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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 140-143

Cemento-ossifying fibroma: Report of a case and emphasis on its diagnosis


1 Department of Dentistry, UCMS and GTB Hospital, New Delhi, India
2 Department of Radiodiagnosis, Pt. B. D. Sharma U. H. S., Rohtak, Haryana, India
3 Department of Pathology, UCMS and GTB Hospital, New Delhi, India

Date of Web Publication28-Dec-2017

Correspondence Address:
Dr. Amita Rani
Department of Dentistry, UCMS and GTB Hospital, Dilshad Garden, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_7_17

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  Abstract 


Cemento-ossifying fibroma (COF) is a benign neoplasm characterized by replacement of normal bone by fibrous tissue and varying amounts of newly formed bone or cementum-like material, or both. The COF has caused considerable controversy because of confusion regarding terminology and the criteria for its diagnosis. A case of COF in a 60-year-old female patient is reported. We are reporting the clinical presentation, diagnostic imaging, and surgical treatments of this lesion in this paper.

Keywords: Cemento-ossifying fibroma; edentulous mandible; fibro-osseous lesion


How to cite this article:
Rani A, Kalra N, Poswal R, Sharma S. Cemento-ossifying fibroma: Report of a case and emphasis on its diagnosis. Indian J Multidiscip Dent 2017;7:140-3

How to cite this URL:
Rani A, Kalra N, Poswal R, Sharma S. Cemento-ossifying fibroma: Report of a case and emphasis on its diagnosis. Indian J Multidiscip Dent [serial online] 2017 [cited 2019 Jul 21];7:140-3. Available from: http://www.ijmdent.com/text.asp?2017/7/2/140/221774




  Introduction Top


Cemento-ossifying fibroma (COF) is a benign osseous neoplasm, which consists of highly cellular, fibrous tissue with varying amounts of calcified tissue, which resembles the bone, the cementum or both.[1] It is most commonly seen between the third and fourth decades of life [2] and is more frequent in women than in men (5:1). The most common location is the mandible in premolar-molar region.[3] The lesion is generally asymptomatic until the growth produces a noticeable swelling and mild deformity. Sometimes, the displacement of teeth may be an early clinical feature.[4] Radiographically, COF presents as a well-defined, unilocular lesion, which contains varying amounts of radiopaque material, correlating the maturity of lesion. Most COFs grow slowly and once completely excised do not recur, but a minority, particularly in children (below 15 years of age), exhibit rapid growth and a tendency to recur; the most frequent name applied to these lesions would appear to be “juvenile ossifying fibroma.”[5]


  Case Report Top


A 60-year-old female patient reported to our department with a chief complaint of painless swelling in left side of her lower jaw since the past 3 years. She had difficulty with chewing meal, so she wanted denture for her. When she reported to local dental clinic for artificial denture, then, she was referred to our department for the evaluation and treatment of swelling. She had no history of associated pain or pus discharge from the swelling [Figure 1].
Figure 1: Preoperative clinical photograph of lesion

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On intraoral examination, there was approximately 3 cm × 2 cm nontender, bony hard swelling on the left side of her edentulous mandible in molar region along with alone standing last molar tooth. Overlying mucosa was of normal color and consistency without any redness or ulceration. Swelling was mainly involving the residual ridge and sparing the inferior border of the mandible. Regional lymph nodes were not palpable. There was no interference with the tongue movements, speech, or swallowing. There was no associated paresthesia or heaviness in lower jaw region. Routine blood investigations and panoramic radiograph was advised as initial work up. All blood parameters were within normal limits. Radiographs of the skull, jaws, chest, and orthopantomogram were taken. The only abnormal finding was a mixed radiopacity in the left mandible [Figure 2]. The latter was a well-demarcated 2.5 cm × 2 cm cauliflower-shaped radiopacity. It occupied the area corresponding to the clinical swelling. This radiopaque lesion was seen projecting partially over and lying partially within the edentulous alveolar ridge and surrounded by radiolucent halo all around. The margins of lesion were well-defined and nonsclerotic. The whole of lesion was lying above the mandibular canal, and there was alone standing third molar distal to the lesion. Correlating the clinical and radiological findings, provisional diagnosis of ossifying fibroma was made. Differential diagnosis included fibro-osseous lesion, squamous cell carcinoma, osteosarcoma, and calcifying epithelial odontogenic tumor.
Figure 2: Preoperative orthopantomogram showing the mixed radiolucent-opaque lesion in mandible left body region

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Incisional biopsy was performed under local anesthesia. Histopathology was suggestive of COF. Hence, excision of lesion was planned under general anesthesia. After Nasotracheal intubation, surgical site was prepared with betadine. Two percent lignocaine with 1:80,000 adrenaline was infiltrated in buccal vestibule to achieve bloodless field. Crestal incision was used to raise full thickness mucoperiosteal flap for surgical exposure of lesion. The whole of lesion was shelled out from the mandible body easily, using fine chisel and mallet after making grooves with 702 SS straight fissure bur [Figure 3] and [Figure 4]. Third molar was also planned for extraction at the same time. After enucleating whole lesion, smoothening of rough bony cortices was done with acrylic trimmer bur. Hemostasis was achieved and primary closure was done with 3-0 vicryl sutures. Gross appearance of specimen was of hard bony mass. Specimen sent for microscopic examination. Histopathology (Hematoxylin and Eosin, ×100) showing cellular fibrous tissue producing multiple rounded psammoma like calcific structure, again confirmed the diagnosis of COF [Figure 5]. The patient was kept on intravenous antibiotics for 7 days. She was asymptomatic thereafter and there was no surgical site infection after surgery. We advised to check panoramic radiograph on 3-month follow-up, which showed no recurrence [Figure 6]. The patient was kept on further long-term follow-up.
Figure 3: Intraoperative photograph showing the lesion

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Figure 4: Excised specimen along with extracted tooth

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Figure 5: Microscopic image showing the cemento-ossifying fibroma in mandible

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Figure 6: Three-month follow-up orthopantomogram showing no recurrence

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  Discussion Top


According to the latest WHO categorization, benign fibro-osseous lesions in the oral and maxillofacial regions were divided into two categories, osteogenic neoplasm, and nonneoplastic osteogenic lesions; COF belonged to the former category. COF is a benign osteogenic tumor with membranous ossification. It, therefore, involves exclusively the maxillofacial bones.[6] It comprises fibrous tissue containing a variable quantity of mineralized material resembling bone and/or cementum, whence the term “cemento-ossifying.” The presence of cementum or bone classifies the lesion as cementifying fibroma or ossifying fibroma, respectively, whereas lesions with mixture of both cementum and bone are called COF. The pathogenesis remains unknown: it may be related to congenital problems in maturation of dental tissue, which can form cementum and bone tissue.[7]

The clinical features of COF can vary from indolent to aggressive behavior. Central COFs are typically solitary and well-defined lesions. The disease usually is asymptomatic at the time of discovery. On rare occasions, however, pain or paresthesia may be elicited if pressure on an adjacent nerve ensues. Teeth in association with the lesion retain their vitality, and as a rule, there is no associated root resorption. The lesion is therefore frequently ignored by the patient until the growth produces a noticeable swelling and facial deformity.[8] This seems to be the case in our patient considering that she has ignored the swelling in her jaw as it had been asymptomatic and that the lesion had all grown considerably large in size when she first reported to our department. Cementifying fibroma often exhibits marked buccal and lingual bony expansion [9] and similar findings were present in our case.

The radiographic appearance is of utmost importance in the diagnosis of cementifying fibroma because it is often needed to differentiate it from other fibro-osseous lesions.[10] Radiographically, two basic patterns have been defined: one characterized by the presence of a unilocular or multilocular radiolucency, and another showing mixed density due to a variable internal amount of radiopaque material. They are typically well-circumscribed and maintain a spherical shape, expand the surrounding cortical bone without any cortical perforation, and may cause tooth-root divergence.[11] In our case, a mixed image was observed on the radiograph with the expansion of buccal and lingual cortical bone. Interestingly, the differences in the amount of opacities within the lesion seem to have correlation with the duration of tumor themselves. The tumor in our case was of 3-year duration and this long duration strongly suggests that the older the tumor the larger the amount of the calcified material found within the lesion. One additional important diagnostic feature radiographically is that there is a 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.[4] This characteristic rounded-shape was reported in our case reported herein. There are three different patterns of radiographic borders of COF, which are defined lesion without sclerotic border (40%), defined lesion with sclerotic border (45%), and lesion with ill-defined border (15%) indicating a rapidly growing tumor.[8] In the present case, defined margins without sclerotic border were seen.

The differential diagnosis includes chondrosarcoma or osteosarcoma, fibrous dysplasia, odontogenic cysts, squamous cell carcinomas, calcifying odontogenic cysts (Gorlin cysts), and calcifying epithelial odontogenic tumors (Pindborg tumors). The well-defined border of the central COF helps differentiate it from the aggressive sarcomas and carcinomas. Fibrous dysplasia has a characteristic “ground glass” appearance not seen in the central COF. The radiologic differentiation of central COF from Gorlin cysts and Pindborg tumors is difficult; the final diagnosis is based on the histologic appearance.[12] The recommended treatment for this tumor is surgical excision. COF usually “shell out” easily in a surgical procedure. The prognosis is usually good since recurrences are not frequent. Eversole et al.[7] reported a recurrence rate of 28% following curettage.[13] Histopathologically, this lesion consists of a highly cellular, fibrous tissue that contains varying amounts of calcified tissue resembling cementum.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toyosawa S, Yuki M, Kishino M, Ogawa Y, Ueda T, Murakami S, et al. Ossifying fibroma vs. fibrous dysplasia of the jaw: Molecular and immunological characterization. Mod Pathol 2007;20:389-96.  Back to cited text no. 1
    
2.
Mithra R, Baskaran P, Sathyakumar M. Imaging in the diagnosis of cemento-ossifying fibroma: A case series. J Clin Imaging Sci 2012;2:52.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Sarita M, Raj KA, Daya SM, Rohtas KY. Cemento-ossifying fibroma of the Maxilla. Indian J Radiol Image 2000;10:103-4.  Back to cited text no. 3
    
4.
Sarwar HG, Jindal MK, Ahmad SS. Cemento-ossifying fibroma – A rare case. J Indian Soc Pedod Prev Dent 2008;26:128-31.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Dominguete PR, Meyer TN, Alves FA, Bittencourt WS. Juvenile ossifying fibroma of the jaw. Br J Oral Maxillofac Surg 2008;46:480-1.  Back to cited text no. 5
    
6.
Buchet C, Baralle MM, Gosset P, Lecomte-Houcke M, Donazzan M. Maxillary ossifying fibroma: Apropos of 3 cases. Rev Stomatol Chir Maxillofac 1994;95:95-7.  Back to cited text no. 6
    
7.
Eversole LR, Leider AS, Nelson K. Ossifying fibroma: A clinicopathologic study of sixty-four cases. Oral Surg Oral Med Oral Pathol 1985;60:505-11.  Back to cited text no. 7
    
8.
Flaitz CM. Peripheral ossifying fibroma of the maxillary gingiva. Am J Dent 2001;14:56.  Back to cited text no. 8
    
9.
Bertrand B, Eloy P, Cornelis JP, Gosseye S, Clotuche J, Gilliard C, et al. Juvenile aggressive cemento-ossifying fibroma: Case report and review of the literature. Laryngoscope 1993;103:1385-90.  Back to cited text no. 9
    
10.
Jayachandran S, Sachdeva S. Cemento ossifying fibroma of mandible: Report of two cases. J Indian Acad Oral Med Radiol 2010;22:53-6.  Back to cited text no. 10
  [Full text]  
11.
Bagi MA, Bokhari K, Nager MA, Basheer SA, Assiri MA. Cemento ossifying fibroma involving mandible. Int J Exp Dent Sci 2013;2:127-9.  Back to cited text no. 11
    
12.
Gopinath D, Beena VT, Sugirtharaj G, Vidhyadharan K, Salmanul Faris K, Kumar SJ, et al. Cemento-ossifying fibroma in a patient with end-stage renal disease. Case Rep Dent 2013;2013:923128.  Back to cited text no. 12
    
13.
MacDonald-Jankowski DS. Cemento-ossifying fibromas in the jaws of Hong Kong Chinese. Dentomaxillofac Radiol 1998;27:298-304.  Back to cited text no. 13
    


    Figures

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



 

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