographic findings for periapical cemento-osseous dysplasia, presented as a bulleted list. The findings include multiple circumscribed apical radiolucencies with variable radiopacity due to maturation, size less than 1.0 cm, non-expansile nature, and vital teeth. The text is displayed in yellow on a dark purple background.  two dental X-ray images side by side, showing the teeth and surrounding bone structure, with a red dot highlighting a specific area of interest in the lower left X-ray. <img src="https://i.imgur.com/9fZjJQl.png" alt="Two dental X-rays showing tooth roots and surrounding bone. The right image has a red circle highlighting a specific area on one of the roots."/>   #### Radiographic Evidence Radiographic imaging of the mandibular anterior region demonstrates the characteristic periapical involvement associated with this condition. Two dental X-rays showing tooth roots and surrounding bone. The left image displays a standard view of multiple teeth, while the right image highlights a specific area on one of the roots with a red circle, indicating a point of interest for diagnosis. A dental X-ray with a red circle highlighting a specific area on a tooth root, likely indicating a lesion or abnormality. The image is part of a series, as indicated by the number '24' in the bottom right corner.  microscopic image of tissue showing cellular structures with varying shades of pink and purple, likely a histological section stained with hematoxylin and eosin, featuring a central red dot indicating a specific point of interest.  Microscopic image of tissue stained with hematoxylin and eosin, showing pink and purple structures indicative of cellular and extracellular components. The image includes various tissue patterns and a small red dot, likely indicating a point of interest or annotation. # Periapical Cemento-Osseous Dysplasia Management: - Clinical – radiographic diagnosis - Benign self limiting process - No progressive growth - No treatment required - Prognosis: excellent - Avoid unnecessary endodontic therapy, surgery or extractions #### Clinical Management - **Diagnosis:** Established through a combination of clinical and radiographic findings. - **Nature of Disease:** Benign, self-limiting process with no progressive growth. - **Treatment Protocol:** No treatment is required. - **Prognosis:** Excellent. #### Clinical Precautions It is essential to avoid unnecessary dental interventions, including: - Endodontic therapy - Surgical intervention - Extractions ```markdown **Focal Cemento-Osseous Dysplasia** **Clinical:** - Etiology: non-neoplastic – disordered growth of cementum and bone - Incidence: most common benign fibro-osseous lesion - Age: 4-5ᵗʰ decade - Gender: female (80%) - Race: caucasian ``` #### Demographic and Etiological Profile - **Etiology**: Non-neoplastic; characterized by the disordered growth of cementum and bone. - **Incidence**: Recognized as the most common benign fibro-osseous lesion. - **Age**: Typically presents in the 4th to 5th decades of life. - **Gender**: Predominantly affects females (approximately 80% of cases). - **Race**: Most frequently observed in Caucasian populations. ```markdown **Focal Cemento-Osseous Dysplasia** **Clinical:** - Site: posterior mandible - Asymptomatic - Solitary - Edentulous areas - Size: < 1.5 cm - Radiographic: mixed radiolucent – opaque, well defined or irregular borders ``` #### Clinical Presentation and Radiographic Findings - **Site**: Most commonly located in the posterior mandible. - **Symptoms**: Typically asymptomatic and discovered during routine examination. - **Presentation**: Usually appears as a solitary lesion, often in edentulous areas. - **Size**: Generally measures less than 1.5 cm. - **Radiographic Appearance**: - Mixed radiolucent-opaque presentation. - Borders may be well-defined or irregular. ```markdown FCOD ``` ```html <table border="1" cellpadding="5" cellspacing="0"> <tr> <td rowspan="2" style="text-align: center; vertical-align: middle;"><img src="https://i.imgur.com/placeholder1.jpg" alt="X-ray image showing dental structures and a highlighted area." /></td> <td rowspan="2" style="text-align: center; vertical-align: middle;"><img src="https://i.imgur.com/placeholder2.jpg" alt="Microscopic image of tissue with a red dot indicating a specific area." /></td> </tr> <tr> <td style="text-align: center; vertical-align: middle;">33</td> </tr> </table> ```   Focal Cemento-Osseous Dysplasia (FCOD) clinical and radiographic documentation. X-ray image showing dental structures and a highlighted area, with the text 'FCOD' displayed below it. Microscopic image of tissue with a red dot indicating a specific area, labeled with the number 33. ```markdown **Focal Cemento-Osseous Dysplasia Histology:** - Benign fibro-osseous lesion - Cellular spindled fibroblasts - Collagen fibers - Globular cementum matrix material - Woven osseous matrix material - Vascular channels ``` #### Histopathological Characteristics As a benign fibro-osseous lesion, the histology is characterized by: - Cellular spindled fibroblasts. - Dense collagen fibers. - Globular cementum matrix material. - Woven osseous matrix material. - Presence of vascular channels.  microscopic view of tissue showing a dense population of spindle-shaped cells with elongated nuclei, interspersed with collagen fibers and blood vessels. the tissue appears to be stained with hematoxylin and eosin, highlighting the cellular and extracellular matrix components. the presence of small, round structures suggests the presence of blood vessels or glandular elements. the overall morphology is consistent with a fibrous or connective tissue sample. ```markdown **Focal Cemento-Osseous Dysplasia** **Treatment – Prognosis:** - Curettage – biopsy - Prognosis: excellent - Limited growth potential - Periodic follow-up ``` #### Management and Clinical Outlook - **Intervention**: Treatment typically involves curettage or biopsy for diagnostic confirmation. - **Prognosis**: The outlook is excellent. - **Growth**: The lesion exhibits limited growth potential. - **Follow-up**: Periodic monitoring and follow-up are recommended. **Florid Cemento-Osseous Dysplasia** Florid cemento-osseous dysplasia is a specific form of bone dysplasia that occurs within the tooth-bearing areas of the jaws. # Florid Cemento-Osseous Dysplasia ## Clinical: - Benign non-neoplastic dysplastic process - Incidence: relatively rare - Age: middle age adults - Gender: female > male - Race: black (90%) - Site: diffuse involvement of jaws - Asymptomatic, expansion, secondary infection #### Demographic and Clinical Characteristics Florid cemento-osseous dysplasia is a benign, non-neoplastic dysplastic process with the following clinical profile: - **Incidence:** Relatively rare. - **Age:** Primarily affects middle-aged adults. - **Gender:** Significant female predilection (Female > Male). - **Race:** Predominantly affects Black individuals (approximately 90% of cases). - **Site:** Characterized by diffuse involvement of the jaws. #### Symptomatology While often discovered incidentally, clinical presentations may include: - Asymptomatic nature in many patients. - Potential for jaw expansion. - Risk of secondary infection. ```markdown **Florid Cemento-Osseous Dysplasia** **Radiographic Findings:** - Irregular lobular dense radiopacities - Mixed radiolucent and radiopaque areas - Diffuse involvement of maxilla and mandible - Bilateral - Symmetrical ``` #### Imaging Characteristics The radiographic appearance of this condition is distinct and typically involves: - Irregular lobular dense radiopacities. - Mixed radiolucent and radiopaque areas (maturing stages). - Diffuse involvement of both the maxilla and mandible. - Bilateral and symmetrical distribution. <figure> <img src="https://i.imgur.com/4XJzQ.png" alt="Dental X-ray image showing teeth and jawbone with a red dot highlighting a specific area on the lower right side."> </figure>  #### Radiographic Presentation Clinical imaging (such as dental X-rays) demonstrates the characteristic dense, lobulated radiopaque masses within the alveolar bone, often localized or diffuse along the mandibular or maxillary arches. A dental X-ray image showing the jawbone and teeth, with a red dot highlighting a specific area on the lower right side of the jaw. The image displays the dental structure, including teeth and surrounding bone, with a focus on a particular region indicated by the red marker. <img src="https://i.imgur.com/5ZvZvZv.png" alt="Microscopic image of tissue stained with hematoxylin and eosin, showing cellular structures and spaces, with a red dot marking a specific area. Page number 42 is visible in the bottom right corner."/>  #### Histopathological Features Microscopic examination typically reveals a mixture of fibrous connective tissue, woven bone, and cementum-like calcifications. The tissue shows varying degrees of mineralization depending on the stage of the lesion. Microscopic image of tissue stained with hematoxylin and eosin, showing cellular structures and spaces, with a red dot marking a specific area. The image displays a complex network of cells and extracellular matrix in shades of pink and purple, typical of histological sections. ```markdown **Management:** - Benign self-limiting process - No treatment required - Potential for significant complications - Avoid exposure of calcific masses - Maintenance of dentition - Chronic osteomyelitis - pain, fistulae, dehiscence, sequestration - Traumatic bone cysts ``` #### Clinical Management Guidelines As a benign and often self-limiting process, the management strategy focuses on observation and prevention: - No active treatment is required for asymptomatic cases. - Emphasis is placed on the maintenance of dentition to avoid the need for extractions. - Avoid surgical exposure of the calcific masses, as these areas have poor vascularity and are prone to infection. #### Potential Complications Despite its benign nature, significant complications can arise, particularly if the bone is compromised: - **Chronic Osteomyelitis:** May present with pain, fistulae, dehiscence, and sequestration. - **Traumatic Bone Cysts:** These secondary lesions may occasionally develop within the dysplastic bone. Benign cementoblastoma Benign cementoblastoma is a rare odontogenic neoplasm characterized by the formation of cementum-like tissue. ```html <table> <tr> <td><img src="https://i.imgur.com/6VXQZqE.png" alt="Presentation slide with title 'Benign cementoblastoma' and a right-click context menu showing options like 'Next', 'Previous', 'Help', etc." /></td> </tr> </table> ```  Benign cementoblastoma. A right-click context menu from a presentation software, showing options like 'Next', 'Previous', 'Zoom In', and 'Help'. The menu is overlaid on a slide with the title 'Benign cementoblastoma' in cyan text on a dark purple background. ```markdown ScienceDirect Journals Books Register Sign in Download PDF Export Search ScienceDirect Advanced search Journal of Oral and Maxillofacial Surgery Volume 65, Issue 10, October 2007, Pages 2080–2082 Case report An Unusual Recurrent Cementoblastoma Associated With a Developing Lower Second Molar Tooth: A Case Report Halla Zaitoun, BDS, MFDS¹, Omar Kujan, DDS, MSc², Philip Sloan, BDS, PhD, FDSRCS, FRCPath³ Show more http://dx.doi.org/10.1016/j.joms.2006.06.288 Get rights and content Cementoblastoma is a benign ectomesenchymal odontogenic neoplasm that forms a mass of cementum or cementum-like tissue continuous with the tooth root, usually a mandibular premolar or first molar.¹ It has been considered analogous to osteoblastoma and can be very destructive of tissue.² This lesion clinically presents as a tender, sometimes painful swelling at the buccal and lingual/palatal aspect of the alveolus.¹ It generally affects persons under age 30 years and has a higher prevalence in males (1.2:1). Radiographically, it appears as a radiopaque mass with a thin radiolucent rim attached to the roots of a tooth. The mass may be rounded or irregular in shape and mottled in texture.³ Several cases of tooth resorption, loss of root outline, and obliteration of the periodontal ligament space have been reported.¹ Histologically, the lesion is composed predominantly of sheets or trabeculae of cementum-like calcified tissue with variably prominent reversal lines, sometimes with a pagetoid appearance.¹ Cells including cementoblasts and cementoclasts are enclosed within the hard tissue or around the periphery of the trabeculae. Cementoblastoma was previously thought to be an innocuous entity, because available data were limited to case reports with little follow-up. Thus, it is usually managed by conservative surgical enucleation. This case report describes the clinical and histopathologic features of an unusual, rapidly growing, recurrent cementoblastoma. Article outline Report of a Case Discussion References Figures and tables ADVERTISEMENT Looking for a new ```       #### Definition and Nature Cementoblastoma is a benign ectomesenchymal odontogenic neoplasm that forms a mass of cementum or cementum-like tissue continuous with the tooth root. It is considered analogous to osteoblastoma and can be destructive to surrounding tissue. #### Clinical Presentation - Typically presents as a tender, sometimes painful swelling at the buccal and lingual/palatal aspect of the alveolus. - Generally affects individuals under the age of 30. - Higher prevalence in males (1.2:1). - Usually involves a mandibular premolar or first molar. #### Radiographic Appearance - Appears as a radiopaque mass with a thin radiolucent rim attached to the roots of a tooth. - The mass may be rounded or irregular in shape and mottled in texture. - Common features include tooth resorption, loss of root outline, and obliteration of the periodontal ligament space. #### Histological Characteristics - Composed predominantly of sheets or trabeculae of cementum-like calcified tissue. - Features variably prominent reversal lines, sometimes exhibiting a pagetoid appearance. - Cementoblasts and cementoclasts are found enclosed within the hard tissue or around the periphery of the trabeculae. #### Management and Prognosis Previously thought to be an innocuous entity due to limited follow-up data, it is usually managed by conservative surgical enucleation. However, cases of rapid growth and recurrence have been documented. A radiographic image showing a radiopaque mass attached to the roots of a tooth, consistent with a cementoblastoma, as described in the case report. A histological section of the cementoblastoma, displaying sheets of cementum-like tissue with variably prominent reversal lines, characteristic of the lesion. A panoramic radiograph illustrating the lesion's attachment to the roots of the lower second molar, demonstrating its association with a developing tooth. A radiographic image showing the mass of cementum-like tissue attached to the roots of the tooth, with a thin radiolucent rim, as seen in the case report. A histological image of the cementoblastoma, highlighting the presence of cementoblasts and cementoclasts within the hard tissue. A high-magnification histological view of the lesion, showing cementum-like calcified tissue with variably prominent reversal lines and a pagetoid appearance. ```markdown **Cementoblastoma- Clinical** - tender, sometimes painful swelling - the buccal and lingual/palatal aspect of the alveolus - under age 30 years - prevalence in males (1.2:1) - Mandible (80%) 1<sup>st</sup> molar 47 ``` #### Clinical Presentation - Tender, sometimes painful swelling. - Located at the buccal and lingual/palatal aspect of the alveolus. - Predominantly affects patients under age 30 years. - Male prevalence (1.2:1). - Most common site: Mandible (80%), specifically the 1st molar. ## Cementoblastoma- Radiological - radiopaque mass with a thin radiolucent rim attached to the roots of a tooth - tooth resorption, loss of root outline, and obliteration of the periodontal ligament space 48 #### Radiographic Features - Radiopaque mass with a thin radiolucent rim attached to the roots of a tooth. - Associated with tooth resorption, loss of root outline, and obliteration of the periodontal ligament space. <figure> <img src="https://i.imgur.com/1234567.jpg" alt="Three dental X-ray images showing different views of teeth and surrounding bone structures. The top-left image highlights a specific area with a red circle. The bottom image is a lateral view with tooth numbering visible on the left side."> </figure>    Radiological imaging of cementoblastoma demonstrates the characteristic attachment to the tooth root and the surrounding radiolucent rim. Three dental X-ray images showing different views of teeth and surrounding bone structures. The top-left image highlights a specific area with a red circle, indicating a point of interest or pathology. A dental X-ray image showing a close-up view of teeth and roots, with a focus on the apical region, likely used for diagnosing dental issues such as abscesses or root canal problems. A lateral dental X-ray image displaying multiple teeth with visible root canals and surrounding bone structure. Tooth numbering is visible on the left side, aiding in identification and clinical assessment. **Cementoblastoma- Histological** - sheets or trabeculae of cementum-like calcified tissue with variably prominent reversal lines, sometimes with a pagetoid appearance 50 #### Microscopic Findings - Presence of sheets or trabeculae of cementum-like calcified tissue. - Prominent reversal lines are variably present, occasionally showing a pagetoid appearance.  Microscopic tissue section labeled 'A', showing a dense cellular structure with pink and purple staining, indicative of a histological sample. The image displays a high magnification view of cellular morphology, with a red dot highlighting a specific region of interest.  Microscopic image showing a histological section with pink-stained tissue, likely a cross-section of a biological sample such as bone or cartilage, with visible cellular structures and matrix. The image is marked with a red dot, possibly indicating a point of interest, and the number 52 in the bottom right corner suggests it is a page or figure number. ```markdown **Cementoblastoma-treatment** - Surgery - Recurrence 35-60% 53 ```  #### Treatment and Prognosis - Primary treatment: Surgery. - Recurrence rate: 35-60%. The image displays a slide with the title 'Cementoblastoma-treatment' in blue text on a dark purple background. The slide lists two bullet points: 'Surgery' and 'Recurrence 35-60%', both in yellow text. The number '53' is visible in the bottom right corner, likely indicating the slide number. ```markdown Classification of Benign Odontogenic Tumours 1. Odontogenic epithelium without odontogenic ectomesenchyme 2. Odontogenic epithelium with odontogenic ectomesenchyme, with or without dental hard tissue formation 3. Odontogenic ectomesenchyme with or without included odontogenic epithelium ```  The classification of benign odontogenic tumors is categorized into three primary groups based on the tissue of origin and the presence of dental hard tissue formation: 1. Odontogenic epithelium without odontogenic ectomesenchyme 2. Odontogenic epithelium with odontogenic ectomesenchyme, with or without dental hard tissue formation 3. Odontogenic ectomesenchyme with or without included odontogenic epithelium The image displays a classification of benign odontogenic tumors presented as a numbered list. The list categorizes the tumors into three types: 1) Odontogenic epithelium without odontogenic ectomesenchyme, 2) Odontogenic epithelium with odontogenic ectomesenchyme, with or without dental hard tissue formation, and 3) Odontogenic ectomesenchyme with or without included odontogenic epithelium. The text is displayed in yellow on a dark purple background.  microscopic image of tissue section stained with hematoxylin and eosin, showing a cross-section of a structure with a central lumen surrounded by epithelial cells and connective tissue, with a red dot indicating a specific point of interest. <img src="layers_of_the_enamel_organ.png" alt="Layers of the enamel organ"/>  #### Histological Components - Layers of the enamel organ Microscopic image showing the layers of the enamel organ, with a distinct pink-stained structure on the left side representing the organized cellular layers, and scattered cells in the surrounding tissue. The image is labeled "Layers of the enamel organ" at the bottom.  The image displays two side-by-side microscopic photographs of tissue sections, likely from a histological examination. The left panel shows a dense cluster of cells with dark nuclei, possibly indicating a tumor or inflammatory infiltrate, adjacent to a structure resembling a gland or duct. The right panel shows a more organized arrangement of elongated cells with prominent nuclei, possibly muscle fibers or epithelial cells, with a red dot highlighting a specific area of interest. These images are likely used to compare different tissue types or pathological states. 1. Odontogenic epithelium without odontogenic ectomesenchyme - Ameloblastoma - Squamous odontogenic tumour - Calcifying epithelial odontogenic tumour (Pindborg Tumour) #### Epithelial Tumors without Ectomesenchyme This category includes tumors derived solely from odontogenic epithelium: - Ameloblastoma - Squamous odontogenic tumour - Calcifying epithelial odontogenic tumour (Pindborg Tumour) 2. Odontogenic epithelium with odontogenic ectomesenchyme with or without dental hard tissue - Ameloblastic fibroma - Ameloblastic fibro-dentinoma - Ameloblastic fibro-odontome - Adenomatoid odontogenic tumour - Calcifying odontogenic cyst - Complex odontome - Compound odontome #### Mixed Epithelial and Ectomesenchymal Tumors These tumors involve both odontogenic epithelium and ectomesenchyme, and may or may not exhibit dental hard tissue formation: - Ameloblastic fibroma - Ameloblastic fibro-dentinoma - Ameloblastic fibro-odontome - Adenomatoid odontogenic tumour - Calcifying odontogenic cyst - Complex odontome - Compound odontome 3. Odontogenic ectomesenchyme with or without included odontogenic epithelium - Odontogenic fibroma - Myxoma [myxofibroma] - Benign cementoblastoma ('true' cementoma) #### Ectomesenchymal Tumors These tumors are primarily composed of odontogenic ectomesenchyme, which may or may not contain included odontogenic epithelium: - Odontogenic fibroma - Myxoma (myxofibroma) - Benign cementoblastoma ('true' cementoma) # Malignant Odontogenic Tumours - 1. Clear cell odontogenic carcinoma - 2. Malignant ameloblastoma - 3. Primary intra-osseous carcinoma - 4. Malignant variants of other odontogenic epithelial tumours - 5. Malignant changes in odontogenic cysts  Malignant odontogenic tumors are classified as follows: 1. Clear cell odontogenic carcinoma 2. Malignant ameloblastoma 3. Primary intra-osseous carcinoma 4. Malignant variants of other odontogenic epithelial tumours 5. Malignant changes in odontogenic cysts A bulleted list of five types of malignant odontogenic tumours, including clear cell odontogenic carcinoma, malignant ameloblastoma, primary intra-osseous carcinoma, malignant variants of other odontogenic epithelial tumours, and malignant changes in odontogenic cysts. The text is displayed in yellow on a dark background with a title in cyan. Ameloblastoma Ameloblastoma is a benign but locally aggressive odontogenic tumor. It is the most common clinically significant odontogenic tumor, characterized by its slow growth and potential for extensive bone destruction.  Close-up photograph of an open mouth showing the tongue, teeth, and oral cavity. The tongue appears to have a textured surface with small white spots, and the teeth are visible with some discoloration. A wooden instrument is inserted into the mouth, likely for examination or treatment. <img src="https://i.imgur.com/5ZjKz6l.jpg" alt="Close-up of an open mouth showing oral lesions, with a red dot highlighting a specific area on the tongue." />  #### Clinical Presentation Clinical examination may reveal oral lesions. In some cases, these present as swelling or abnormalities within the oral cavity, including the tongue or alveolar ridges, which require careful diagnostic evaluation. Close-up photograph of an open mouth showing oral lesions, with a red dot highlighting a specific area on the tongue. The image appears to be part of a medical case study, likely illustrating a condition such as oral cancer or infection, with visible tissue abnormalities and discoloration.  a black and white dental X-ray image showing the lower jaw with multiple teeth, highlighting a large radiolucent lesion in the mandible, marked by a red dot indicating a specific area of interest.  A dental X-ray image showing a panoramic view of the jaw, highlighting teeth and surrounding bone structure. The image reveals a large radiolucent lesion in the mandible, indicative of a pathological condition such as a cyst or tumor, with adjacent teeth appearing displaced or affected.  A black and white radiographic image showing a dental X-ray, highlighting a tooth with a bright white filling or restoration. The surrounding bone structure is visible, with darker areas indicating softer tissues or voids. The image appears to be a clinical dental radiograph used for diagnostic purposes.  A black and white radiographic image showing a dental implant in the jawbone, with a red dot highlighting a specific area of interest near the implant site. The surrounding bone structure is visible, and the image appears to be part of a medical or dental examination.  Microscopic image of tissue showing cellular structures with a mix of pink and purple staining, indicating a histological section. The image is labeled "Ameloblastoma" at the bottom, suggesting it depicts a pathological sample of this type of tumor. The central area contains a highlighted region with a red dot, possibly indicating a point of interest or diagnostic feature.  Microscopic image showing tissue sections with purple-stained nuclei and pale cytoplasm, likely a histological section of epithelial tissue. The image includes glandular structures with organized cell layers and a red dot marking a specific point of interest. <figure> <img src="https://i.imgur.com/1Q0lQ.png" alt="Dental X-ray image showing teeth and jawbone with a red dot indicating a specific area of interest."> </figure>  #### Radiographic Features Dental imaging and X-rays are essential for identifying the extent of the tumor. Radiographically, these lesions often appear as well-defined radiolucencies, which may be unilocular or multilocular (soap-bubble or honeycombed appearance), frequently associated with the jawbone and surrounding teeth. Dental X-ray image showing teeth and jawbone with a red dot indicating a specific area of interest, likely highlighting a dental structure or anomaly.  A photographic image of a biological specimen, likely a sectioned organ or tissue, placed on a green background. The specimen is accompanied by a scale ruler at the bottom marked in centimeters and a label with the text '789/95' at the top left corner. The specimen shows internal structures with varying textures and colors, including a highlighted red dot indicating a specific point of interest. <img src="https://i.imgur.com/7zQZQzQ.jpg" alt="Microscopic image of a unicystic ameloblastoma, showing a cystic lesion with a lining of odontogenic epithelium and a stroma composed of spindle cells and inflammatory cells."/>  #### Histopathological Characteristics Microscopic analysis of a unicystic ameloblastoma typically reveals: - **Cystic Lesion Structure**: A central cystic cavity. - **Epithelial Lining**: The lesion is lined by odontogenic epithelium. - **Stroma Composition**: The supporting stroma is composed of spindle cells and may contain inflammatory cells. Microscopic image of a unicystic ameloblastoma, showing a cystic lesion with a lining of odontogenic epithelium and a stroma composed of spindle cells and inflammatory cells. The image highlights the histological features of the tumor, with a red dot indicating a specific area of interest.  Microscopic image of tissue showing a histological section with dense cellular structures and purple staining, identified as unicystic ameloblastoma. The image displays a cross-section of the lesion with distinct epithelial and stromal components, characteristic of this benign odontogenic tumor. # Osteoma - Benign bone forming tumor - Reactive – developmental (non-neoplastic) - Site: craniofacial bones: skull, paranasal sinuses - Solitary exophytic mass of dense bone arising from periosteal or endosteal surface - Asymptomatic - Non-aggressive, no malignant transformation #### Clinical Overview An osteoma is a benign bone-forming tumor, often considered reactive or developmental rather than truly neoplastic. These lesions typically present as a solitary exophytic mass composed of dense bone. #### Location and Presentation - **Primary Sites:** Craniofacial bones, including the skull and paranasal sinuses. - **Origin:** Arises from either the periosteal or endosteal surface. - **Symptoms:** Generally asymptomatic. #### Behavior and Prognosis - **Growth Pattern:** Non-aggressive. - **Malignancy:** There is no risk of malignant transformation.  A close-up intraoral photograph showing a large, reddish, smooth-surfaced mass on the palate, likely a benign lesion or growth, with adjacent teeth visible in the lower right portion of the image.  A close-up medical photograph showing a surgical site with exposed tissue and sutures. The image highlights a section of the body with visible internal structures, including yellowish material that appears to be fat or connective tissue, and a red dot marking a specific point of interest. The surrounding area is moist and reddish, indicating active surgical intervention.   a black-and-white radiographic image showing a lateral view of a human skull, focusing on the mandible and maxilla regions with visible teeth and bone structures. a black-and-white radiographic image of a human skull from a different angle, highlighting the nasal cavity and upper jaw area, with a red dot marking a specific point of interest.  A microscopic image of a tissue section, likely stained with hematoxylin and eosin, showing a cross-section of bone with osteocytes in lacunae and trabecular bone structure. The red dot highlights a specific area of interest within the tissue.  Microscopic image of tissue stained with hematoxylin and eosin, showing adipose tissue with large lipid-filled cells surrounded by connective tissue. A red dot highlights a specific area of interest within the tissue. ```markdown Bone Pathology Osteosarcoma ``` Osteosarcoma is a primary malignancy of the bone characterized by the production of osteoid by neoplastic cells. # Osteosarcoma - Malignant mesenchymal neoplasm - Osteoid production by tumor cells - Most common primary bone malignancy - Age: 2nd decade - Gender: male > female (1.6:1) - Site: - metaphysis of long bones - distal femur, proximal tibia, humerus #### Clinical Features and Demographics - **Nature:** Malignant mesenchymal neoplasm - **Diagnostic Hallmark:** Osteoid production by tumor cells - **Prevalence:** Most common primary bone malignancy - **Age Predilection:** 2nd decade of life - **Gender Predilection:** Male > female (1.6:1 ratio) #### Common Anatomical Sites - Metaphysis of long bones - Distal femur - Proximal tibia - Humerus ```markdown **Secondary Osteosarcoma:** - Paget’s disease of bone - Fibrous dysplasia - Irradiation - Retinoblastoma - tumor suppressor gene (13q14) - Osteochondromatosis - Chronic osteomyelitis ```  #### Predisposing Conditions and Etiology Secondary osteosarcoma may arise in the context of: - Paget’s disease of bone - Fibrous dysplasia - Prior irradiation - Retinoblastoma - Associated with tumor suppressor gene (13q14) - Osteochondromatosis - Chronic osteomyelitis A bulleted list under the heading "Secondary Osteosarcoma:" detailing various conditions associated with the disease, including Paget's disease of bone, fibrous dysplasia, irradiation, retinoblastoma (with a note on tumor suppressor gene 13q14), osteochondromatosis, and chronic osteomyelitis. # Osteosarcoma of Head & Neck - Incidence: rare in the jaws - 6-8% occur in gnathic skeleton - Age: 3-4th decade (mean age 33 years) - Gender: male > female - Site: - mandible = maxilla, paranasal sinuses, skull - Symptoms: - painful swelling, paresthesia, loose teeth #### Clinical Presentation - **Incidence:** Rare in the jaws; approximately 6-8% occur in the gnathic skeleton - **Age:** 3rd to 4th decade (mean age 33 years) - **Gender:** Male > female - **Site Distribution:** - Mandible - Maxilla - Paranasal sinuses - Skull - **Symptoms:** - Painful swelling - Paresthesia - Loose teeth  Close-up photograph of a dental implant site with surrounding gingival tissue, showing a small red dot indicating the implant placement area. The adjacent natural teeth are visible, and the overall image appears to be from a clinical examination or surgical procedure.  Close-up medical photograph of an oral cavity showing a red, inflamed lesion on the inner cheek near the teeth, with a small red dot indicating a specific point of interest. The surrounding tissue appears swollen and irritated, with visible teeth and gums in the background. # Osteosarcoma of Head & Neck ## Radiographic Findings: - Mixed radiolucent – radiopaque - Destructive - Poorly defined infiltrative borders - Sunburst pattern (25%) - Symmetric widening of periodontal ligament - Calcification above level of alveolar crest - Spiking root resorption #### Radiographic Findings - **Appearance:** Mixed radiolucent – radiopaque - **Growth Pattern:** Destructive with poorly defined, infiltrative borders - **Classic Patterns:** - Sunburst pattern (observed in 25% of cases) - Symmetric widening of the periodontal ligament - Calcification occurring above the level of the alveolar crest - Spiking root resorption  a panoramic X-ray image of a human skull showing dental structures, with visible teeth and jawbones, and a red dot highlighting a specific area on the left side of the jaw.  Close-up photograph of a person's face showing a large, swollen area on the cheek, with a red dot highlighting a specific point of interest. The skin appears inflamed and discolored, suggesting a medical condition or injury. # Osteosarcoma - Histology: - Pleomorphic malignant mesenchymal cells - Spindled to polygonal morphology - Osteoid production - Osteoblastic, chondroblastic, fibroblastic types - Atypical mitotic figures - Necrosis - Gnathic tumors are better differentiated #### Microscopic Features - **Cellular Morphology:** Pleomorphic malignant mesenchymal cells ranging from spindled to polygonal shapes - **Matrix Production:** Evidence of osteoid production - **Histologic Variants:** - Osteoblastic - Chondroblastic - Fibroblastic - **Malignancy Indicators:** - Atypical mitotic figures - Necrosis - **Gnathic Specificity:** Tumors of the jaws tend to be better differentiated than those in long bones  microscopic view of tissue sample showing cellular structures with pink and purple staining, likely from a histological section, with a red dot indicating a specific area of interest.  Microscopic image showing a tissue sample with scattered purple-stained cells against a pale background, likely indicating a histological section. A red dot highlights a specific area of interest within the tissue.  Microscopic image of tissue showing a dense population of cells with purple-stained nuclei and pink cytoplasmic regions, likely indicating a histological section. The red dot highlights a specific area of interest within the tissue.  A dental X-ray image showing two teeth with root canals, likely illustrating a dental procedure or condition. The image includes a red dot highlighting a specific area of interest, possibly indicating a lesion or treatment site. The surrounding bone structure is visible, with varying densities suggesting different tissue types. # Osteosarcoma of the Head & Neck - Clinical labs: elevated alkaline phosphatase - Treatment: - radical surgery - chemotherapy - radiation therapy #### Clinical Laboratory Findings - Elevated alkaline phosphatase levels #### Therapeutic Interventions - Radical surgery - Chemotherapy - Radiation therapy # Osteosarcoma - Prognosis: - aggressive neoplasm - 30-50% survival - local recurrence – 70% - metastasis (6-50%) - lung, brain, lymph nodes - mortality: persistent local/regional disease #### Clinical Outlook - **Nature:** Aggressive neoplasm - **Survival Rate:** 30-50% - **Recurrence:** Local recurrence occurs in approximately 70% of cases - **Metastasis:** Occurs in 6-50% of cases - Common sites: Lung, brain, and lymph nodes - **Mortality:** Primarily driven by persistent local or regional disease ```markdown Metastases to the jaws ``` Metastases to the jaws represent a significant clinical concern in oral oncology, involving the spread of malignant cells from distant primary sites to the gnathic bones. # Metastatic Tumors to Bone - Most common form of cancer involving bone - Carcinomas - Breast, prostate, lung, kidney, thyroid - Site: vertebral column, pelvis, ribs, skull - Hematogenous (Batson’s venous plexus) - Osteolytic or osteoblastic (cytokine mediated) - Poor prognosis #### General Characteristics of Bone Metastasis Metastatic disease is the most common form of cancer involving the skeletal system. These lesions typically originate from carcinomas, with the most frequent primary sites being: - Breast - Prostate - Lung - Kidney - Thyroid #### Common Skeletal Sites and Pathogenesis Metastatic spread frequently involves the vertebral column, pelvis, ribs, and skull. The spread is primarily hematogenous, often occurring via Batson’s venous plexus. #### Clinical Presentation and Prognosis - **Lesion Types:** Depending on cytokine mediation, lesions may appear as osteolytic (bone-destroying) or osteoblastic (bone-forming). - **Prognosis:** Generally poor, indicating advanced systemic disease. # Metastatic Tumors to the Jaws - Incidence: uncommon (16%) - Site: mandible (80%) - Age: older adults - 50% metastasis is first evidence of malignancy - Symptoms: - painful mass – swelling - loose teeth - paresthesia #### Clinical Features of Jaw Metastasis Metastatic tumors to the jaws are relatively uncommon, representing approximately 1% of oral malignancies. They primarily affect older adults. - **Primary Locations:** The mandible is the most frequent site, accounting for 80% of cases. - **Initial Presentation:** In 50% of cases, the jaw metastasis is the first clinical evidence of an underlying malignancy. #### Common Symptoms Patients often present with the following clinical signs: - Painful mass or swelling - Unexplained loosening of teeth - Paresthesia (numbness), particularly of the lower lip and chin # Metastatic Tumors to the Jaws - Radiographic features: - osteolytic: ill defined destructive radiolucency - osteoblastic: radiopaque or mixed lesion - May simulate periapical or periodontal disease - Histology: infiltrating nests and cords of pleomorphic epithelial cells with fibrous stroma - Prognosis: poor, widely disseminated disease - Survival: less than one year #### Radiographic Presentation The radiographic appearance of metastatic lesions varies based on the nature of the tumor: - **Osteolytic lesions:** Present as ill-defined, destructive radiolucencies. - **Osteoblastic lesions:** Present as radiopaque or mixed radiolucent-radiopaque lesions. - **Diagnostic Pitfalls:** These lesions may simulate common dental conditions, such as periapical or periodontal disease. #### Histopathology and Outcomes - **Histology:** Characterized by infiltrating nests and cords of pleomorphic epithelial cells supported by a fibrous stroma. - **Prognosis:** The outlook is poor, as jaw involvement usually signifies widely disseminated disease. - **Survival Rate:** Typically less than one year following diagnosis.  A close-up medical photograph showing a vaginal examination view with visible cervical tissue. The image displays abnormal tissue growths or lesions, with a red dot highlighting a specific area of interest. The surrounding tissue appears inflamed and irregular, suggesting a pathological condition.  X-ray image showing a dental or maxillofacial region with a red dot highlighting a specific area of interest, likely indicating a lesion or abnormality. The image includes visible teeth and surrounding bone structures, with the red dot positioned near the lower jaw.  Microscopic image of tissue stained with hematoxylin and eosin, showing epithelial cells with prominent nuclei and glandular structures. The red dot indicates a specific area of interest within the tissue sample.  The image displays a dark, gradient background with a central red dot and four cyan question marks at the top. The number '109' is visible in the bottom right corner, suggesting it is a page or slide number. This appears to be a minimalist visual element, possibly representing an unknown or unresolved state. 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