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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 27  |  Issue : 2  |  Page : 282-285

Central cemento-ossifying fibroma of posterior maxilla


Department of Oral Medicine and Radiology, MNR Dental College and Hospital, Hyderabad, Telangana, India

Date of Submission30-Nov-2014
Date of Acceptance15-Oct-2015
Date of Web Publication21-Nov-2015

Correspondence Address:
Nishanth Gollamudi
Department of Oral Medicine and Radiology, MNR Dental College and Hospital, Narsapur Road, Sangareddy - 502 294, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.170159

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   Abstract 

Cemento-ossifying fibromas (COFs) are relatively rare, benign lesions affecting the jaws and other craniofacial bones and are included in the group of mesodermal odontogenic tumors by Gorlin. They have a predilection for females between the third and fourth decades of life, and about 60% of the lesions are seen most often in the mandibular arch, predominantly occurring in the premolar/molar region of the mandible. This report describes a case of central COF in a 49-year-old male involving the maxillary posterior region. The current case is reported because of the rarity of such lesions and the paucity of information concerning them in the dental literature. We believe that this case illustrates many of the clinical, radiographic, and histologic features associated with cemento-ossifying tumors.

Keywords: Cemento-ossifying fibroma, CT scan, fibro-osseous lesions, maxilla


How to cite this article:
Yaga US, Mengji AK, Kesary SR, Gollamudi N. Central cemento-ossifying fibroma of posterior maxilla. J Indian Acad Oral Med Radiol 2015;27:282-5

How to cite this URL:
Yaga US, Mengji AK, Kesary SR, Gollamudi N. Central cemento-ossifying fibroma of posterior maxilla. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Aug 23];27:282-5. Available from: http://www.jiaomr.in/text.asp?2015/27/2/282/170159


   Introduction Top


Benign fibrous overgrowths arising from the mucus membrane are termed as fibromas and are common growths in the oral cavity. There are two types of ossifying fibromas, namely, the central type and the peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes expansion of the medullary cavity of the bone. The peripheral type occurs on the soft tissue overlying the alveolar process and is a "non-neoplastic," reactive fibrous proliferation. [1]

The cemento-ossifying fibroma (COF) is classified as a fibro-osseous (FO) lesion or a non-odontogenic tumor of the jaws according to the World Health Organization (WHO). Fibro-osseous lesions are characterized by replacement of normal bone architecture by collagen fibers and fibroblasts that contain varying amounts of mineralized substances, which may be bony or cementum-like in appearance. Fibro Osseous lesions comprise fibrous dysplasia, periapical cemento-osseous dysplasia, focal cemento-osseous dysplasia, florid cemento-osseous dysplasia, COF, etc. [2] The present report describes a case of a central COF in a 49-year-old male patient.


   Case Report Top


A 49-year-old male patient reported to the outpatient department of Oral Medicine, Diagnosis and Radiology with the chief complaint of swelling over the right cheek region since last 10 months. Detailed history revealed that he was asymptomatic 10 months back, after which he noticed a small swelling in the right cheek region, initially peanut sized, which gradually increased to attain the present size without any history of pain or trauma. His past dental history revealed that he underwent extraction of upper front teeth 4 years ago due to caries. Extraoral examination revealed mild facial asymmetry involving the middle one-third of the face in the right cheek region due to a diffuse swelling measuring approximately 5 × 4 cm size, with ill-defined borders. On palpation, obvious bony expansion was found; swelling was bony hard in consistency, and showed no tenderness on palpation, signs of inflammation or any discharge. The surface over the swelling was smooth and shiny, and showed no stretching of the skin. The surrounding skin showed no signs of pathology.

Intraoral examination revealed missing teeth in relation to 13, 14, and a localized swelling of surrounding mucosal color involving the buccal vestibule, extending anteroposteriorly from the distal aspect of right lateral incisor to the distal aspect of first molar region and mediolaterally 2 cm from the buccal gingival margin to 3 cm from the palatal gingival margin, measuring approximately 7 × 5 cm, obliterating the buccal vestibule. The surface over the swelling was smooth and shiny. On palpation, the swelling was non-tender with well-defined borders and hard in consistency [Figure 1]. Based on history and clinical examination, a provisional diagnosis of benign bony neoplasm was made. The differential diagnosis included calcifying fibroma, fibrous dysplasia, irritational fibroma, pyogenic granuloma, and giant cell granuloma. Radiologic investigations such as intraoral periapical (IOPA) radiograph, orthopantomograph (OPG), paranasal sinus (PNS) view, and computed tomography (CT) scan were advised.
Figure 1: Intraoral picture showing swelling with obliteration of buccal vestibule on the right side

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Intra oral periapical radiograph of 15, 16, and 17 showed an ill-defined radiolucent lesion at the root apices of 15 and 16 with ragged borders, loss of normal bone trabecular pattern, and loss of lamina dura [Figure 2]. The OPG revealed a well-defined radiolucent lesion corresponding to the root apex of 15, extending mesiodistally 2 cm anterior from the mesial aspect of 15 to the mesial aspect of 17, superoinferiorly 3 cm above the root apices of 15 and 16 to the alveolar crest interdentally, measuring approximately 21 × 18 mm in the greatest dimension [Figure 3]. The surrounding structures appeared normal. The PNS view revealed thickening of right zygomatic arch and haziness of right maxillary antrum [Figure 4]. To know the extension of the lesion and the relationship of the lesion with the surrounding vital structures, a CT scan was advised, which revealed a well-defined, heterogeneous, and expansile osteolytic lesion involving the zygomatic and maxillary bones of the right side, extending into the alveolar process with multiple small foci of calcifications and expansion of the right maxillary antrum. Remodeling of the maxillary antrum involving the lateral and inferior walls was seen and floor of the sinus was raised in comparison to the healthy counterpart [Figure 5].
Figure 2: IOPA of 15, 16, and 17 showing a well-defi ned mixed radiolucent radio-opaque lesion at the root apices of 15 and 16 with ragged borders, loss of normal bone trabecular pattern, and loss of lamina dura

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Figure 3: Panoramic radiograph revealing a well-defined radiolucent lesion corresponding to the root apex of 15

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Figure 4: Paranasal sinus view revealing thickening of right zygomatic arch and haziness of right maxillary antrum

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Figure 5: CT revealing a well-defined, heterogeneous, and expansile osteolytic lesion involving the zygomatic and maxillary bones of the right side, extending into the alveolar process with multiple small foci of calcifications and remodeling of the maxillary antrum

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Routine biochemical investigations such as complete blood picture (CBP), erythrocyte sedimentation rate (ESR), and alkaline phosphatase were also advised. Hemoglobin estimation, total and differential white blood cell counts, serum protein, calcium, phosphorus, and alkaline phophatase estimations were all within normal limits. Diagnosis of ossifying fibroma was made based on clinical and typical radiographic features. Consent for the surgical procedure was obtained from the patient. Under local anesthesia, scaling and root planing of adjacent teeth, complete surgical removal of the lesion, and debridement were done by raising a mucoperiosteal flap via a Weber-Fergusson approach, and the bony wall of the cavity and roots of the teeth were thoroughly curetted. Chemical cauterization was done using carbolic acid. After controlling bleeding, periodontal dressing was placed. The patient was discharged and advised medications (analgesics and antibiotics), and was recalled after 1 week for a follow-up. The 1-week follow-up was uneventful with the surgical site showing signs of healing. The excised tissue was sent for histopathologic analysis. A 6-month postsurgical follow-up of the patient showed no evidence of recurrence. Histopathology report revealed cellular connective tissue stroma interspersed with spherules of basophilic cementum-like calcification (10×). The diagnosis was confirmed by histopathology as central COF [Figure 6]. The postoperative course was favorable, and 1 year later, the patient reported no discomfort in the zone.
Figure 6: Histopathological picture revealing cellular connective tissue stroma interspersed with spherules of basophilic cementum-like calcification

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   Discussion Top


Cemento-ossifying fibroma is an FO lesion that arises from the periodontal membrane. Cemento-ossifying fibroma is defined by WHO [3] as a demarcated or rarely encapsulated neoplasm consisting of fibrous tissue containing varying amounts of mineralized material (bone and/or cementum). These lesions are best classified as osteogenic tumors. [4] In 1872, Menzel gave the first description of COF as a variant of ossifying fibroma. [5] Cemento-ossifying fibroma is a disorder of unknown etiology. Bernier hypothesized that it might be caused by an irritant stimulus (such as tooth extraction) which may activate the production of new tissue from the remaining periodontal membranes (as in our case) that contains multipotent cells. [6] The current theories regarding their origin include traumatic and developmental causes. [7]

Clinical presentation

Cemento-ossifying fibroma may be diagnosed in patients of any age, but the majority of cases are seen in young and middle-aged adults. Peak incidence is seen mostly in the third and fourth decades of life. The disease commonly affects females with a female:male ratio of 5: 1 [8] and shows predilection toward mandible than maxilla. In both the jaws, the lesion is always associated with the tooth-bearing areas. [9] The male patient discussed here was in his fourth decade of life and the condition involved the posterior right maxilla. Clinically it presents as asymptomatic, slow-growing intrabony lesion. The growth of the tumor over time may lead to facial asymmetry, with the appearance of a mass causing discomfort.

Radiographic features

Radiographs are of utmost importance in the diagnosis of COF for differentiating it from other FO lesions of the jaw. Radiographically, it is characterized by three stages: Initial, mixed, and mature stage. In the initial stage, the COF appears as a well-defined radiolucent lesion with no evidence of internal radio-opacities. As the tumor matures, there is evidence of calcification due to which the radiolucent area becomes flecked with opacities and ultimately the lesion appears as an extremely radio-opaque mass in the mature stage. An important diagnostic feature of COF is the centrifugal growth pattern rather than a linear one, and therefore, the lesions grow by expansion equally in all directions and present as a round tumor mass. Cemento-ossifying fibroma can produce migration of teeth with interdental bone destruction, but resorption is not associated with this tumor. Foci of radio-opaque material, bone, and/or cementum may be seen, particularly in large lesions.

Histopathologic features

Ossifying fibromas consist of fibrous tissue that exhibit varying degrees of cellularity and contain mineralized material. The hard tissue portion may be in the form of trabeculae of osteoid and bone or basophilic and poorly cellular spherules that resemble cementum. Admixtures of the two types are typical. The bony trabeculae vary in size and frequently demonstrate a mixture of woven and lamellar patterns. Peripheral osteoid and osteoblastic rimming are usually present. The spherules of cementum-like material often demonstrate peripheral brush borders that blend into the adjacent connective tissue. Variation in the types of mineralized material produced may be helpful in distinguishing ossifying fibroma from fibrous dysplasia which has a more uniform pattern of osseous differentiation. [4]

Treatment and prognosis

The circumscribed nature of the ossifying fibroma generally permits enucleation of the tumor with relative ease. Ideal treatment for large COF includes wide surgical resection. Due to their resistant nature and post radiation complications, radiotherapy is contraindicated. Conservative surgery is, therefore, recommended even if the tumor is large with bowing and erosion of the inferior border of the mandible. The prognosis is known to be fair and recurrence is rare. The recurrence rate of maxillary central COFs is likely to be higher because of the greater difficulty of their surgical removal and larger size at the time of presentation. [10]


   Conclusion Top


It is difficult to differentiate between any of the reactive gingival lesions and FO lesions in the initial stages. Irrespective of the treatment modality employed, the utmost importance is given for the elimination of the possible etiologic factor and the tissue has to be histopathologically studied for confirmative diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 1
    
2.
More C, Thakkar K, Asrani M. Cemento-ossifying fibroma. Indian J Dent Res 2011;22:352-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Orkin DA, Amaidas VD. Ossifying fibrous epulis. An abbreviated case report. Oral Surg Oral Med Oral Pathol 1984;57:147-8.  Back to cited text no. 3
    
4.
Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982:54:40-8.  Back to cited text no. 4
    
5.
Kramer IR, Pindborg JJ, Shear M. The World Health Organization histological typing of odontogenic tumours: Introducing the second edition. Eur J Cancer B Oral Oncol 1993;29B:169-71.  Back to cited text no. 5
    
6.
Neville BW, Damm DD, Allen CM, Banquet JE. Oral and Maxillofacial Pathology. Philadelphia: WB Saunders; 1995. p. 468-70.  Back to cited text no. 6
    
7.
Cakir B, Karadayi N. Ossifying fibroma in the nasopharynx. A case report. Clin Imaging 1991;15:290-2.  Back to cited text no. 7
    
8.
Bernier J. Changes in bone and dental cementum in periodontal diseases. Med Hyg (Geneve) 1952;10:474.  Back to cited text no. 8
    
9.
Sakoda S, Shiba R, Irino S. Immediate reconstruction of the mandible in a patient with ossifying fibroma by replantation of the resected segment after freezing. J Oral Maxillofac Surg 1992;50:521-4.  Back to cited text no. 9
    
10.
Reddy KJ, Ramlal G, Dayanandam, Patil R. Cemento-ossifying fibroma of the mandible: A case report and review of literature. Indian J Stomatol 2011;2:197-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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