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Management of Fibro-osseous lesions PowerPoint Presentation

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Description : ossifying fibroma of the craniofacial bones

Tags : ossifying fibroma, Fibrous dysplasia, Fibro-osseous lesions

Published on : Jan 08, 2021 | Views : 2057 | Downloads : 2

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Management of fibro-osseous lesions Presented by : Husam Abdulabbas Supervised by: Ass. Prof. Auday M. Al- Anee Ossifying Fibroma
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OSSIFYING FIBROMA Uncommon Benign expansile neoplasm with significant growth potential.[1,2,3] Can be aggressive or indolent. [2] seen in the jaws and craniofacial bones. [10] In the recent 2017 WHO classifications, classifications of OF divide into ; (1) Ossifying fibroma of odontogenic origin (2) Juvenile ossifying fibroma (JOF) - TrJOF - PsJOF The most frequent type of OF - Classical OF > TrJOF> PsJOF [7] Fig 1. panoramic radiograph showing an ossifying fibroma at edentulous right mandible [8]
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Etiopathogeny The etiology of OF is unknown - odontogenic, developmental and traumatic origins have been suggested - thought to be of PDL origin because of their capacity to produce cementum and osteoid. [9] chromosome translocations have been identified in a few cases of ossifying fibroma, but genetic studies have been insufficient to determine the molecular mechanisms that underlie the development of this neoplasm. [10]
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Histopathologic Features Ossifying fibroma is composed fibrous connective tissue well-differentiated spindled fibroblasts Collagen fibers are arranged haphazardly Bony spheroids, trabeculae, or islands are evenly distributed throughout the fibrous stroma Bone is immature and often is surrounded by osteoblasts. Osteoclasts are infrequently seen [10] Fig 2. Ossifying fibroma exhibiting islands of new bone in fibroblastic matrix. Note cortex at upper left. [10]
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Fig 3. (A) ossifying fibroma. This example contains densely mineralized and darkly staining islands of cementum-like tissue lying in cellular fibrous tissue. Towards the actively growing margin of the lesion (lower part) the fibrous tissue is more cellular and is forming woven bone. Fig 3.(B) ossifying fibroma. In this mature lesion there are large coalescing islands of dense bone and little fibrous tissue. Note the well-demarcated periphery of fibrous tissue which has shelled away from the adjacent bone during removal.
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Clinical Findings Patient demographics middle-aged patients (peak 3rd & 4th decade). [1,3,4] Female > Male. [1,2,3,4] primarily seen in patients of Caucasian descent. followed by patients of African descent. [11] In children, Juvenile ossifying fibroma occurs before age 15 years in 80% cases. sex predilection is debated. [5]
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Clinical Findings Uncommon. slow-growing, expansile lesion. characteristically arise in the tooth-bearing regions. expansion and thinning of cortical plates is common. mucosal ulceration are rare. [10] Mandible > Maxilla. [1,2,3,4] Posterior mandible is the most affected. [6] asymptomatic, discovered accidently. [6] Maxillary lesions tend to involve the antrum. At surgery, the lesion tends to separate easily from the surrounding bone. [1] Fig 4. Intraoral picture of an ossifying fibroma shows buccal cortical plate swelling at the edentulous alveolar ridge of the #46 and #47 areas. [8]
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Juvenile ossifying fibroma (JOF) locally aggressive with significant growth potential despite its benign character and have a strong tendency for recurrence.[5] very rare, painless swelling. grows rapidly. more common in the maxilla. [9] occurs before age 15 years in 80% cases. [10] Mostly extra gnathic, gnathic involvement favors the maxilla. [1,3] PsJOF is observed in a wider age range and predominantly found in the sinonasal and orbital bones, whereas TrJOF affects patients of a younger age group, more aggressive and mainly affects the jaws. [ 7] Two distinctive microscopic patterns have been reported: The 'trabecular' type shows a loose, fibroblastic stroma containing very fine, lace-like trabeculae of immature osteoid and collections of giant cells are common. The 'psammomatoid' variant consists of an exceedingly cellular fibroblastic stroma containing compact, rounded Calcifications.
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Radiological findings from most included studies reported the pathognomonic sign of OF in radiology was well-defined margin. [7] These Well‐defined borders, may be corticated. A surrounding lucent margin (band) may be present, which suppurate them from the surrounding bone. [2] Internal density varies substantially, depending on the amount of mineralized material. It can be essentially lucent, but mostly appear as a mixed lucent-opaque with different degrees of calcified bone present. The effect on the surrounding structures include: cortical bony expansion is common. [1,2] a characteristic downward bowing of the inferior cortex. [1,2] adjacent teeth may exhibit root divergence or root resorption and the lamina dura is usually missing. [1,2,3,4] expansion can result in displacement of teeth or the inferior alveolar canal. [4] A significant point is that the outer cortical plate, although displaced and thinned, remains intact. [4] Radiological findings
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Fig 5. periapical radiograph of an ossifying fibroma reveals a well-defined, mixed radiolucent and radio-opaque lesion with sclerotic border at the edentulous alveolar ridge of the #46 area. [8] Fig 6. Ossifying fibroma in the anterior mandible showing cortical expansion. [8]
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Fig 7. Part of a panoramic radiograph displaying an oval-shaped OF. It has slightly displaced adjacent teeth and displaced the inferior dental canal downward. It is well defined with a radiolucent space between the ground-glass opaque tissue and adjacent normal bone.[12] Fig 8. rounded well-circumscribed OF, It is slow-growing, as can be seen by the displacement of the teeth. [3]
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Fig 9. (A) Cropped panoramic radiograph of an ossifying fibroma right maxilla shows concentric expansion. (B–D) Axial, coronal, and sagittal CT showing expansion of the lesion into the right maxillary sinus. A lucent band visible throughout most of the periphery of the lesion surrounding heterogeneous calcification. [11]
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Fig 10. Magnetic resonance images of an ossifying fibroma on left side of maxilla. [12]
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Fig 11. Clinical pictures of the previous case showing (a) Facial asymmetry on the left side of the face. (b, c) Intraoral photographs showing a large mass in the upper left gingival region.[12]
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Differential diagnosis Distinguishing between ossifying fibroma and fibrous dysplasia is the primary diagnostic challenge. These lesions may exhibit similar clinical, radiographic, and microscopic features. The most helpful feature in distinguishing the two is the well-circumscribed radiographic appearance of ossifying fibroma and the ease with which it can be separated from normal bone. [10] Key radiological differences Fibrous dysplasia Borders are less well defined There is no surrounding lucent margin. Expansion is not tumor like, resembling the original anatomy. Root resorption is rare. [2] Fig 12. Panoramic radiograph showing a Fibrous dysplasia with ill defined borders on the right mandible. [14]
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Fig 13. (A) Occlusal image of an ossifying fibroma. The concentric expansion of the mandible is characteristic of a benign tumor. (B) Occlusal image of fibrous dysplasia with mild fusiform expansion of the mandible but without an obvious epicenter. [15]
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Differential diagnosis periapical cemento-osseous dysplasia (PCOD) Key radiological differences Periapical osseous dysplasia usually multifocal. Less tumor‐like growth. Especially in relation to teeth.[2,15] wider sclerotic border is more characteristic of the slow growing of cemento-osseous dysplasia as well as a more undulating Expansion [15] No or little expansion of cortical bone. Fig 14. Radiological appearance of osseous dysplasia, as a well-defined multiple radiopaque mass with circumferential radiolucency, surrounding the root apices and scattered on both sides of the mandible. [14]
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Treatment options OF treatment involves 2 types, conservative surgery and radical surgery. Conservative surgical procedure including curettage, enucleation or peripheral osteotomies in the context of small lesions and Radical surgery including local resection, marginal resection and total resection with or without reconstructive surgery in case of very large, debilitating, or rapidly evolving lesions . [3,7] Recurrence rate after surgery Recurrence rate after surgery reported vary between studies. Global recurrence rate after surgery was 14.4% with most frequent recurrence occurs in conservative surgery. Recurrence rate after conservative surgery was 19.7%, compared with radical surgery which relatively lower in percentage, with recurrence rate after surgery was 10.6%. [7] Figure 15. (A) vestibular swelling in the right maxillary diagnosed as TrJOF. [5]
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Fig 15. (B) Imaging and surgical Excision
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Case report.[16] Fig 16. CT scans: (A) coronal slice; (B and C) axial slice; and (D) 3D reconstruction. The fractures in the zygomatic bone and the lesion in the mandible are indicated by arrows.
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Fig 17. (A) Panoramic radiograph Fig 17.(B) Close-up view of the lesion in the panoramic radiograph.
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Fig 18. (A) Posteroanterior radiograph of the mandible; (B) close-up view.
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Fig. 19 (A and C) Surgical procedure; (B) placement of plates and fixation screws; (D) removal of the lesion and surgical specimen.
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Fig 20. Postoperative panoramic radiograph.
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References Neville et al. (2016). oral and maxillofacial pathology, 4th edition. Bernard Koong. (2017). Atlas of oral and maxillofacial radiology. R.A. cawson et al. (2002). cawson's essentials of oral pathology and oral medicine 7th edi. Y Liu et al. (2010). Ossifying fibromas of the jaw bone: 20 cases. Lemoine et al. (2018). Juvenile ossifying fibroma: case report and literature review. Management and differential diagnosis. Le Donne et al. (2019). Impacted canine and ossifying fibroma: case report and literature review. Adham et al. (2020). Comparison radical surgery versus conservative surgery to decrease post-operative recurrence in ossifying fibroma: systematic review. Chia- Chuan Chang et al. (2008). Central Ossifying Fibroma: A Clinico-pathologic Study of 28 Cases. Bruno Carvalho et al. (2012). Ossifying Fibromas of the Craniofacial Skeleton. Joseph a. regezi et al. (2012). oral pathology: clinical pathologic correlations. Ahmad & Gaalaas. (2017). Fibro-Osseous and Other Lesions of Bone in the Jaws. MacDonald-Jankowski. (2003). Fibro-osseous lesions of the face and jaws. Hara et al. (2012). Ossifying fibroma of the maxilla: a case report including its imaging features and dynamic magnetic resonance imaging findings. Dube et al. (2019). Benign fibro-osseous lesions of the jaws: a clinico-pathologic study of 98 Tanzanian patients. Mallya et al. White and Pharoah's Oral Radiology Principles and Interpretation 8th edi. Daniel Trivelato da Silveira et al. (2015). Ossifying fibroma: report on a clinical case, with the imaging and histopathological diagnosis made and treatment administered.