Oral Surgery

Cemento-Ossifying
Fibroma A case
report

Abstract
|| Brief Background
Cemento-ossifying fibroma is a rare non odontogenic tumour,
included in the group of fibro-osseous lesions, arising from
periodontal ligament and is usually seen in tooth bearing areas
of the jaws. The article reports a case of cemento-ossifying
fibroma involving the posterior part of the mandible and its
management.
|| Materials and Methods
Based on history and findings on clinical / radiological
examination a diagnosis of fibro-osseous lesion was made.
Surgical resection is the mode of treatment adopted.
|| Discussion
Discussion relates to unknown aetiology, the possible causes,
predilection for adult females of middle age and the predominant
site involved, the nature of the lesion, early clinical feature and
radiographic appearances, important diagnostic features, and
the need for complete resection of the lesion.
|| Summary and Conclusions
It is not always easy to diagnose and manage the fibro-osseous
lesions in the mandible or maxilla because their clinical,
radiographic, and histological criteria often overlap causing
confusion to radiologist, pathologist and oral surgeons. This
can result in difference of opinion and management of these
lesions.

Dr. Prachi Goel

P. G. Student
Correspondence Address
Dr. Vijay Raghavan
Oral Medicine & Radiology Department
Seema Dental College & Hospital, Rishikesh- 249203

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|| Key Words
Cemento-ossifying fibroma, Cementum, Fibro-osseous lesion,
Mandible, Odontogenic tumour.

Dentistr y,

Mumbai

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|| Introduction
In 1971, WHO Classified four types of cementumcontaining lesions: fibrous dysplasia, ossifying fibroma,
cementifying fibroma and cemento-ossifying fibroma.
According to the second WHO classification, benign
fibro- osseous lesions in the oral and maxillofacial
regions were divided into two categories, osteogenic
neoplasm and non neoplastic bone lesions;
cementifying ossifying fibroma belonged to the former
category. However, the term Cementifying ossifying
fibroma was reduced to Ossifying fibroma in the new
WHO classification in 2005.1

defined, extending from 1st premolar to 3rd molar

region measuring approximately 4 x 3 cms in size
[Fig. 2]. Mandibular second premolar, first molar
and second molar were clinically missing. Overlying
mucosa appeared apparently normal. On palpation,
swelling was bony hard in consistency, non tender
and fixed to underlying bone. No evidence of egg
shell crackling was noted.

Cementifying ossifying fibroma is composed of

fibrous tissue that contains a variable mixture of
bony trabeculae, cementum-like spherules, or
both. Although the lesions do contain a variety of
mineralized structures, most authorities agree the
same progenitor cells produce the different materials.
It has been suggested that the origin of these tumours
is odontogenic or from periodontal ligament.2
|| Case Report
A 55 year old female reported to the Department of
Oral Medicine and Radiology with a chief complaint
of swelling in the lower right side of face since 4-5
months. History of present illness revealed pain
in teeth in lower right back region 1 year back,
associated with a swelling which was initially small
in size and gradually progressed to the present size.
3 posterior teeth in the same region were extracted
during this period (reason not known, probably
erroneously)
Extra orally, facial asymmetry was noted. A solitary
swelling was present on right side of the face
which was ovoid in shape, moderately well defined,
extending antero- posteriorly from commissural
area up to an imaginary line drawn perpendicular
from the outer canthus of eye and superoinferiorly from level of occlusal plane to the lower
border of mandible and extending on to the right
submandibular region [Fig.1]. The overlying skin
appeared normal. On palpation the swelling was
bony hard in consistency, non tender with no local
rise of temperature of overlying skin.
Intra orally, swelling was noted in mandibular right
posterior region with obliteration of right buccal
vestibule. The swelling was ovoid in shape, well

Clinical

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Dentistr y,

Fig. 1: Photograph showing asymmetry of face with swelling on

right side

Fig. 2: Intra oral photograph showing swelling with obliteration

of buccal sulcus

Panoramic Radiograph [Fig. 3] revealed a solitary

large well defined radiolucency in mandibular
right posterior region. The radiolucency was well
circumscribed with a sclerotic margin all around
except at the superior border and showed intervening

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radiopaque foci. The entire lesion measured

approximately 5cms antero-posteriorly and 4 cms
supero-inferiorly in size. Inferior displacement of
mandibular canal was seen. Occlusal radiograph
[Fig. 4] showed cortical expansion bucco-lingually
with expansion more on the buccal.

Fig. 5: H & E stained sections revealed fibrous connective tissue

stroma with abundant plump spindle shaped fibroblasts

Fig. 3: Panoramic radiograph with a mixed lesion on right side

of lower jaw

Fig. 6: Islands of bone, osteoid and cementum like spherules

were seen dispersed throughout the stroma

|| Discussion

Fig. 4: Marked buccal expansion seen in lower occlusal view.

H & E stained sections revealed fibrous connective

tissue stroma with abundant plump spindle shaped
fibroblasts [Fig. 5]. Collagen fibres were seen to
be arranged in a whorled pattern. Islands of bone,
osteoid and cementum like spherules were seen
dispersed throughout the stroma [Fig. 6]. Bony
trabeculae showed a mixture of both woven and
lamellar pattern. Osteoblastic rimming was evident.
Histopathological features were suggestive of
Cemento-ossifying Fibroma.

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Dentistr y,

Cemento-ossifying fibroma is a disorder of unknown

etiology. Bernier3 hypothesized that cementoossifying fibroma in the bone might be caused by an
irritant stimulus which may activate the production
of new tissue from the remaining periodontal
membranes. The periodontal membrane contains
multipotent cells that are capable of forming
cementum, lamellar bone and fibrous tissue.2,4
The cemento-ossifying fibroma is a benign osseous
tumour that commonly affects adults of middle age,
30-40 years.5 The premolar-molar region of mandible
is more commonly involved than maxilla although
cases have been reported in the other craniofacial
bones. 70% of cases of cemento-ossifying fibroma
involve mandible, but a significant 22% has been

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found in the molar region of maxilla, ethmoidal and

orbital regions and exceptionally in petrous bone.6
The lesion is generally asymptomatic until the
growth produces a noticeable swelling and mild
deformity; displacement of teeth may be an early
clinical feature.7 Radiographic appearances of
lesion vary according to stage of development of
tumour. In early stage it is radiolucent lesion with
no evidence of internal radiopacities. As it matures,
there is increasing calcification so that radiolucency
becomes flecked with opacities and ultimately
appears as uniform radiopaque mass.1
An important diagnostic feature of cementoossifying fibroma 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 tumour mass. The borders
are well defined, and a thin radiolucent line
representing a fibrous capsule separates the lesion
from the surrounding bone. A significant point is
that the outer cortical plate, although displaced and
thinned, remain intact.8
Teeth adjacent to or involved in the lesion may be
displaced but root resorption is not associated with
this tumour.9,10
Microscopically, cemento-ossifying fibroma reveals
many delicate interlacing collagen fibres, seldom
arranged in discrete bundles, interspersed with
large numbers of active, proliferating fibroblast
and cementoblasts. Although mitotic figures may

be present in small numbers, there is seldom any

remarkable cellular pleomorphism. As the lesion
matures, the islands of cementum increase in
number, enlarge, and ultimately coalesce.11
As
cemento-ossifying
fibroma
is
sharply
circumscribed and demarcated from bone, it should
be excised conservatively, but complete resection of
the lesion is a must. Since cemento-ossifying fibroma
is less vascularised and well circumscribed, it is easy
to remove from the surrounding bone. Even if the
tumour has reached appreciable size, the neoplasm
usually is easily separated from the surrounding
tissue. Continued growth does not necessarily
follow partial removal. Sakoda et al4 describe the
procedure of a segmental resection of an extensive
ossifying fibroma with the replacement of the excised
segment after cryotherapy. Conservative surgery is
therefore recommended even if the tumour is large
with blowing and erosion of the inferior border of
mandible. Radical treatment of the tumour such as
an en bloc resection should only be considered if
there are recurrences due to its aggressive nature.
|| Conclusion
It is not always easy to diagnose and manage the
fibro-osseous lesions in the mandible or maxilla
because their clinical, radiographic and histological
criteria often overlap causing confusion to clinical,
radiologist, pathologist and oral surgeons. This can
result in difference of opinion and management of
these lesions.

Co-authors

Dr. Vijay Raghavan

Professor & Head

Clinical

NEW CD March 2013.indd 15

Dr. K Nagaraju
Reader

Dentistr y,

Mumbai

Dr. Sonali Bedi

Senior Lecture

March 2013

Dr. Ravneet Arora

Senior Lecturer

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|| References
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Sreenivasan BS, Joseph E, Sunil S. Central ossifying

fibroma of mandible A case report.OMPJ. 2010; 1: 2021.

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Van heerden WF, Raubenheimer EJ, Weis RG, Kreidler

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Neville BW, Damm DD, Alen CM, Bouquot JE. Oral and
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Sarwar HG, Jindal MK, Ahmed SS. Cemento-ossifying

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3.

Bernier J. Changes in bone and dental cementum in

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4.

Sakoda S, Shiba R, Irino S. Immediate reconstruction

of the mandible in a patient with ossifying fibromsa by
replantation of the resected segment after freezing. J
Oral Maxillofac Surg 1992;50:521-4.

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Waldron CA. Fibro-osseous lesions of the jaws. J Oral

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