Correction of proptosis and zygomaticomaxillary asymmetry using orbital wall decompression and zygoma reduction in craniofacial fibrous dysplasia. J Craniofac Surg. 2009;20:326-330. [PMID: 19276831 DOI: 10.1097/scs.0b013e31819922d3]

Functional outcomes and recurrence determinants in craniofacial fibrous dysplasia: Insights from 3D computed tomography and comprehensive clinical evaluation

BACKGROUND

This study aimed to identify risk factors for postoperative lesion regrowth and to assess functional outcomes in craniofacial fibrous dysplasia, using a three-dimensional computed tomographic volumetric analysis.

METHODS

A retrospective analysis was conducted on 47 patients with craniofacial fibrous dysplasia who were treated from July 2005 to December 2020. Patients were treated with either conservative shaving or radical excision followed by reconstruction. Demographic data, surgical details, lesion recurrence, and functional outcomes were assessed. Lesion volume changes and recurrence were evaluated clinically and through a computed tomographic volumetric analysis.

RESULTS

Among the patients, 16 underwent conservative treatment, whereas 31 received radical treatment. The radical group showed more significant improvements in functional outcomes, particularly in orbital dystopia and facial asymmetry. Postoperative lesion volume was notably lower in the radical group (41.94 ± 38.13 cm3) compared with the conservative group (78.3 ± 47.3 cm3, p = 0.008). This reduction was maintained over an average follow-up of 3 years. Lesion growth rates were similar between the groups (8.17 ± 5.85% in radical vs. 5.84 ± 6.43% in conservative, p = 0.268). Multivariate analysis indicated that patients aged ≤20 years and those with multifocal involvement had significantly higher risks of recurrence, with adjusted odds ratios of 11.269 (p = 0.039) and 6.914 (p = 0.046), respectively.

CONCLUSIONS

Our findings suggest that both conservative and radical treatments for craniofacial fibrous dysplasia provide benefits, with the radical approach notably enhancing functional outcomes. However, neither method definitively reduces lesion recurrence, highlighting the necessity for an individualized treatment strategy. This approach should balance functional enhancement with recurrence risks, tailored to each patient's specific clinical scenario.

Craniofacial Fibrous Dysplasia in Fronto-Orbital Region: A Single-Center Retrospective Study of 38 Cases

OBJECTIVE

This study presents the clinical characteristics, imaging manifestations, and surgical experience in 38 patients diagnosed with craniofacial fibrous dysplasia in fronto-orbital region (foFD).

METHODS

We retrospectively analyzed the clinical data from 38 patients who had surgery for foFD. The surgical procedure typically involved extensive tumor removal, followed by immediate reconstruction of the frontal bone and orbit using synthetic materials. Additionally, 9 patients underwent simultaneous microscopic decompression of the optic canal.

RESULTS

Common clinical manifestations included progressive fronto-orbital bone deformity (35), proptosis (28), orbital dystopia (21), and visual impairment (9). The disease primarily affecting the frontal bone (38), the sphenoid bone (28), and the ethmoid bone (24). The optic canal was involved in 9 patients with functional impairment. Computed tomography scans in all 38 cases revealed satisfactory repair material positioning and complete resolution of frontal deformities. Among the 9 patients who underwent optic canal decompression, 7 experienced partial recovery of visual acuity after surgery.

CONCLUSIONS

In the surgical treatment of foFD, it is crucial to achieve maximal bone resection and repair skull defects, while decompressing the optic canal can provide significant benefits for patients with decreased visual function preoperatively. The use of preformed artificial materials offers advantages in aesthetic restoration after lesion excision.

Craniofacial fibrous dysplasia: Systematic review of facial management

Craniofacial fibrous dysplasia (CFD) may be associated with major cosmetic or functional consequences. However, management recommendations for CFD are currently unavailable. Therefore, this systematic literature review aimed to review the existing approaches for CFD management and propose a management algorithm. The focus question was "What are the different options for CFD treatment and their complication rates?" The MEDLINE database was searched, and 33 articles evaluating a total of 1154 patients were reviewed. The bias assessment showed that 20 of the 33 studies had a high or intermediate risk of bias, mainly because of retrospective data collection and small patient numbers. Radical surgery showed a lower recurrence rate than debulking, but its use should be weighed against the morbidity caused by the reconstruction performed in this technique. Orbital decompression using a radical technique or debulking is effective in cases showing exophthalmos or dystopia. Surveillance is a viable option for asymptomatic and/or non-progressive lesions. In cases showing optic nerve compression, prophylactic decompression should be avoided, and decompression should be performed only when patients show diminished visual acuity or visual field defect. Although bisphosphonates have shown efficacy in pain management, their posology requires further discussion. A management algorithm is presented.

Fibula allograft transplantation combined with locking plate for treatment of recurrent monostotic fibular fibrous dysplasia: A case report

BACKGROUND

Fibrous dysplasia is a congenital disorder in which normal bone is replaced by fibro-osseous tissue or irregular trabeculae of woven bone intermixed with mature collagenous tissue. A single or multiple bones are affected. This rare bone disorder has three clinical patterns including monostotic, polyostotic, and that associated with McCune–Albright syndrome. Most studies report primary fibrous dysplasia. However, a few cases of recurrent monostotic fibular fibrous dysplasia have been reported. Here, we report a therapeutic strategy for recurrent fibular fibrous dysplasia.

CASE SUMMARY

A 4-year-old boy was admitted for persistent pain in the left lower limb and abnormal gait over the previous 9 mo. He had no history of present or past illness. Preoperative imaging data showed erosion-like changes with bone expansion of the left middle and lower fibular segment. Tumor tissue in the fibular bone marrow cavity was removed by curettage, and rapid intraoperative pathological examination suggested fibular fibrous dysplasia. An allograft was implanted into the fibular medullary cavity. However, he was readmitted with clinical symptoms including persistent pain, abnormal gait, and local swelling at the age of 6 years. He was diagnosed with recurrent fibular fibrous dysplasia based on the second medical examination. He underwent fibular bone tumor radical resection and longus fibular allograft transplantation combined with fibular bone locking plate and screws. Good host bone to allogenic bone graft fusion was observed by the physician on postoperative regular follow-up.

CONCLUSION

Radical resection of fibrous dysplasia and longus fibula allograft combined with internal fixation for reconstruction are suitable for the treatment of recurrent monostotic fibular fibrous dysplasia.

Current concepts of craniofacial fibrous dysplasia: pathophysiology and treatment

Fibrous dysplasia is an uncommon genetic disorder in which bone is replaced by immature bone and fibrous tissue, manifesting as slowgrowing lesions. Sporadic post-zygotic activating mutations in GNAS gene result in dysregulated GαS-protein signaling and elevation of cyclic adenosine monophosphate in affected tissues. This condition has a broad clinical spectrum, ranging from insignificant solitary lesions to severe disease. The craniofacial area is the most common site of fibrous dysplasia, and nine out of 10 patients with fibrous dysplasia affecting the craniofacial bones present before the age of 5. Surgery is the mainstay of treatment, but the technique varies according to the location and severity of the lesion and associated symptoms. The timing and indications of surgery should be carefully chosen with multidisciplinary consultations and a patient-specific approach.

Long-term outcomes after core extirpation of fibrous dysplasia of the zygomaticomaxillary region

BACKGROUND

Fibrous dysplasia (FD) is a localized bone disorder in which fibro-osseous tissue replaces the normal bone structure. Patients with craniofacial FD often present with gradual swelling, deformity, and compromised vision or hearing. We previously introduced "the core extirpation method," a novel surgical technique that is minimally invasive like traditional bone shaving but has longer-lasting effects. This study presents the long-term outcomes of our core extirpation method.

METHODS

We conducted a retrospective analysis of patients who underwent core extirpation for FD of the zygomaticomaxillary region from 2012 through 2021. Computed tomography (CT) scans were performed 6 to 12 months before the operation, immediately before and after the operation, and during follow-up visits. We performed all operations using the upper gingivobuccal approach, and we extirpated the core of the lesion while preserving the cortical structures of the zygoma and the maxilla to maintain symmetrical facial contour.

RESULTS

In 12 patients with lesions in the growth phase, anteroposterior/mediolateral (AP/ML) length discrepancies and the volume increased between preoperative and immediate postoperative CT scans. All patients' immediate postoperative AP/ML discrepancies were stable up to 12-17 months postoperatively. Postoperative volume showed continuous lesion growth; the median volume growth rate was 0.61 cc per month.

CONCLUSION

In this article, we present our experiences managing FD using the minimally invasive core extirpation technique, which entails small expected blood loss and can be performed as day surgery. It provides similar cosmetic outcomes as traditional bone shaving but with longer-lasting results. Although there are some limitations with the study's retrospective nature and small sample size, our 4-year follow-up results show promising results of the core extirpation method in well-indicated patients.

A Novel Bone Contouring Technique Using Multiple Tangential Shaving for Conservative Management of Craniofacial Fibrous Dysplasia

This study aimed to propose a novel surgical technique, named multiple tangential shaving of bone contour, for the conservative management of craniofacial fibrous dysplasia. We retrospectively reviewed 17 patients who underwent conservative management of craniofacial fibrous dysplasia using multiple tangential shaving technique between July 2005 and December 2020. Demographics, tumor characteristics, and surgery-related factors were investigated. All patients underwent preoperative (T0) and postoperative computed tomography scans taken at least twice within 1 month for immediate assessment (T1) and at least 12 months postoperatively for long-term assessment (T2). Clinical outcomes, including tumor recurrence, perioperative complications, and physician measure of esthetic outcomes (Whitaker score), were investigated. This technique was applied for contouring of the zygomatic-maxillary and calvarial bone for patients aged between 16 and 60 years (mean age: 26 y). The mean±SD tumor volume reduction was 15.5±8.95 cm 3 , and the postoperative mean±SD tumor growth rate was 5.52±6.26% per year. Satisfactory outcome was obtained in terms of esthetics with a mean±SD Whitaker score of 1.41±0.62. Patients required a mean operation time of 1.67±0.43 hours and a mean number of shaving operations of 1.35±0.61 during the follow-up period. Five of 17 patients required reoperation because of the tumor recurrence (N=4) and to correct new-onset diplopia after surgery (N=1). In conclusion, the multiple tangential shaving technique allows an easy approach for conservative management of craniofacial fibrous dysplasia. An acceptable rate of tumor recurrence and esthetic outcomes can be obtained by selecting the appropriate candidate for a conservative approach.

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.

Surgical Correction of Craniofacial Fibrous Dysplasia Involving Orbits: A Unique Application of Patient-Specific Implants

ABSTRACT

Craniofacial fibrous dysplasia is a slow-growing bony disorder causing asymmetry of the face; leading to aesthetic, functional, and psychological ramifications. Surgical recontouring is the most accepted form of treatment. Reconstruction of the orbit poses a serious challenge to the surgeon; hence the present study is intended to describe and evaluate a most anatomically accurate virtual treatment planning and defect-specific implant technique, enumerating postoperative functional and esthetic outcome. The study highlights a valid application of three-dimensional models and computer-guided surgical splints. The current study included 5 patients with craniofacial fibrous dysplasia involving orbits with a mean age of 19.6 years. Detailed pre- and post-operative ophthalmologic workup were documented for one year. All the participants showed improvement in eyeball position and movement. Visual acuity and intraocular pressure have returned to near normal values, and astigmatism was reduced significantly. No recurrence was noted in any of the subjects. The current technique was found helpful in reconstructing the complex orbital anatomy; however, long-term follow-up studies with a greater number of patients are recommended.

Discontinuous polyostotic fibrous dysplasia with multiple systemic disorders and unique genetic mutations: A case report

BACKGROUND

Polyostotic fibrous dysplasia (PFD) is an uncommon developmental bone disease in which normal bone and marrow are replaced by pseudotumoral tissue. The etiology of PFD is unclear, but it is generally thought to be caused by sporadic, post-zygotic mutations in the GNAS gene. Herein, we report the case of a young female with bone pain and lesions consistent with PFD, unique physical findings, and gene mutations.

CASE SUMMARY

A 27-year-old female presented with unbearable bone pain in her left foot for 4 years. Multiple bone lesions were detected by radiographic examinations, and a diagnosis of PFD was made after a biopsy of her left calcaneus with symptoms including pre-axial polydactyly on her left hand and severe ophthalmological problems such as high myopia, vitreous opacity, and choroidal atrophy. Her serum cortisol level was high, consistent with Cushing syndrome. Due to consanguineous marriage of her grandparents, boosted whole exome screening was performed to identify gene mutations. The results revealed mutations in HSPG2 and RIMS1, which may be contributing factors to her unique findings.

CONCLUSION

The unique findings in this patient with PFD may be related to mutations in the HSPG2 and RIMS1 genes.

Mandibular 3-dimensional finite element analysis for a patient with an aggressive form of craniofacial fibrous dysplasia

The longitudinal change in mandibular volume and configuration was quantitatively evaluated in a patient with craniofacial fibrous dysplasia (FD). The influence of mechanical stress on the enlargement that is characteristic of FD was verified via finite element analysis (FEA). The patient was a 38-year-old man diagnosed with craniofacial FD in the mandible. He underwent surgical reduction of FD, but the lesion continued to grow and caused facial asymmetry and masticatory disturbance because of missing teeth. An occlusal overlay removable partial denture was constructed for his lower jaw. Computed tomography (CT) images were acquired 4 times in 10 years, and 3-dimensional (3-D) models were reconstructed from these data. The 3-D models were analyzed volumetrically and morphologically and used for FEA. The FD lesion in the mandible enlarged nonuniformly and had site specificity. From the results of FEA, it is suggested that compression stress induced by the occlusal force through the denture may have influenced the direction of enlargement in FD.

Our experience in the surgical management of craniofacial fibrous dysplasia: what has changed in the last 10 years?

The mainstay of treatment of craniofacial dysplasia (CFD) remains surgery once clinical observation has been excluded. Nevertheless, disagreement remains about the type of surgical intervention (remodelling versus radical resection). The aim of this paper is to present our experience until 2013 comparing CFD management between 1980 and 2002 and between 2003 and 2013 and to propose our surgical algorithm. From January 2003 to December 2013, 41 new patients (18 males and 23 females) with histologically demonstrated CFD presented to our Department. Data were compared with those of 95 patients observed and/or treated between 1980 and 2002. Considering the last period, we noted that observation (26/41 patients) was the most used method; radical resection was performed in most cases (8/15 patients), but in proportion the numbers of patients undergoing bone shaving has increased (6% between 1980 and 2002 vs 15% between 2003 and 2013), while a decrease in the number of patients undergoing excision was seen (63% between 1980 and 2002 vs. 19% between 2003 and 2013). On this basis, we believe that radical resection is the only technique to obtain resolution of fibrous dysplasia. Wait-and-see is indicated in case of stable lesions. Reconstructive techniques allow obtaining adequate aesthetical and functional results; nevertheless, in most cases adjunctive surgical refinements are required and recovery time is higher than with surgical shaving, so that most patients prefer to perform remodelling. Nevertheless, in case of aggressive lesions radical resection is mandatory, except in paediatric patients with residual large defects in which it can be acceptable to try to resolve symptoms via bone shaving, reserving more aggressive treatments in case of relapse or after skeletal maturity.

Strategies for the Optimal Individualized Surgical Management of Craniofacial Fibrous Dysplasia

BACKGROUND

The surgical management of craniofacial fibrous dysplasia is controversial. The purpose of this study was to report the surgical outcomes of individualized management of craniofacial fibrous dysplasia of a single institution.

METHODS

Data from patients (n = 20) with craniofacial fibrous dysplasia, who were surgically treated between 2007 and 2014, were analyzed. Surgical approach (radical or conservative surgery) was individualized according to age, craniofacial anatomical site (zones I to IV of Chen and Noordhoff), functional issues, aesthetic impairment, patients/parents' preferences, and surgical team experience. The surgical outcomes (radical surgery group versus conservative surgery group) were compared based on the age at the time of the procedure, the length of hospital stay, reoperation, recurrence and complication rates, and the Whitaker grading system.

RESULTS

Significant (all P < 0.05) differences were observed in patients with craniofacial fibrous dysplasia who were treated with radical excision (65%) compared with those treated with limited reduction burring (35%), according to age (19.22 years versus 12.57 years), the length of hospital stay (3.56 days versus 1.29 days), recurrence (15% versus 71%), and number of subsequent procedures (1 intervention versus 2.4 interventions), respectively. The radical surgery group presented a significantly (P < 0.05) lower initial Whitaker outcome score than the conservative surgery group (1.89 and 2.57, respectively). Similar (all P > 0.05) final Whitaker outcome scores (1.56 versus 1.71) and surgical complication rates (11% versus 14%) were recorded between the treatment groups.

CONCLUSIONS

Based on clinical experience and surgical outcomes presented in this study, the surgical approach of craniofacial fibrous dysplasia should be tailored to individual patient's needs.

Recurrent Monostotic Fibrous Dysplasia in the Mandible

Fibrous dysplasia (FD) is a condition in which normal bone marrow is replaced by an abnormal proliferation of new fibrous connective tissue. Female patient, white, 20 years old, attended the dental clinic reporting a slow increase in volume in the right mandible region over the last 5 years. She was examined by imaging: the panoramic X-ray revealed a lesion with the appearance of ground glass while the cone-beam computed tomography showed an extensive lesion in the region of the right hemimandible. The histopathological examination was compatible with fibrous dysplasia. Bone gammagraphy was indicated, plus an endocrinological study to eliminate polyostotic forms, which produced a negative result. Monostotic fibrous dysplasia in the right hemimandible was diagnosed. Conservative surgery was carried out and after 1 year recurrence of the tumour was observed. We may conclude that conservative surgery might not be the best choice for treatment for monostotic fibrous dysplasia in the mandible and that other options must be considered, such as radical surgery or the use of bisphosphonates. In our study, we may also conclude that it is very important to explain to the patient the possibility of recurrence of the lesion and the need for monitoring with periodic imaging studies.

A Novel and Easy Approach for Contouring Surgery in Patients With Craniofacial Fibrous Dysplasia

Although the bone-shaving procedure is the optimal alternative treatment of craniofacial fibrous dysplasia affecting the maxilla and zygoma, it is difficult to determine the appropriate amount of bone to be removed. The authors therefore developed a novel method for bone shaving using three-dimensional printing technology on computed tomography (CT) scans and screws as a guide. In our method, we implanted screws of predetermined lengths into surgical sites and then performed a burring within the visual field. By using screws, the exact amount of bone could be removed, as determined preoperatively. Thus, the operation time was shorted and the method was less effort intensive. Moreover, this procedure had reduced risk of radiation exposure owing to frequent use of CT, and had a low cost. This simple new method is more precise and effective, and shows satisfactory cosmetic outcomes than those with current bone-shaving practices.

Recurring craniofacial fibrous dysplasia with extensive titanium mesh invasion

The recurrence and regrowth of craniofacial fibrous dysplasia (FD) along the repaired titanium mesh (TM) after total removal are extremely rare. A 22-year-old man was admitted to our hospital complaining of progressive proptosis and sudden vision loss of the right eye. Craniofacial FD was histologically diagnosed 3 years ago, and the involved frontal bone was totally removed and reconstructed with TM in his first surgery. Based on previous medical history, radiographic features, and clinical findings, the recurrence was considered, and the patient underwent surgical treatment. He had an uneventful postoperative course, and during the follow-up, his proptosis was gradually relieved, and the visual acuity also improved. In this article, we present the regrowth of craniofacial FD into TM and describe the clinical features, mechanism, and treatment of this condition.

Fibrous dysplasia of the zygomaticomaxillary region: outcomes of surgical intervention

BACKGROUND

Fibrous dysplasia is the most common craniofacial tumor, presenting in both monostotic and polyostotic forms with varying degrees of severity. No consensus exists regarding the surgical management of craniofacial fibrous dysplasia, particularly in the zygomaticomaxillary region. The present study compared long-term outcomes of limited reduction burring versus radical resection of zygomaticomaxillary fibrous dysplasia.

METHODS

Patients with craniofacial fibrous dysplasia at the University of California, Los Angeles, Craniofacial Center from 1982 to 2008 were studied based on demographics, treatment, and follow-up data, including examinations, computed tomographic scans, photographs, physician Whitaker scoring, and patient surveys (n=97). Outcomes were compared for zygomaticomaxillary disease treated with radical resection with cranial bone graft reconstruction or limited reduction burring (n=58).

RESULTS

Thirty-four percent of patients had monostotic disease, 66 percent had polyostotic disease, 3 percent had McCune-Albright syndrome, and 2.1 percent had malignant degeneration into osteosarcoma. Most patients had surgical treatment (84.5 percent). Of the patients that required optic nerve decompression for vision changes (11.4 percent), most (75 percent) had vision stabilization postoperatively. Differences were recorded in zygomaticomaxillary disease treated with radical resection (63.8 percent) versus reduction burring (36.2 percent) according to age (19.6 versus 14.2 years), complications (13.5 percent versus 4.8 percent), recurrence (66.7 percent versus 24.3 percent), and number of subsequent procedures (2.8 versus 4.0). There were similarities in Whitaker outcome score (1.3±0.3 versus 1.5±0.6) and patient satisfaction (2.7±0.4 versus 2.8±0.3).

CONCLUSIONS

Although different approaches have been advocated to treat fibrous dysplasia, the authors' data support a more aggressive management for zygomaticomaxillary disease with radical resection and cranial bone graft reconstruction, especially for more involved disease. CLINICAL QUESTION OF EVIDENCE: Therapeutic, III.

Alveolar bone grafting in association with polyostotic fibrous dysplasia and bisphosphonate-induced abnormal bone turnover in a bilateral cleft lip and palate patient: a case report

A case is presented of extensive alveolar bone grafting in a patient with bilateral cleft lip and palate and polyostotic fibrous dysplasia. The patient previously underwent bisphosphonate therapy. Because of an abnormal and often decreased bone turnover caused by the fibrous dysplasia and the bisphosphonate therapy, bone grafting in such a patient poses several potential difficulties. In addition, the histomorphometric analysis of the bone grafts showed markedly decreased bone turnover. However, alveolar bone grafting using the iliac crest was performed successfully. Sufficient occlusion was achieved by postoperative low-loading orthodontic treatment.

An epidemiological and clinical analysis of craniomaxillofacial fibrous dysplasia in a Chinese population

BACKGROUND

Craniomaxillofacial fibrous dysplasia (FD) is a benign bone lesion characterized by facial disfigurement and functional impairment. The aim of this study was to characterize the epidemiological and clinical features of craniomaxillofacial FD by presenting data from a representative Chinese population during a 15-year period (1994-2009).

METHOD

The craniomaxillofacial disease registries of two Chinese tertiary referral hospitals (Shanghai Ninth People's Hospital and Stomatological hospital of Jiangsu Province) were searched and reviewed to collect relevant information for patients with craniomaxillofacial FD between Jan.1994 and Dec.2009. All included cases were further analyzed with regard to associated epidemiological and clinicopathological variables.

RESULTS

A total number of 266 cases with definitive diagnosis were identified with 219 primary cases and 47 recurrent cases. There were 111 males and 155 females with a male to female ratio of 0.716:1. They were clinically categorized into three groups: monostotic (71.1%), polysotic (27.4%) and Albright syndrome (1.5%). Maxilla alone or with adjacent bones was the most common affected site. The serum alkaline phosphatase (ALP) in patients was much higher than that in healthy control, whereas comparable between primary patients and recurrent ones. Three patients (3/266, 1.1%) with polysotic lesions underwent spontaneous malignant transformation into osteosarcoma. The majority of patients underwent conservative surgery, while the others received radical resection with or without reconstruction.

CONCLUSIONS

Craniomaxillofacial FD is a rare bony disorder with defined epidemiological and clinicopathological features in Chinese population. Further investigations are warranted to establish the optimized timing, treatment strategy and prognostic prediction for this clinical entity.

Craniofacial fibrous dysplasia

Despite recent advances in the understanding of the natural history and molecular abnormalities, many questions remain surrounding the progression and management of fibrous dysplasia (FD). In the absence of comorbidities, the expected behavior of craniofacial FD (CFD) is to be slow growing and without functional consequence. Understanding of the pathophysiologic mechanisms contributing to the various phenotypes of this condition, as well as the predictors of the different behaviors of FD lesions, must be improved. Long-term follow-up of patients with CFD is vital because spontaneous recovery is unlikely, and the course of disease can be unpredictable.

Clinical guidelines for the management of craniofacial fibrous dysplasia

Fibrous dysplasia (FD) is a non-malignant condition caused by post-zygotic, activating mutations of the GNAS gene that results in inhibition of the differentiation and proliferation of bone-forming stromal cells and leads to the replacement of normal bone and marrow by fibrous tissue and woven bone. The phenotype is variable and may be isolated to a single skeletal site or multiple sites and sometimes is associated with extraskeletal manifestations in the skin and/or endocrine organs (McCune-Albright syndrome). The clinical behavior and progression of FD may also vary, thereby making the management of this condition difficult with few established clinical guidelines. This paper provides a clinically-focused comprehensive description of craniofacial FD, its natural progression, the components of the diagnostic evaluation and the multi-disciplinary management, and considerations for future research.

[Orbital pain from a cranio-maxillofacial surgery perspective]

Orbital pain can be provoked by diseases of the orbital skeleton as well as the maxillary sinus. Infections of the maxillary sinus caused by dental infections (e.g. periodontitis) or root canal treatment represent the majority of these cases followed by injuries of the orbital skeleton. An appropriate medical history usually provides indications for the further diagnostic procedure. In rare cases diseases of the facial skeleton as well as Wegener's granulomatosis can also cause orbital pain. In contrast temporomandibular disorders (TMD) may cause motility disorders and alterations in binocular vision but are not responsible for orbital pain.