Aggressive Juvenile Ossifying Fibroma of The Anterior Mandible

Aggressive Juvenile Ossifying Fibroma
Volume 2 Issue 1 February 2011
Case Report
Aggressive Juvenile Ossifying Fibroma of the Anterior Mandible

Dr.Ravikumar.R1, Dr.Raghavendra.K2, Dr.Santhosh Kumar3
1
Senior Lecturer, 2Reader Department of Oral Surgery, 3Senior Lecturer Departmant
of Periodontics, Sri Siddhartha Dental College, Tumkur, Karnataka.
Abstract: Juvenile ossifying fibroma (JOF) is an uncommon fibro-osseous lesion containing different amounts of calcified tissue scattered in a cellular fibroblastic stroma. bones. It is highly aggressive and has a strong tendency to recur. It has been recognized as a separate histopathological entity among the fibro-osseous group of lesions. The clinical behavior of Juvenile ossifying fibroma is variable and difficult to predict. This article reports a case of Aggressive JOF of the anterior mandible in a 10 year old girl. Key words: ossifying fibroma; fibro-osseous lesion; juvenile ossifying fibroma; psammomatoid; trabecular; active fibrous dysphasia.
Journal of Dental Sciences & Research 2:1: Pages 26-34
Introduction: The fibro osseous lesions of the jaws represent a diverse group of entities that are characterized by replacement of normal bone by a fibrous connective tissue matrix,
developmental lesions, reactive
(hamartomatous) or dysplastic
processes and neoplasms. One such rare or atypical fibro
osseous lesion is Juvenile ossifying Fibroma describes histopathological Psammomatoid and (JOF). The two term JOF
with in which varying amounts of osteoid, immature and mature bone and in some instances, cementumlike material are deposited1. Fibro osseous lesions of the jaws include
distinct variants: Trabecular
varieties2 .Psammomatoid JOF is an extra-gnathic lesion occurring
26 Journal of Dental Sciences and Research
Volume 2 Issue 1 February 2011 Panoramic and intra-oral periapical radiographs revealed a radiolucent mass in the 31, symphyseal 32, 41 region 42
predominantly in the sinonasal and orbital bones. Trabecular JOF is a gnathic lesion affecting the jaws with a predilection for maxilla2, 3, 4. Cases affecting the mandible have been reported; the ramus- molar area being the most common site3. This presentation highlights the third
displacing
and
laterally and perforating both the cortical plates of the mandible
[Figure-3a, b]. CT scan revealed mass, an expansile
documentation of a JOF occurring in the mandibular anterior region; thus making it a rare entity. Case report: A 10-year-old girl presented to the department of oral and maxillofacial surgery with a rapidly enlarging
osteolytic
encompassing
symphysis of the mandible causing splaying of the incisors; with an intact lower mandibular border. Few bony spicules were seen with in the lesion [Figure-4 a,b]. Routine blood examination and
mass of 20days duration over the mandibular anterior region[Figure1]. On physical firm, examination, oral an
biochemical investigations were with in the normal limits. An incisional biopsy was performed, fixed in 10% formalin and sent for
ovoid,
intra
swelling,
measuring about 3x3 cm; in relation to 31, 32, 41 and 42, slightly
histopathological
examination.
Correlating the age, duration, clinical behavior, radiological pattern and microscopic appearance [Figure-
extending into the floor of the mouth with minimal tenderness on
palpation and no significant regional lymphadenopathy.There was Lateral displacement with gradeII mobility of permanent mandibular incisors and deciduous mandibular
5a,b,c],the lesion was diagnosised as Aggressive JOF(Trabecular general
variant).
Under
anaesthesia, an enbloc resection was carried out through a by trans-oral chemical
canines[Figure-2a,b].
approach
followed
Volume 2 Issue 1 February 2011 is by El-Mofty

[4]
cauterization acid[Figure-6 postoperative eventful
using a,b,c]. recovery a
carbolic The was un
who identified two
categories, trabecular JOF (TrJOF) and psammomatoid on JOF (PsJOF), criteria.
without
significant
based
histologic
problem[Figure-6c]. The patient was reviewed regularly and on a follow up of one year, showed no signs of recurrence[Figure-8&9]. Discussion: The most characteristic feature of JOF, as the name suggests, is its higher incidence in children and
4
However, the two categories also have a distinct predilection for
specific age-groups: the average age of occurrence of TrJOF is 8-12 years, whereas that of PsJOF is 1633 years.4 Although JOF can occur anywhere in the skeleton, its highest incidence is in the facial bones, most commonly the maxilla.3,4,5,8 One clinical feature that helps differentiate TrJOF from PsJOF is the site of involvement, with PsJOF occurring mainly in the paranasal sinuses and TrJOF occurring mainly in the maxilla.4 Mandibular and extracranial involvement is rare.5 Gender predilection has been a
young adults.5,6 However, it can also occur in the

5
older
age-groups .
Johnson et al
have reported JOFs
occurring at any age between 3 months and 72 years. Among the many classification systems for this lesion, the classification by Slootweg et al
7
is noteworthy. They have JOF into two distinct
classified
groups, the JOF-WHO type and JOFPO (psammoma-like ossicles) type, based primarily on the difference in the age of occurrence: the mean age of occurrence of JOF-WHO is 11.8 years and that of JOF-PO is 22.6 years. The most recent classification
2
matter of controversy, with some authors claiming no predilection for either sex, whereas Johnson et al . found a higher incidence in females
3,5
and El-Mofty reported a male
predilection.4
Volume 2 Issue 1 February 2011 of the involved site and the first presentation will be a clinically
The histogenesis of this lesion is poorly understood.Johnson et
al.believe that
mandibular
obvious swelling. All these features were seen in our case. Radiographically the internal
lesions arise from the myxoid dental papilla of the developing tooth.
Virtanen et al. consider JOF as a neoplasm that develops from the undifferentiated cells of the periodontal ligament.4 JOF usually manifests bony-hard as an
structure can be radiolucent, mixed, or radiopaque, depending on the degree of calcification.3,4 is though The lesion common rare, can Root and can cause
displacement resorption, occur.4,8,9
asymptomatic
swelling,
the duration and extent of which may vary depending on the site and aggressiveness of the lesion;
expansion as well as perforation.4 The radiographic features of JOF can resemble that of other lesions, such as fibrous dysplasia and cementoossifying fibroma.
2,4
however, it does not demonstrate the chronic, long-standing evolution of some of the other fibro-osseous lesions. It can expand the involved bones, causing facial asymmetry.
JOF
is
not
capsulated but is separated from surrounding bone by a radiopaque border, 3,8and this finding can help in differentiating dysplasia.3,10 it A from fibrous
Depending on the site, symptoms such as pain, sinusitis, paresthesia, proptosis,
malocclusion, swelling.8,9 In general,
'ground-glass'
etc., can also occur due to the
appearance on radiographs has been reported.4 It usually has a concentric
JOF
has
more
or centrifugal growth pattern, which can lead to an erroneous clinical diagnosis fibroma.8,10 of JOF cemento-ossifying has also been
aggressive growth pattern than the adult variant of are ossifying usually
fibromas.They
asymptomatic, exhibit rapid growth
reported to be associated with other
Volume 2 Issue 1 February 2011 conservative curettage, is therefore the preferred line of treatment.6,8 In the present case et we als followed staged
bony lesions such as aneurysmal bone cyst.4 Aggressive lesions with marked structures destruction may of adjacent
radiographically
modified
Troulis
mimic osteogenic sarcoma. 8,9 The microscopic features of the
protocol for the treatment of the jaw tumours in children. Conclusion: Although JOF is an uncommon
lesion are distinctive and include a cell-rich fibrous stroma containing bands of cellular osteoid without osteoblastic lining, osteoid strands, and trabeculae of woven bone.4,7,10 PsJOF is slightly more cellular than TrJOF. Due to the resemblance of the psammoma-like ossicles seen in PsJOF to the cementicles in
clinical entity, its aggressive local behaviour and high recurrence rate calls for an early diagnosis, prompt treatment and especially, long term follow up of the patient.The rapid growth rate often exhibited by these lesions can be quite alarming and cause the
cemento-ossifying fibroma, it has been argued that PsJOF is a type of cemento-ossifying

2,4
clinician to suspect the presence of a malignancy.
fibroma.
However, the marked cellularity of
JOF is in sharp contrast to the usually stroma-rich appearance of the latter group of lesions. The aggressive nature of this entity, along with the reported high rates of recurrence (30-58%),
4,8
suggests
FIGURE-1: A 10-year-old girl presented with a rapidly enlarging mass of 20 days duration region. over the mandibular anterior
that JOF should be treated like a locally aggressive neoplasm, very much Surgical like an ameloblastoma. rather than
resection,
Figure 2a:
Figure 3b:
FIGURE-3a, b: OPG and IOPA radiographs revealed a radiolucent mass in the
symphyseal region
displacing 31, 32, 41
and 42 laterally and perforating both the cortical plates of the mandible.
Figure 2b:
FIGURE-2a, b: Local examination reveals an ovoid, firm, intra oral swelling, measuring about 3x3 cm; in relation to 31,32, 41 and 42, slightly extending into the floor of the mouth and causing lateral displacement of the above mentioned teeth.
Figure-4a:
Figure 3a:
Figure-4b: FIGURE-4a, b: CT revealed a

well-defined radiolucent expansile mass encompassing symphysis of the mandible causing splaying of the incisors; with an intact lower mandibular border. Few bony spicules were seen with in the lesion.
Figure 6a: Figure-5a
Figure-5b:
Figure-6 b:
Figure-5c:
FIGURE-5a,
and
c:
Figure-6 c:
FIGURE-6a, b and c: An enbloc resection was carried out through a trans oral
Histopathological
examination
revealed
highly cellular fibrous stroma consisting of spindle to polyhedral shaped fibroblast-like cells with vesiculated nuclei were seen that are arranged in a swirling pattern and a flowing whorled pattern. The highly cellular nature of the fibrous matrix and the woven bone reflected the aggressive behaviour of the tumor.Multi nucleated giant cells were also seen.
approach followed by chemical cauterization using carbolic acid.
Figure-7 a
Post-operative
FIGURE-8a, b: Follow up of one year,
showed no signs of recurrence.(Extra-oral photograph)
Figure -9a,b:FOLLOW-UP
Figure-7b:
FIGURE-7a,
b:
The
macroscopic appearance of the lesion and the teeth involved by the mass.
Figure -8a,b:FOLLOW-UP
Pre-operative
Pre-operative
Post-operative
FIGURE-9a,b: Follow up of one year,
showed no signs of recurrence.(Intra-oral photograph)
Volume 2 Issue 1 February 2011 active massive mandible. ossifying fibroma of with the Surg
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involvement Plast
Reconstr
2004;113:970-4. 7. Slootweg PJ, Panders AK,
2003;38:648-50. 2. Philipsen HP, Reichert PA.
Koopmans R, Nikkels PG. Juvenile ossifying fibroma: An analysis of 33 cases with emphasis aspects. J on Oral
Ossifying
fibroma,
odontogenic
tumors and allied lesions. London: Quintessence 2004. 3. Saiz-Pardo-Pinos MV, AJ, OlmedoE, Publishing Co, Ltd;
histopathological
Pathol Med 1994;23:385-8. 8. Noffke CE. Juvenile ossifying
Gaya
Prados-Snchez M.
fibroma of the mandible: An 8 year radiological Dentomaxillofac 1998;27:363-6. 9. Offiah C, Hall E. The rapidly enlarging chin mass. Br J Radiol 2005;78:175-6. 10. Williams PM. HK, Mangham C, follow-up. Radiol
Vallecillo-Capilla
Juvenile
ossifying fibroma: A case study. Med Oral Patol Oral Cir Bucal
2004;9:454-8. 4. El-Mofty S. Psammomatoid and trabecular juvenile ossifying fibroma of the craniofacial skeleton: Two distinct clinicopathologic entities.
Speight
Juvenile
ossifying
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:296-304. 5. Johnson LC, Yousefi M, Vinh TN, Heffner DK, Hyams VJ, Hartman KS. Juvenile active ossifying fibroma: Its nature, dynamics and origin. Acta Otolaryngol Suppl 1991;488:1-40. 6. Zama M, Gallo S, Santecchia L, Bertozzi E, De Stefano C. Juvenile
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Aggressive Juvenile Ossifying Fibroma

Volume 2 Issue 1 February 2011