w w w . r b o . o r g . b r
Case
Report
Ossifying
fibroma:
report
on
a
clinical
case,
with
the
imaging
and
histopathological
diagnosis
made
and
treatment
administered
夽
Daniel
Trivelato
da
Silveira,
Fábio
Oliveira
Cardoso,
Brisa
Janine
Alves
e
Silva,
Cláudia
Assunc¸ão
e
Alves
Cardoso
∗,
Flávio
Ricardo
Manzi
PontifíciaUniversidadeCatólicadeMinasGerais(PUC-MG),BeloHorizonte,MG,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received13November2014
Accepted14January2015
Availableonline21December2015
Keywords:
Ossifyingfibroma
Osseousfibrousdysplasia
Tomography
a
b
s
t
r
a
c
t
Theaimwastoreportonacaseofossifyingfibroma,consistingofabenignfibro-osseous
lesioncharacterizedbyslowgrowthandproliferationoffibrouscellulartissue,bone,cement
oracombination.
A29-year-oldmalepatientwasattendedatahospital,afterhehadsufferedacar
acci-dent.Duringtheclinicalexamination,increasedvolumeintheregionoftherightsideofthe
mandiblewasobserved,andafractureinthemiddlethirdofthefacewassuspected.The
tomographicexaminationshowedanimagesuggestiveoffracturingoftheleft-side
zygo-maticcomplex,withoutdisplacement,andwithawell-delimitedradiopaqueimageofthe
mandible.Thepatientwassenttoahospitalwherepanoramicradiography,posteroanterior
radiographyofthefaceandteleradiographywereperformedinordertobetterdocument
thecase.Anincisionalbiopsywasperformed.Histopathologicalexaminationshowedthe
presenceofabenignbonelesionsuggestiveofossifyingfibroma.Surgerywasperformed
inordertocompletelyremovethelesion,withfixationusingareconstructionplate.Anew
anatomopathologicalexaminationconfirmedthediagnosis.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
Fibroma
ossificante:
relato
de
caso
clínico,
diagnóstico
imaginológico
e
histopatológico
e
tratamento
feito
Palavras-chave:
Fibromaossificante
Displasiafibrosaóssea
Tomografia
r
e
s
u
m
o
Relatar um caso de fibroma ossificante, uma lesão fibro-óssea benigna caracterizada
por crescimento lento e proliferac¸ão de tecido celular fibroso, osso, cemento ou uma
combinac¸ão.
Pacientedosexomasculino,29anos,foiatendidoemumservic¸odeemergência,após
sofrerumacidenteautomobilístico.Duranteoexameclínicoobservou-seumaumentode
夽
WorkdevelopedintheHospitaldeProntoSocorroJoãoXXIII,BeloHorizonte,MG,Brazil.
∗ Correspondingauthor.
E-mail:claudiassuncao@yahoo.com.br(C.A.eAlvesCardoso).
http://dx.doi.org/10.1016/j.rboe.2015.12.002
rev bras ortop.2016;51(1):100–104
101
volumenaregiãomandibulardireitaesuspeitadefraturanoterc¸omédiodaface.Oexame
tomográficodemonstrouimagemsugestivadefraturadocomplexozigomáticoesquerdo,
semdeslocamento,eimagemradiopacabemdelimitadanamandíbula.Opacientefoilevado
paraohospital,ondeforamfeitosumaradiografiapanorâmica,PAdefaceetelerradiografia
paramelhordocumentac¸ãodocaso.Foifeitaumabiópsiaincisional.Oexame
histopa-tológicotevecomoresultadolesãoósseabenigna,sugestivadefibromaossificante.Fez-se
umacirurgiapararemoc¸ãocompletadalesãoefixac¸ãocomumaplacadereconstruc¸ão.O
novoexameanatomopatológicoconfirmouodiagnóstico.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Todososdireitosreservados.
Introduction
Thetermossifyingfibromaincludeslesionswithsimilar
histo-logicalcompositionsanddifferentformsofclinicalbehavior.
Ossifying fibromas are benign asymptomatic neoplasms of
the maxillae that generally haveslow growth and present
proliferation of fibrous cell tissue, with a varyingquantity
ofboneproductsthatincludebone,cement ora
combina-tionofthese.1,2Theyareoftenconsideredtobefibro-osseous
lesions.
Ossifyingfibromasoccurmostoftenintheposteriorregion
ofthemandible2–5 andmayalsooccurinthemaxilla,
com-monlyintheregionofthecaninefossaandintheareaofthe
zygomaticarch.Theyaremorecommoninfemales,3,5–7and
presentgreatestincidenceinthethirdandfourthdecadesof
life.5,8 Facialasymmetryandtooth displacementmay
occa-sionallyoccur.
Uponradiographic examination, it is observed that the
edgesofthelesionareusuallywelldefined,withathin
radi-olucentlinethat representsafibrous capsule.Theinternal
structureshowsmixedradiolucent–radiopaquedensity,witha
patternthatdependsontheformandquantityofthecalcified
materialthatispresent.
Thedifferential diagnosis is generally made with other
lesions that present mixed radiolucent–radiopaque
inter-nalstructures,especially withfibrous dysplasia.6,9,10 These
two types of lesion present similar clinical, radiographic
andmicroscopiccharacteristics.Thewell-delimited
clinical-radiographicappearance ofossifying fibroma and the ease
with which it can be separated from normal bone is the
main differential in relation to fibrous dysplasia. Other
lesions should also be taken into consideration as
dif-ferentialdiagnoses: calcifying odontogeniccysts, calcifying
odontogenictumors(Pindborg)andadenomatoidodontogenic
tumors.
Thecircumscribedandwelldelimitednatureofthelesion
generallyallowsenucleationofthetumor.2Theremaybea
needforreconstructivesurgeryinordertosurmountesthetic
andfunctionalproblemsafterremovalofthelesion.
Theaimofthisstudywastoreportonaclinicalcaseof
ossi-fyingfibroma thatwastreatedbymeansoftumorexcision
throughmarginalresection,inassociationwith
reconstruc-tionusingatitanium plate.Thiswasacaseinwhichafter
anaccidentandidentification offacialfracturing,aclinical
examinationwasconductedinwhichthepresenceofalesion
inthemandiblewasobserved.
Case
report
A29-year-oldmanwasattendedinahospitalaftersuffering
acaraccident.Hewasexaminedbythesurgicalandtheoral
andmaxillofacialtraumatologyteam,andduringthis
exami-nation,increasedvolumeintherightmandibularregionand
themiddlethirdoftheleftsideofthefacewasobserved,in
associationwithablepharohematoma.
Acomputed tomography scanofthis patient’sface was
requested.Thisshowedfracturingoftheleft-sidezygomatic
complex,withoutdisplacement,anditwasdecidedto
imple-mentconservativetreatment.Inthemandible,ahyperdense
imagewithwell-definededges,separatedfromtheadjacent
bonebyathinhypodenseline,wasnoted.Insidethelesion,
animageofmixeddensitywasobserved(Fig.1A–D).
Afterreleasefromtheemergencyservice,thepatientwas
takentothehospital,forfollow-uponthefracturinginthe
zygomaticcomplexandforabetterdiagnosisofthe
mandibu-larlesiontobemade.Aposteroanteriorpanoramicradiograph
ofthepatient’s faceandteleradiographywere requestedin
ordertobetterdocumentthecase(Figs.2–4).
Anincisionalbiopsywasperformed,andthematerialwas
takenforanalysisinthehistopathologicalanatomylaboratory
ofauniversity.Theanalysisshowedthatthis wasabenign
bonelesion,suggestiveofossifyingfibroma.Basedonthese
results,itwasdecidedtoundertakeasurgicalprocedure.
The patient underwent an elective surgical procedure
undergeneralanesthesiaandnasotrachealintubation.Before
openingthesurgicalaccess,dental osteosynthesiswas
per-formedusinganErichbar,alongwithmaxillary-mandibular
blockadeusingsteelwires,forreferencetoandmaintenance
ofthepatient’socclusion.Thesurgicalaccesschosenwasthe
Risdonaccess(submandibular).Thelesionwasremoved
com-pletely,withrigidinternalfixationusingatitaniumsystem
2.7reconstructionplate(Fig.5).Radiographswereproduced
for postoperative follow-ups. A new anatomopathological
examinationconfirmedthediagnosis.Thepatientunderwent
postoperativefollow-upfor1year,withoutanysignsof
recur-rence(Fig.6).
Discussion
Ossifyingfibromasareformedfrompluripotentmesenchymal
cellsthatoriginatefromtheperiodontalligament.Thesecells
Fig.1–Computedtomographyscans:(A)coronalslice;(BandC)axialslice;and(D)3Dreconstruction.Thefracturesinthe zygomaticboneandthelesioninthemandibleareindicatedbyarrows.
thepresenceoflesionsthatare microscopicallyidenticalto
these,inotherregions,meansthatthetheoriesontheorigin
ofossifyingfibromasremainanopenquestion.2,12,13Thereis
asuppositionthatprevioustoothextractionorperiodontitis
mightprovideastimulus,3,12orthattheformationof
ossify-ingfibromasmightbesimplylinkedtoadisturbanceofbone
maturationofcongenitalorigin.4
Ossifying fibromas are more common in females.3,5,6,14
They occur predominantly between the third and fourth
decadesoflife.2,3,5,6,14–16 Thepremolarandmolarregionsof
themandiblearethecommonestsites.2,5,17–19Smalllesions
are asymptomatic and, as they grow and expand, they
causetumefactionthatispain-free,despitesignificantfacial
asymmetry.2,3,5,9,19,20 Their growth is relatively slow.3,9,16,20
Fig.2–Panoramicradiograph.
Pain and paresthesia are only rarely associatedwith
ossi-fyingfibromas.2Mobilityandrootreabsorptionoftheteeth
involvedarefrequentfindings5,7,14–16androotdivergencecan
be foundin17%ofthe cases.5,7,14,15 However,accordingto
anotherauthor,divergencesandreabsorptionoftherootsare
uncommonfindings.8Inthecasereportedhere,therewasno
rootreabsorptionordivergence.Thepatientpresentedfacial
asymmetryanddidnotreporthavinganyparesthesiaorpain.
rev bras ortop.2016;51(1):100–104
103
Fig.4–(A)Posteroanteriorradiographofthemandible;(B)close-upview.
The lesions present in uni or multilocular form.4,21 In
mostcases,thelesionsareradiolucentwithradiopaquefoci,
dependingonthequantityoftissuecalcification,whichgives
rise tovarying degreesof radiopacity.2,8 Aggressivelesions
mayshowlossofthelimitsattheedges,similarto
perfora-tionsincorticalbone.22Inthecasereportedhere,inanalyzing
the radiographicand tomographicimages, it was observed
thatallthecorticalboneshadbecomeruptured.The
differ-entialdiagnosis is usuallymade in relation to monostotic
fibrousdysplasia.Thus,thefinaldiagnosisismadethrough
ahistopathologicalexamination.
Whenthesurgicalresectionisextensive,additional
recon-structionusingbonegraftsand implantsmaybenecessary
due to esthetic and functional problems, especially when
teethare removed.2,8 Inthe casedescribed here, sincethe
lesion presented rupture of all of the cortical bones, and
becausetheareathatcouldbesubjecttostrongmusclearea
wasextensive,itwasdecidedtoemplaceatitanium
recon-struction plate. Thisalso had the aimof maintaining the
mandibularoutline.
Theimportanceofmakinganoverallassessmentofsuch
patientsneedstobeemphasized.Ratherthanfocusingonly
Fig.6–Postoperativepanoramicradiograph.
on evaluating their main complaints, a complete clinical
examinationshouldbeperformedwhileremainingalert to
variations from normality and, especially, to pathological
alterations.Inthismanner,patients’conditionscanbe
cor-rectly diagnosed and appropriate treatment plans can be
drawnup.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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