OSSIFYING FIBROMA

BY: MAHA JABEEN

 OSSIFYING
FIBROMA
Other names: Cementifying Fibroma , Cemento- ossifying Fibroma
Introduction:
• Ossifying fibroma is a part of benign fibro-osseous lesions of the jaw that are
characterised by replacement of normal bone by fibrous tissue containing a
newly formed mineralized product
• Ossifying fibroma is defined as an encapsulated,well demarcated benign
neoplasm composed of varying amounts of bone or cementum-like tissue in
the fibrous tissue stroma or mixture of them
• ORIGIN :Derived from progenitor cells of the periodontal ligament, capable
of differentiation into fibroblasts, osteoblasts and cementoblasts
• ETIOLOGY: Mutation in HRPT2 gene that normally encodes parafibromin
protein which maintain cell mobility , multiplication and survival
 Clinical Features:

Age : 3rd to 4th Decades.

Sex : Female Predilection ( 5:1)
Site : Mandible is commonly affected than maxilla especially the premolar and molar
region

Suet al reported that 52 (70%) of their 75 cases of ossifying fibromas were located in the mandible, with 43%
located in the posterior region including the ramus area, followed by 22% in the posterior maxilla.
 Clinical Presentation:

• Early lesions are small and detected only during routine Radiographic examination ,
they remain clinically asymptomatic until they become large enough to cause facial
deformity (painless expansion) or hinder function
• Ossifying fibromas are usually solitary
• Root divergence, displacement of teeth in the tooth-bearing region or root resorption
may be associated with the tumor.
• Large ossifying fibromas of the mandible often demonstrate a characteristic downward
bowing of the inferior cortex of the mandible.The size of the lesion can range from 0.2
to 15 cm
• Pain and paresthesia is absent because
of it’s slowly growing behaviour
 Radiographic Features:
• The most important radiographical feature of this lesion is well-circumscribed and sharply
defined border
• Three different patterns of radiographical borders were reported by Su et al
1. A defined lesion without a sclerotic border (40%)
2. A well-defined lesion with a sclerotic border (45%)
3. A lesion with an ill-defined border (15%)
• Most often lesion are unilocular, but larger lesions may be multilocular
• MacDonald-Jankowski described three stages in the radiographic appearance.
- Initially the lesion is radiolucent (osteolytic image)
- It becomes progressively radiopaque as the stroma mineralizes thus transforming
in to mixed lesion.
- Eventually, the individual radiopacities coalesce to the extent that the mature lesion
may appear sclerotic or radiopaque lesion
• Larger lesion may produce root divergence and root resorption
Stage 1 :

Stage 2:

Stage 3:
 Histological features:

On histopathology, well circumscribed and proliferating mass was seen to consist of fibrous
and osseous elements.
In the fibrous area, proliferating fibroblast-like spindle cells which had oval middle-sized
nuclei and fusiform slightly basophilic cytoplasm were seen in combination with collagen
fibers and blood vessels.
Few mitotic figures were observed.
In the osseous elements, there were irregularly shaped osteoid spicules and woven bone
rimmed with osteoblasts.
Osteoclasts were clearly observed at the trabecular margin.
The fibroblast-like cells were partially aggregated, and some mild calcification was
observed.
 Management:

• The treatment of COF must be directed towards the complete

removal of the tumour mass using enucleation or curettage
techniques. Surgical resection of the jaw is advised only for large
neoplasms
• Recurrence after resection is less
 JUVENILE
OSSIFYING
FIBROMA
first reported by Benjamins in 1938
Introduction:
• Juvenile ossifying fibroma (JOF) is a rare benign fibro-osseous neoplasm
that is characterized by cell-rich fibrous tissue, bands of cellular osteoid
trabeculae and giant cells
• Differentiation from ossifying fibroma on the basis of
-Age incidencs : as it occur usually in children and young adults
-Site Predilection: It frequently affect maxilla (involves the paranasal
sinuses, the orbit, the fronto–ethmoid bones) than mandible
-Behaviour: it has more aggressive clinical behaviour
• Two pathological types / Patterns are recognized
1. Trabecular juvenile ossifying fibroma
2. Psammomatoid juvenile ossifying fibroma
 Psammomatoid Juvenile Ossifying Fibroma

• It is characterized by the presence of small uniform spherical ossicles that

resemble psammoma bodies
• It is reported more commonly than trabecular JOF
• Age incidence : 3 months to 72 years
• Occurs predominantly (75%) in sinonasal and orbital bones and calvaria and
25% in maxilla and mandible
• Orbital extension causes Proptosis and visual complaints including
blindness, nasal obstruction, ptosis and disturbance in occular mobility
• it has aggressive behaviour and higher tendency to reoccur
 Histological features:
• Microscopically the lesion is characterized by a fibroblastic stroma containing
small ossicles resembling psammoma bodies
• psammoma-like bodies possess a dark rim of crystals from which small spicules
and needle-like crystalloids project (brush border) toward the periphery.
• The stroma varies from being loose and fibroblastic to intensely cellular with
minimum intervening collagen.
• Other features such as trabeculae of woven bone as well as lamellar bone,
pseudocystic stromal degeneration, and hemorrhages
 Radiographic Features:

• Round, well defined , osteolytic lesion with a cystic appearance

• In CT scans, appear less dense than normal bone

Management:
• Smaller lesions can be simply excised with surrounding marginal bone.
• Larger lesions however warrant more aggressive surgical management.
• The recurrence rate for this lesion is about 30–60%
• Malignant transformation has not been documented
 Trabecular Juvenile Ossifying Fibroma

• Mojority of patients are children and adoloscents

• M:F = 1 : 1
• Maxilla and mandible are dominant sites with maxilla being more affected
• It is progressive and sometime cause rapid expansion of bone
• in maxilla , obstruction of nasal passages and epistaxis may be present
 histological features:

• Uncapsulated and shows infiltration of surrounding bone

• stroma is cell rich with spindle or polyhedral cells produce little
collagen
• cellular immature osteoid forms strands
• myxomatous foci
 Radiographic features:

• Expansive and well demarcated

• with cortical thinning and perforation
• Shows varying amount of radiolucency and opacity depending
upon amount of calcified tissue
• Ground glass and honeycomb like appearance
 CASE REPORT
A 46-year-old female presented with a growth in relation to right maxillary posterior tooth
region for past 2 years. Past history revealed that the lesion was present for past 2 years, was
slow growing, and showed a progressive increase in size for past 6 months. On intraoral
examination, a diffuse proliferative mass was present in the right maxilla extending
anteriorly from right permanent maxillary central incisor and posteriorly up to the maxillary
tuberosity, laterally obliterating the mucobuccal sulcus and medially up to the midline of the
palate. The lesion was soft, nontender and measured 4 cm × 3 cm × 2 cm approximately
[Figure 2]. Radiographic examination showed a unilocular radiolucent lesion with areas of
radiopacity extending from 11 anteriorly up to the maxillary tuberosity region posteriorly.
The lesion did not show involvement of maxillary sinus. A provisional diagnosis of ossifying
fibroma was made. Partial maxillectomy was done under general anesthesia and specimen
was sent for histopathological examination. On macroscopic examination, the resected right
maxillary segment along with 13 and root stump of 14 measured about 4 × 3 × 2 cm
approximately, brownish white in color and varied from firm to hard in consistency [Figure
3]
 Figure 2:

Figure 1:

Figure 3:
Microscopic examination of the lesional tissue in both the cases revealed cellular fibroblastic
stroma containing spherical and curved ossicles [Figure 4]. Concentric lamellated ossicles
resembling psammoma bodies were present [Figure 5]. Periphery of these ossicles showed a
brush border which was blending into the surrounding stroma [Figure 6]
Figure 4: Figure 5:
Figure 6:
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