A clinicoradiologic analysis of symptomatic craniofacial fibro-osseous lesions

Aneurysmal bone cyst arising from the surgically removed craniofacial fibrous dysplasia in the long-term follow-up: a case report

Fibrous dysplasia (FD) is a rare skeletal disorder characterized by abnormal fibro-osseous connective tissue replacing normal bone. Despite its benign behavior, craniofacial FD can cause morphological disfigurement, headache, and even blindness as a result of the produced mass effect. Surgical resection is recommended when the patient shows apparent clinical symptoms or aggravating facial asymmetry. Postoperative complications have been reported, such as hematoma, surgical site infection, abscess formation, resorption of the bone graft used for reconstruction, and recurrence. An aneurysmal bone cyst (ABC) is a rare benign bony lesion that can occur secondary to preexisting bone tumor. Secondary ABCs in craniofacial FD are extremely rare in the literature, accounting for less than 30, all of which are either case reports or series. We report an extremely rare case of symptomatic secondary ABC arising from craniofacial FD that had been misdiagnosed with abscess formation or recurrence and was surgically removed. Notably, 17 years elapsed between the primary surgery and the complication of secondary ABC. The patient underwent total removal of secondary ABC. After surgery, symptoms were relieved, with no recurrence observed during a 6-month follow-up.

Polyostotic Fibrous Dysplasia: A Case Report of Rarity

A skeletal condition known as fibrous dysplasia (FD) is characterized by the replacement of healthy bone with fibrous bone tissue. One bone (monostotic) or several bones could be involved (polyostotic). Any bone in the body might become affected by FD. The skull and face bones are the most typical locations. It is connected to a GNAS1 gene mutation (20q13.2). It begins during childhood and could continue far into adolescence and adulthood. In this case study, a 22-year-old woman was identified as having polyostotic FD based on her clinical, radiological, and histological characteristics.

Cranial fibrous dysplasia: An institutional experience and review of the literature

Background:

Cranial or craniofacial fibrous dysplasia (CFD) is a rare entity which most often presents with either incidental finding or with pain/cosmetic disfigurement or visual/hearing problems. Multidisciplinary treatment with close follow-up or medical management/surgery is options. Management of these lesions can often give satisfying results. There is a dearth of neurosurgical literature on this subject matter. Our objective was to review the clinical symptomatology and outcome of CFD patients managed in our institution.

Methods:

This is a retrospective observational study of CFD patients managed in our institution over a period of 5 years. Clinical and radiological data were collected from departmental database. Outcomes were evaluated immediately and on 1–4 years follow-up.

Results:

A total of 21 patients were managed over a period of 5 years with age ranging from 12 to 55 years and symptoms of cosmetic issues or visual disturbance. Preoperative computed tomography scan with 3D reconstruction with bone window was done in all patients. In most of the patients (16/20), immediate reconstruction was done following excision. Five patients were managed conservatively. Follow-up was obtained over a period ranging from 1 to 4 years and all (except one) patients are doing well. Only one patient had permanent visual impairment in spite of early intervention.

Conclusion:

Craniofacial dysplasia has various modalities of management. Careful selection of patients for surgical or conservative management is feasible with good results both in short and long term.

Core Extirpation and Zygoma Reduction: A New Surgical Approach for Fibrous Dysplasia of Zygomaticomaxillary Region

INTRODUCTION

In case of zygomaticomaxillary fibrous dysplasia (FD), surgical treatment is often required due to visual disturbance, exophthalmos, and also necessary for cosmetic reasons. However, it is not easy to determine the timing and method of operation. The objective of our study is to define a new surgical option, for the treatment of FD of zygomaticomaxillary area.

MATERIALS AND METHODS

Five patients affected by FD of their zygomaticomaxillary area who underwent surgery with a core extirpation were included in this study. A retrospective chart review and pre- and post-operative analysis of computed tomography scan were performed.

RESULTS

All patients underwent core extirpation surgery and zygoma reduction was combined in 2 patients. All patients showed the cessation of the increase of external size postoperatively and results of the operation were well maintained over the follow-up period of 1 year.

CONCLUSIONS

In this article, we present our experiences in the management of FD using the core extirpation with or without zygoma reduction, focusing on surgical indication, techniques, and results. Although there are limitations due to selective operative indication, the procedure can be usefully performed to prevent external growth and avoid repetitive surgery.

An unusual presentation of non-specific cystic degeneration of craniofacial fibrous dysplasia: a case report and review of literature

Background

Fibrous dysplasia (FD) is a rare, sporadic, and benign congenital condition in which normal cancellous bone is replaced by fibro-osseous tissue with immature osteogenesis. FD localized in the cranial and facial bones is called craniofacial fibrous dysplasia (CFD). Cystic degeneration in CFD cases is rare; cystic degeneration appearing in both the maxilla and the mandible FD lesion is even rarer. The aim of this article was to report a case of fibrous dysplasia of the mandible and maxilla complicated by nonspecific cystic degeneration.

Case presentation

A 30-year-old woman presented with a rare case of non-specific cystic degeneration in a mandible and maxilla FD lesion that occurred 11 years after surgery. She was diagnosed with polyostotic CFD and underwent maxillary and mandibular bone contouring. Cyst enucleation under general anesthesia was performed in the mandibular region due to pain and discomfort.

Conclusions

In cases involving non-aggressive and non-invasive FD cystic degeneration in focal areas, conservative treatment is recommended. However, if cystic degeneration of FD develops rapidly and causes discomfort, pain, or dysfunction, surgical treatment should be considered.

An incidental dense bone island: A review of potential medical and orthodontic implications of dense bone islands and case report

Dense bone islands (DBIs) are usually asymptomatic and do not require any treatment. This case report presents a DBI of an unusual presentation, which was an incidental finding on a radiograph of a 15-year-old orthodontic patient. The DBI lesion was 24 mm in size, occupying at least 50% of the alveolar process between the upper right canine and lateral incisor, extending up the lateral aspect of the anterior margin of the right nasal fossa. Generally, DBIs are 2-3 mm in size and more commonly found in the mandible in the molar and premolar region. This article further discusses the impact of DBIs on orthodontic treatment such as difficulty with achieving space closure and adequate root tip or torque. We also examine the potential medical implications of DBIs. This is clinically important, especially if multiple DBIs, or osteomas which have a similar radiographic appearance to DBIs, are found in a patient as they may be associated with adenomatous intestinal polyps, which, if not treated, have a 100% chance of becoming malignant transformation.

Dental implants in a patient with left mandibular fibrous dysplasia: Two-year outcomes on the normal and affected sides

Dental rehabilitation raises specific challenges in patients with mandibular fibrous dysplasia. We report the 2-year post-operative outcomes on the normal and affected sides in a 64-year-old female with focal left mandibular fibrous dysplasia and bilateral posterior edentulism. On the left, bone shaving of the lesion to restore sufficient vertical height was followed by the insertion of two dental implants. Three dental implants were inserted into the normal bone on the right. Dental prostheses were added 6 months later. Two years after the first procedure, no complications had been recorded and the patient reported similar high satisfaction for both sides. This comparison of outcomes of dental implants inserted into dysplastic versus normal bone in the same patient suggests that dental implants may constitute a valid option for managing edentulism in selected patients with fibrous dysplasia, provided appropriate precautions are taken.

Retrospective Study of 383 Cases of Fibro-Osseous Lesions of the Jaws

PURPOSE

The aims of this study were to describe the clinical and radiologic features of 383 fibro-osseous lesions (FOLs) from an oral pathology reference service in Brazil and to compare the findings with previous studies. The hypothesis of the study was that the most common type of FOL would differ from other investigations.

MATERIALS AND METHODS

We conducted a descriptive and retrospective study with review of the records of the clinical and biopsy services (1990 to 2015). All records of the patients included showed a definitive diagnosis of FOL. The primary outcome variable was the type of FOL, and the predictor variables were gender, age, ethnicity, location, and clinical and radiologic characteristics. Descriptive analyses and χ² tests were performed. The P value was set at .05.

RESULTS

From the 27,998 records available, 383 showed FOLs, with 187 (48.8%) being cemento-osseous dysplasias (CODs), 103 (26.9%) being fibrous dysplasias (FDs), and 93 (24.3%) being ossifying fibromas (OFs). The mean age of the patients was 38.5 ± 17.5 years. CODs presented a predilection for female gender (n = 314, 82.0%), African descent (n = 134, 71.6%), and the mandible (n = 248, 64.6%). The most common radiologic feature was a mixed radiolucent-radiopaque image (n = 149, 51.7%). FDs and OFs were commonly diagnosed during the first and second decades of life (P < .001), whereas CODs were more frequently diagnosed beyond the third decade (P < .001). Secondary osteomyelitis was more significantly observed in CODs (P < .001) than in FDs and OFs. Swelling was more frequently reported for FDs and OFs than for CODs (P < .001).

CONCLUSIONS

CODs were the most frequently observed FOLs in this Brazilian population. Female patients, patients of African descent, and patients with mandibular localization were most commonly affected by these conditions. The most common type of FOL differed from that in similar case reports or series from various geographic locations. It is believed that the data source (clinical and/or biopsy services) can directly influence the outcome.

Management and Treatment Outcomes of Maxillofacial Fibro-osseous Lesions: A Retrospective Study

INTRODUCTION

Fibro-osseous lesions are a diverse group of bone disorders and include developmental, reactive or dysplastic diseases and neoplasms. They share overlapping clinical, radiographic and histopathologic features and demonstrate a wide range of biological behaviour.

AIM

To evaluate the characteristics, treatment and outcome of benign fibro-osseous lesions of the jaws.

PATIENTS AND METHOD

All patients with fibro-osseous lesions of the jaws treated at the department of Oral and Maxillofacial Surgery of the Kamineni Institute of Dental Sciences from 2007 to 2013 were included in this study.

RESULTS

Six males and four females were treated. Juvenile ossifying fibroma was most often encountered (40 %), and the mandible was the most frequent location (70 %). Main clinical feature in most of the cases was a painless expansile swelling with facial asymmetry, and radiologically mixed (radiolucent and radiopaque lesions) were seen in majority of cases. All cases were surgically treated and histopathologically confirmed. Segmental ostectomy was performed in six cases; maxillectomy was done in one case and excision along with margin in three cases. Mean follow-up was of 3.3 years with no recurrence.

CONCLUSIONS

Fibro-osseous lesions, although sharing similar microscopic features, exhibit a variety of clinical behavior rendering their treatment highly individualized. Radical treatment is the choice to achieve an outcome without recurrence.

Craniofacial Fibrous Dysplasia Involving the Orbit: A Case Report and Literature Review

PURPOSE

Craniofacial fibrous dysplasia is a benign slowly progressive disease in which normal craniofacial bones are replaced by immature fibro-osseous tissue. Orbital involvement may present as visual loss in some patients. The etiology of visual loss in orbital fibrous dysplasia is still unclear, with many theories proposed in recent literature. This has led to developments in the controversy regarding the role of prophylactic optic nerve decompression in asymptomatic orbital fibrous dysplasia patients. This case report and literature review evaluates the need for early surgical intervention in such patients, as well as highlights other aspects of the condition and its management.

DESIGN

Case report and literature review.

METHODS

This was a case report of a 12-year-old Chinese girl who developed progressive visual loss in association with craniofacial fibrous dysplasia involving the orbit. Literature regarding the epidemiology, pathophysiology, clinical features, diagnosis, investigations, and management was searched from the PubMed database.

RESULTS

Extradural decompression of the optic nerve resulted in marked visual improvement, with temporal optic atrophy noted postoperatively. Literature review revealed a number of recent studies recommending against prophylactic optic nerve decompression, but early surgical intervention upon onset of visual loss is suggested.

CONCLUSIONS

Immediate surgical referral and early optic nerve decompression is recommended upon onset of visual loss. Periodic follow-up is recommended to monitor for recurrence and malignant transformation.

A Clinicopathologic Analysis of 207 Cases of Benign Fibro-Osseous Lesions of the Jaws

Benign fibro-osseous lesion (BFOL) is a distinct group of jaw entities composed of fibrocellular tissue and mineralized materials. In this study, we examined the epidemiological, clinical, and pathological features of patients with BFOL. Records and microslides of 207 BFOLs submitted to pathology service were retrospectively reviewed. Overall, fibrous dysplasia (FD) was the most prevalent (36.7%), followed by ossifying fibroma (OF; 32.4%), osseous dysplasia (OD; 24.6%), and juvenile ossifying fibroma (JOF; 6.3%). Female predilection was noted. FD and JOF were common in maxilla, whereas most OF and OD affected the mandible. Most patients with FD and OF presented with painless swelling, while patients with OD were symptomless. The majority of FD specimens showed woven bone, while a mixture of woven bone and cementum-like materials was often noted in OF and OD. Our data show variations in the clinicopathologic features of BFOLs. A thorough examination of all aspects of BFOL patients is imperative for accurate diagnosis.

Craniofacial fibrous dysplasia: Surgery and literature review

Objective:

To highlight the clinical and radiologic features and management of craniofacial fibrous dysplasia with review of literature.

Materials and Methods:

A retrospective review of 6 patients who underwent surgical treatment in a tertiary healthcare centre was done using the parameters of patients' details, clinical features, radiological findings, management and postoperative review.

Results:

Of the six patients, 3 females and 2 males were in the 2^nd decade of life and 1 male in the 1^st decade of life. The disease was restricted to maxilla in 3 patients, involved the temporal and frontal bones in addition to maxilla in one, involved the frontal bone in one patient and involved frontal and parietal bones in one patient. The primary reason for seeking treatment in all the 6 cases was facial deformity. There was absence of pain in all 6 cases. For surgical treatment in all three cases involving the maxilla, the approach was intraoral while bicoronal approach was used for the other three cases. Treatment consisted of surgical contouring and reshaping the area. All cases were followed up over a period of 2 years with no signs of recurrence.

Conclusion:

Treatment of craniofacial fibro-osseous lesions is highly individualized. Most cases of craniofacial fibrous dysplasia manifest as swellings that cause facial deformity and surgical recontouring after cessation of growth seems to provide the best results.

Management of fibro-osseous lesions of the craniofacial area. Presentation of 19 cases and review of the literature

INTRODUCTION

Fibro-osseous lesions constitute a rare benign type of pathology with a non-odontogenic lineage that affect the craniofacial area. According to Waldrom's classification, these lesions are divided into: fibrous dysplasia (FD), cemento-ossifying fibroma (COF) and desmoplastic fibroma (DF).

MATERIAL AND METHODS

A retrospective study was performed on patients diagnosed with fibro-osseous lesions of the craniofacial area at the Hospital Universitario La Fe, Valencia, during 1987-2009. A total of 19 cases were collected: 15 cases compatible with an FD diagnosis, 3 cases with a COF diagnosis and 1 case with a DF diagnosis.

RESULTS

In the differential diagnosis, entities having similar clinical manifestations in the maxillofacial area with possible involvement of teeth or manifestations present as an asymptomatic radiolucent image should be ruled out. We hereby present the management and development of patients treated in our hospital for fibro-osseous lesions.

CONCLUSIONS

Fibro-osseous lesions share many clinical and radiological characteristics in common, with histological features confirming the nature of the lesion. Management of patients should be individualized and case-specific, assessing the clinical evolution of each case and taking into account the benign nature and growth behavior of this type of tumors.

Ossifying fibroma of the nose and paranasal sinuses

BACKGROUND

The purpose of this work was to perform a systematic review regarding ossifying fibroma and its multiple variants of the paranasal sinuses, and to identify any clinical differences between the multiple variants.

METHODS

A search of the U.S. National Library of Medicine (PubMed) database was performed for the non–Medical Subject Heading (MeSH) search term “ossifying fibroma.” The bibliographies of the retrieved manuscripts were searched to identify additional potentially relevant articles. Finally, textbooks of head and neck pathology were searched to identify peer-reviewed literature that addresses the histopathology of ossifying fibroma and its variants. Abstracts were screened by 2 of the authors to identify reports of ossifying fibroma lesions (and its variants) that involved the paranasal sinuses. Extracted data from case reports or case series included the clinical presentation, age, gender, site of involvement, surgical approach, treatment outcome, follow-up period, and recurrence rate. Information derived from cases is summarized in tables, and simple descriptive statistics were applied to the data.

RESULTS

A total of 137 distinct patients were identified in 103 reports. Extracted data did not show any appreciable difference in clinical presentation or outcomes. Data on recurrence of these lesions was often limited by a lack of follow-up.

CONCLUSION

Although differentiation between the subtypes of ossifying fibroma can be made histologically, and a diverse nomenclature exists, there does not appear to be any overriding clinical significance to the histopathologic differentiation of OF variants.

Tooth in the nose: unusual presentation of a misdiagnosed maxillary ossifying fibroma

Fibro-osseous lesions involving the paranasal sinuses are uncommon, and making a determination of their histologic type is challenging. Correlating clinical and surgical findings with radiologic and histologic characteristics is essential for making a definitive diagnosis. We describe a case of misdiagnosed maxillary ossifying fibroma presenting as a solitary mass that completely filled and enlarged the left maxillary sinus. Another interesting finding was the presence of a molar tooth embedded in the tumor. We briefly comment on the genesis, natural course, and differential diagnosis of this lesion.

Surgery versus watchful waiting in patients with craniofacial fibrous dysplasia--a meta-analysis

Background

Fibrous dysplasia (FD) is a benign bone tumor which most commonly involves the craniofacial skeleton. The most devastating consequence of craniofacial FD (CFD) is loss of vision due to optic nerve compression (ONC). Radiological evidence of ONC is common, however the management of this condition is not well established. Our objective was to compare the long-term outcome of patients with optic nerve compression (ONC) due to craniofacial fibrous dysplasia (CFD) who either underwent surgery or were managed expectantly.

Methodology/Principal Findings

We performed a meta-analysis of 27 studies along with analysis of the records of a cohort of patients enrolled in National Institutes of Health (NIH) protocol 98-D-0145, entitled Screening and Natural History of Fibrous Dysplasia, with a diagnosis of CFD. The study group consisted of 241 patients; 122 were enrolled in the NIH study and 119 were extracted from cases published in the literature. The median follow-up period was 54 months (range, 6–228 months). A total of 368 optic nerves were investigated. All clinically impaired optic nerves (n = 86, 23.3%) underwent therapeutic decompression. Of the 282 clinically intact nerves, 41 (15%) were surgically decompressed and 241 (85%) were followed expectantly. Improvement in visual function was reported in fifty-eight (67.4%) of the clinically impaired nerves after surgery. In the intact nerves group, long-term stable vision was achieved in 31/45 (75.6%) of the operated nerves, compared to 229/241 (95.1%) of the non-operated ones (p = 0.0003). Surgery in asymptomatic patients was associated with visual deterioration (RR 4.89; 95% CI 2.26–10.59).

Conclusions

Most patients with CFD will remain asymptomatic during long-term follow-up. Expectant management is recommended in asymptomatic patients even in the presence of radiological evidence of ONC.

Ultrastructual morphology of juvenile psammomatoid ossifying fibroma

We investigated the ultrastructural morphology of the hard tissue in a fibro-osseous lesion. Bone samples were obtained from a juvenile psammomatoid ossifying fibroma and were observed under a scanning electron microscope. The lesion had a spongy lamellar structure containing bony tissue. On histological examination, resorbing preexisting lamellar bone associated with a large number of cathepsin K-positive osteoclasts was confirmed. Scanning electron microscopy revealed the bony material to have a cribriform structure and to indicate resorption related to osteoclasts throughout the tumor. These characteristic findings revealed the presence of active bony reconstruction and destruction in this lesion. The spongy calcified structure observed by scanning electron microscopy expressed the characteristic ground glass appearance in computed tomography of this patient. This remarkable activation of osteoclasts may deeply relate to characteristic calcified structure in this lesion. Observation of hard tissue structure under a scanning electron microscope may shed light on the pathology of fibro-osseous lesions in the head and neck.

The nature of fibrous dysplasia

Fibrous dysplasia has been regarded as a developmental skeletal disorder characterized by replacement of normal bone with benign cellular fibrous connective tissue. It has now become evident that fibrous dysplasia is a genetic disease caused by somatic activating mutation of the Gsα subunit of G protein-coupled receptor resulting in upregulation of cAMP. This leads to defects in differentiation of osteoblasts with subsequent production of abnormal bone in an abundant fibrous stroma. In addition there is an increased production of IL-6 by mutated stromal fibrous dysplastic cells that induce osteoclastic bone resorption.

Fibrous dysplasia: a systematic review

OBJECTIVES

To evaluate the principal features of fibrous dysplasia (FD) by systematic review (SR) and to compare their frequencies between four global groups.

METHODS

The databases searched were the PubMed interface of Medline and LILACS. Only those reports of FD which occurred in a series in the reporting authors' caseload were considered. All cases were confirmed fibro-osseous lesions histopathologically. The SR-included series must also have included radiographs.

RESULTS

Of the 106 reports considered (including the Hong Kong report), 31 reports and a total of 788 cases were included in the SR. 11 SR-included series were in languages other than English. FD affected both genders equally, but was 50% more prevalent in the maxilla. The mean age at first presentation was 24 years. The decade with the greatest frequency was the second, in which males accounted for 63%. The main symptom in 90% of all SR-included cases was swelling (including deformation of the jaws). Not one SR-included case directly involved the ocular apparatus. All cases displayed buccolingual expansion; all mandibular cases exhibited downward displacement of the lower border of the mandible and almost all maxillary cases involved the maxillary antrum. Only 35% of reports included follow-up; 18% of cases recurred or were reactivated. Not one case displayed sarcomatous change.

CONCLUSIONS

Long-term follow-up of large series that would have revealed the long-term outcomes of FD was lacking. This is necessary because many cases do not burn out at the end of adolescence, as expected of a hamartoma, but are reactivated.

Correction of proptosis and zygomaticomaxillary asymmetry using orbital wall decompression and zygoma reduction in craniofacial fibrous dysplasia

Craniofacial fibrous dysplasia is associated with facial asymmetry, orbital dystopia, and orbital proptosis. Although radical excision of the affected bone with immediate craniofacial reconstruction is usually the best treatment option, complete excision may be impossible in some patients because of involvement of the skull base, including the sphenoid and ethmoidal bones. In adult patients without functional loss or rapid disease progression, a shaving procedure is the optimal alternative for fibrous dysplasia affecting the maxilla and zygoma areas. Lesions in the skull base causing exophthalmos, however, cannot be corrected by shaving, whereas shaving only the zygoma and maxilla can worsen the exophthalmos or cause incomplete contouring of the zygomatic arch area. Thus, we had undertaken malar reduction with osteotomies and orbital wall decompression to avoid these adverse effects and complement the shaving procedure in these patients. Five patients with craniofacial fibrous dysplasia and unacceptable aesthetic appearance were treated from December 2005 to July 2006. Operative extent was decided using computed tomography (CT) scans and three-dimensional skull models. Orbital wall decompression was performed through a subciliary incision by burring and osteotomies, and zygoma reduction was performed by an intraoral approach with minimal dissection. Some patients underwent shaving in the maxillary area at the same time. Outcomes were assessed using CT scans and photographs. All outcomes were successful, as determined using CT scans and clinical photographs, and all 5 patients were satisfied with the results of their surgery. No complications were observed, including facial nerve and optic nerve injury. This procedure may be an acceptable alternative for contouring in adult patients with nonprogressing fibrous dysplasia, who suffer from exophthalmos and asymmetry of the midcheek.

Craniofacial fibrous dysplasia of orbit

Fibrous dysplasia is a benign, rare, and idiopathic skeletal disorder characterized by replacement and expansion of medullary bone by disorganized fibro-osseous tissue. Treatment for these lesions is usually sought for cosmetic or functional reasons. The surgical approaches vary from watchful expectancy for the lesion to stop growing after puberty to conservative resection to radical resection. In this case reports, 3 patients with craniofacial fibrous dysplasia involving orbital region underwent surgery. In these primary cases, resection and immediate reconstruction were performed to regain facial contour, dental occlusion, and masticatory function. Significant improvement was seen in facial appearance, and all patients also felt that there had been improvement aesthetically. Therefore, conservative treatment for fibrous dysplasia, unless there is involvement of vital structure as orbital region, can be suggested. Early surgery to address progressive sensory disturbance is recommended so as to avoid the hazards of late-stage decompression.