|Year : 2020 | Volume
| Issue : 4 | Page : 206-209
Cemento-ossifying fibroma of maxilla: An unusual case report
Meetkamal Grewal1, Swati Gautam2, Renu Tanwar3, Nitin Saini4
1 Department of Oral Pathology and Microbiology, Gian Sagar Dental College and Hospital, Patiala, Punjab, India
2 Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Baddi, India
3 Private Practitioner, Smile Care Dental Clinic Noida, Uttar Pradesh, India
4 Department of oral pathology and Microbiology, HIDS, Paonta Sahib, Himachal Pradesh, India
|Date of Submission||15-Feb-2020|
|Date of Decision||28-Feb-2020|
|Date of Acceptance||24-Aug-2020|
|Date of Web Publication||30-Nov-2020|
R-602, Jalvayu Towers, Sector 125, Mohali, Punjab
Source of Support: None, Conflict of Interest: None
Cemento-ossifying fibroma (COF) is a benign fibro-osseous lesion which belongs to the same category of fibrous dysplasia and cement-ossifying dysplasia. It arises from the periodontal membrane which contains multipotent cells that are capable of forming cementum, lamellar bone, and fibrous tissue. It is more common in the mandible than in the maxilla. We present a case of COF in the maxilla, a rare occurrence in a 66-year-old female with the chief complaint of a swelling in the left upper back tooth region for the past 3 years. A panoramic radiograph was taken, which showed an oval radiopaque lesion in the second quadrant from 24 to maxillary tuberosity. In the maxilla, the clinical and radiological differential diagnosis includes fibrous dysplasia, giant cell lesions, cementoblastoma, calcifying epithelial odontogenic tumor, and peripheral giant cell granuloma. It is sharply circumscribed and demarcated from the surrounding bone, so surgical excision is the treatment of choice.
Keywords: Cemento-ossifying fibroma, fibro-osseous lesion, radiographic features
|How to cite this article:|
Grewal M, Gautam S, Tanwar R, Saini N. Cemento-ossifying fibroma of maxilla: An unusual case report. J Dent Res Rev 2020;7:206-9
|How to cite this URL:|
Grewal M, Gautam S, Tanwar R, Saini N. Cemento-ossifying fibroma of maxilla: An unusual case report. J Dent Res Rev [serial online] 2020 [cited 2021 Jan 23];7:206-9. Available from: https://www.jdrr.org/text.asp?2020/7/4/206/302045
| Introduction|| |
Cemento-ossifying fibroma (COF) is categorized as a benign fibro-osseous tumor. It arises in the mandible in 62%–89% of patients, with 77% of them occurring in the premolar region. It is not commonly seen in the maxilla. The common age of occurrence is between the third and fourth decades of life and is seen more frequently in females than in males.
COF is a benign neoplasm characterized by the replacement of normal bone by fibrous tissue and varying amount of newly formed bone or cementum-like material or both.
It is a fibro-osseous lesion that arises from periodontal membrane. Periodontal membrane is comprised of a layer of connective tissue which surrounds the roots of teeth. Multipotent cells capable of forming cementum, lamellar bone, and fibrous tissue are an important component of periodontal membrane.
Fibro-osseous lesions are characterized by three radiographic stages: initial or early (radiolucent), mixed (radiolucent and radiopaque), and mature (radiopaque). In early stages, the COF appears as a radiolucent lesion because proliferation of only fibrous tissue occurs. As the tumor advances, flecks of calcification appear, making the lesion a mixture of radiolucency and opacity, until the lesion ultimately appears as a complete radio-opaque mass due to the advanced calcification because of bone and cementum formation.
The peculiarity of this lesion is the centrifugal growth pattern rather than a linear one, therefore this lesion tends to grow equally in all directions, causing bony expansion, and presents as a round tumor mass.
Other lesions which present with similar radiographic features include chondrosarcoma, osteosarcoma, fibrous dysplasia, odontogenic cysts, squamous cell carcinoma, Gorlin's cyst, and Pindborg's tumor. These lesions constitute the radiographic differential diagnosis of COF. The well-defined borders of COF help in differentiation from aggressive sarcomas and carcinomas, which present with ill-defined and infiltrative margins on radiograph.
Treatment comprises surgical resection of the lesion with enucleation and curettage of the bone bed. Radiotherapy has been proven inefficient and is contraindicated. Inadequate surgical treatment may cause recurrence of the lesions, therefore proper diagnosis and treatment plan is required to achieve good result in the management of this tumor.
We present a case of COF in the maxillary premolar–molar region, a rare site for its occurrence.
| Case Report|| |
A 66-year-old female reported to the outpatient department of oral and maxillofacial surgery, with the chief complaint of swelling in the left upper back tooth region and on the left side of the face for 3 years [Figure 1].
|Figure 1: Preoperative extraoral photograph showing mild asymmetry on the left side of the face|
Click here to view
She was apparently asymptomatic 3 years back when she first noticed a pea-sized, hard, painless swelling in the upper back tooth region. The swelling has been growing slowly. On extraoral examination, there was mild facial asymmetry seen with slight swelling in the left midfacial region. The overlying skin extraorally was normal in color and texture.
Intraorally, there was a uniform, well-circumscribed, ovoid growth present in the left maxillary posterior region measuring approximately 3 cm × 2 cm extending from 24 to 28 region and showing the expansion of the cortices [Figure 2]. The overlying mucosa was coral pink in color and firm in consistency. The swelling was smooth and noncompressible.
|Figure 2: Preoperative intraoral photograph showing the expansion of cortices|
Click here to view
Panoramic examination [Figure 3] showed ovoid radiopacity in the left maxilla extending from 24 to maxillary tuberosity anteroposteriorly and superoinferiorly from the floor of the maxillary sinus to the alveolar crest. Cone-beam computed tomography was done, which revealed considerable thinning and expansion of the buccal and lingual cortical plates. Routine hemogram values were within normal range except the alkaline phosphate level which was 135 IU/L.
|Figure 3: Preoperative orthopantomogram showing the extent of the lesion from 24 to maxillary tuberosity|
Click here to view
The incisional biopsy of the lesion revealed proliferating fibroblastic stroma without any mitotic activity with deposition of lamellar bone and rounded psammoma-like masses [Figure 4], suggesting the lesion to be COF.
|Figure 4: High-resolution photomicrograph showing proliferating fibroblastic stroma|
Click here to view
Management – surgical excision was planned and preoperative antibiotics were given 1 day before surgery. The tumor was removed together with the adjacent bone with segmental resection of the left maxilla under general anesthesia, followed by primary closure of the wound with 3-0 silk suture [Figure 5]. The excised mass [Figure 6] was sent for histopathological examination and was confirmed to be COF. The antibiotics and anti-inflammatory agents were continued for the next 1 week. The sutures were removed on the 7th postoperative day and the postoperative healing was uneventful. The patient is comfortable and is on regular follow-up for the past 2 years [Figure 7] and [Figure 8]. Postoperative orthopantomogram was taken [Figure 9].
| Discussion|| |
COF is a true neoplasm composed of fibrous tissue interspersed with a mixture of bony trabeculae and cementum-like spherules. It arises from the multipotent cells of the periodontal membrane which are capable of forming cementum, lamellar bone, and fibrous tissue. It occurs across a wide age range, with the greatest number of cases during the thirdand fourth decades of life with a definite female predilection.
Small lesions are detected only on radiographic examination and seldom cause any symptom. Large tumors result in a painless swelling of the involved bone; they may cause obvious facial asymmetry and are rarely associated with pain and paresthesia. Few cases show root resorption or displacement of the neighboring teeth.
Radiographically, it is characterized by three stages: initial or early, mixed, and mature stages. In the early stages, the COF appears as a radiolucent lesion because proliferation of only fibrous tissue occurs. As the tumor advances, flecks of calcification appear, making the lesion a mixture of radiolucency and opacity, until the lesion ultimately appears as a complete radio-opaque mass due to the advanced calcification because of bone and cementum formation.
In the maxilla, the clinical and radiological differential diagnosis includes fibrous dysplasia, giant cell lesions, cementoblastoma, calcifying epithelial odontogenic tumor, and peripheral giant cell granuloma.
Continuity of normal bone and lesional bone is seen in fibrous dysplasia in contrast to COF where the lesional bone is distinct and well demarcated from the surrounding bone. Reed used the criteria of presence or absence of woven and lamellar bone to differentiate COF from other osseous lesions. Fibrous dysplasia consists of woven bone, whereas COF and ossifying fibroma contain woven bone with the presence of osteoblastic rimming. Another differentiating feature between fibrous dysplasia and COF is the presence of cementum in the form of psammoma bodies in a benign fibrous tissue matrix.
Peripheral giant cell granuloma clinically mimics COF as both the lesions occur anterior to the molar and present as pedunculated or sessile masses. However, on histopathological examination, giant cells seen in peripheral giant cell granuloma are an important differentiating feature.
Cementoblastoma can also resemble COF. It usually arises in the molar or premolar region. This tumor has no predilection for either sex, and it occurs predominantly before 30 years of age. Pain and swelling are common symptoms.
Another lesion which resembles COF is calcifying epithelial odontogenic cyst. Initial radiographic features of both the lesions are common, but as the lesion progresses, it takes on a “honeycomb” or “driven snow” appearance. Histologically, it can be differentiated by the presence of polyhedral epithelial cells as well as multinucleated giant cells.
As COF is circumscribed and well demarcated from the surrounding bone, it should be excised conservatively, but complete resection of the lesion is a must. Because COF is less vascularized and circumscribed, it is easy to be removed from the surrounding bone. Even if the tumor has reached the appreciable size, the neoplasm is usually separated from the surrounding tissue.
Therefore, complete excision of the tumor is the treatment of choice for COF. Because the tumor is radioresistant, radiotherapy is contraindicated.
| Conclusion|| |
COF is categorized as a fibro-osseous lesion with its origin from periodontal membrane. The lesion can be easily removed from the surrounding bone because of its distinct boundaries. It is not always easy to diagnose and manage fibro-osseous lesions in the mandible or maxilla owing to their similar clinical, radiographic, and histological criteria, which causes confusion to clinicians, radiologists, pathologists, and oral surgeons.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Verma P, Rathore PK, Mrig S, Pal M, Sial A. Cemento-ossifying fibroma of the maxilla: A case report. Indian J Otolaryngol Head Neck Surg 2011;63:38-40.
Kamadjaja DB. Cemento ossifying fibroma of the jaw. Dental J 2009;42:164-71.
Sarwar HG, Jindal MK, Ahmad SS. Cemento-ossifying fibroma--a rare case. J Indian Soc Pedod Prev Dent 2008;26:128-31.
] [Full text]
More C, Thakkar K, Asrani M. Cemento-ossifying fibroma. Indian J Dent Res 2011;22:352-5.
] [Full text]
Sarwar HG, Jindal MK, Ahmad S. A case report of cemento ossifying fibroma. J Maxillofac Surg 2010;9:178-81.
Silvestre-Rangil J, Silvestre FJ, Requeni-Bernal J. Cemento-ossifying fibroma of the mandible: Presentation of a case and review of the literature. J Clin Exp Dent 2011;3:e66-9.
Liu Y, You M, Wang H, Yang Z, Maio J, Shimiutani K, et al
. Ossifying fibroma of the jaw bone: 20 cases. Dentomaxillofac Radiol 2010;39:57-63.
Dalghous A, Alkhabuli JO. Cemento-ossifying fibroma occurring in an elderly patient. A case report and a review of literature. Libyan J Med 2007;2:95-8.
Imanimoghaddam M, Hoseini Zarch SH, Javadian Langaroodi A, Nemati S. Cementoossifying fibroma: Report of two interesting cases. DJH 2011;3:61-5.
Hwang EH, Kim HW, Kim KD, Lee SR. Multiple cemento ossifying fibroma: Report of an 18 year follow up. Dentomaxillofac Radiol 2001;30:230-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]