Advances in Diagnosis and Management of Fibro-Osseous Lesions

SH3BP2-related fibro-osseous disorders of the maxilla and mandible: A systematic review

Cherubism is a disorder of bony overgrowth of the jaws that manifests in childhood. SH3BP2 gene variants have been associated with cherubism; this gene plays a major role in bone homeostasis. Due to its rare occurrence, there is as yet no comprehensive understanding of the natural history and clinical course of the disease. The aim of this review was to compile and analyze all cases of SH3BP2-related cherubism and cherubism-like disorders. Thirty publications were identified, including 92 individuals from 34 families, who were diagnosed with SH3BP2-related fibro-osseous lesions of the jaw. Only 15% of cases included in this review had no known family history of the disease. The distribution of cherubism was equal with respect to biological sex. Missing teeth were reported in 38% of cases. Lesions were restricted to the mandible in 36% of cases and involved both the maxilla and mandible in 54% of cases. The clinical phenotypes reported in the articles analyzed varied greatly in detail, making comparisons between studies and conclusive analysis difficult. Further work is necessary to describe the connection between SH3BP2 gene variants and cherubism in order to advance its diagnosis and treatment.

Innovative Surgical Treatment of Severe Cherubism

Background:

Cherubism is an autosomal dominant syndrome characterized by excessive bilateral maxillomandibular bony degeneration and fibrous tissue hyperplasia. Conservative management is the preferred treatment as cherubism has a self-limiting course. Functional or emotional disturbances may, however, demand surgical intervention. We report a patient who underwent surgical intervention.

Method/Description:

He had significant enlargement of lower cheeks and bilateral lower lid scleral show. On computed tomography of the face, the patient had significant fibrous tissue involving bilateral maxilla and mandible. The mandibular tumor was excised. Given normal inferior border, bilateral sagittal split osteotomy was performed to infracture and inset the outer cortex. During the procedure, patient required blood transfusion intraoperatively, so the maxillary portion of the procedure was delayed until 6 months later. For the maxilla, bilateral transconjunctival approach was used to resect parts of the orbital floors that were concave, resulting in 1 × 2 cm defects bilaterally which were reconstructed using resorbable plates. Then the anterior maxillary tumor was excised.

Results:

The patient and his parents were satisfied with his appearance after surgery. The patient was noted to have improvement in contour and decreased scleral show. He has most recently followed up 15 months after the initial surgery. There were no long-term complications.

Conclusions:

Severity of cherubism influences the type of surgical intervention. The present case is innovative because this is the first reported case of recontouring orbital floors with resorbable plates and infracturing of the mandible using sagittal split osteotomies for surgical treatment of cherubism.

Trabecular Variant: A Rare Entity of Juvenile Ossifying Fibroma of the Mandible

One of the rarest entities of fibro-osseous lesions that arise within the craniofacial bones is Juvenile ossifying fibroma (JOF). It is an intraosseous expansile lesion of the jaw that imitate odontogenic lesions. WHO has described two distinct histopathological variants of JOF; trabecular and psammomatoid. Histologically, they are characterized by the presence of fibrous connective tissue stroma along with osteoblastic and osteoclastic cells. Clinical, characteristics show an early age of onset, typical histological patterns, high rate of aggressive behavior and recurrence. This article presents a rare clinical case of the trabecular variant of JOF, its clinical, radiological, histological, and treatment aspects.

Juvenile Trabecular Ossifying Fibroma of the Maxilla: a Case Report

Introduction:

Juvenile ossifying fibromas are uncommon benign tumors. Their aggressiveness added to their high tendency to recur, provoke real diagnostic and therapeutic challenges for the dental practitioner and make a postoperative follow-up over the years indispensable.

Case report:

In this report, we present a case of a seven-year-old girl presented with a swelling in the face at the upper right maxillary region. After clinical, radiological, and histopathological examinations the diagnosis of trabecular juvenile ossifying fibroma was made. The lesion was surgically excised and followed up for two years with no evidence of recurrence.

Management of Large Maxillomandibular Osteofibrous Dysplasia as Part of a Humanitarian Mission

PURPOSE

Maxillomandibular ossifying fibroma is a benign tumor that affects young adults. Complete excision can allow satisfactory management with no recurrence. During a humanitarian mission, one is confronted with many types of damage from these fibromas. Their management requires wide resection (mandibulectomy interrupter or maxillectomy) and free flap reconstruction. However, technical conditions during a humanitarian mission might not allow the performance of a free flap reconstruction. How can such patients be managed? Should these patients receive a straightforward intervention performed on site during the mission or should they go to another country with a technical platform suitable for microsurgical reconstruction?

PATIENTS AND METHODS

During a humanitarian mission in Ouagadougou, Burkina Faso, 6 patients with large ossifying fibromas traveled to France to undergo wide excision of the lesion and free flap reconstruction using the fibula. The Enfants du Noma paid for the travel and medical costs.

RESULTS

No flap was lost. Four patients (67%) had local (disunity of scar or local infection) or general (malaria) complications that quickly resolved.

CONCLUSIONS

Most teams agree that free flaps should not be performed during humanitarian missions, and only 1 German team practices in Sokoto, Nigeria. Therefore, medical travel is an attractive solution that allows optimal management and requires financial assistance from humanitarian organizations.

Case Report of Nonfamilial Cherubism in a Toddler: Description of Clinic-Radiographic Features and Osseous-Dental Treatments

Cherubism is a rare familial disease that occurs between the ages two and five years and regresses after puberty. Most of the cherubism cases show familial history, but there are some cases without familial histories of disorder. A two-year-old boy with a painless symmetrical progressive swelling of the jaws had visited maxillofacial radiology department. Panoramic radiograph revealed well-defined multilocular, radiolucent areas of both jaws. Computed tomography of the jaws showed well-defined, bilateral, multilocular, expansile lesions with thinning of cortical plate of maxilla and mandible and displacing the unerupted first molar anteriorly. Clinical, radiologic, and histopathologic characteristics confirmed the diagnosis of cherubism.

Onlay bone augmentation and bilateral open sinus lifting with simultaneous implant placement in a cherubic patient

A 20-year-old edentulous woman, who was previously treated with the shave of the inferior border of the mandible and malar prominent region for aesthetic facial contouring, was selected for full mouth rehabilitation of the maxillomandibular region. The patient was treated with bilateral open sinus lifting through a lateral approach in the posterior of the maxilla and an onlay bone graft with lateral ramus as a donor site in the mandible anterior. Eight implants in the maxilla and 7 in the mandible were inserted, and implant-supported prostheses were fabricated. The 18-month follow-up showed good bone condition that suggests graft interventions and implant treatment as a good treatment modality for patients with cherubism.

Endoscopic resection of sinonasal ossifying fibroma: 31 cases report at an institution

A retrospective analysis of 31 lesions undergoing endoscopic surgery between 2006 and 2012 was undertaken. The data of patients' demographics, clinical features, operative parameters, follow-up period, and treatment outcomes were collected. A total of 31 patients were reviewed and consisted of 19 females and 12 males. The median age was 23 years (range 6-55). The surgical strategy included the exclusive endoscopic approach in 26 cases, endoscopic approach with external approach in 5 cases. Twenty-two cases were achieved completely resection and nine cases were subtotally resected. During the follow-up period (median: 25 months, range 4-80 months), 4 cases developed recurrences and there was no evidence of recurrence in the additional 27 cases included 8 cases living with no progressively growing residual tumor and 19 cases living without diseases. Our experience indicates that the endoscopic approach to manage ossifying fibroma of the nose and paranasal sinuses is safe and effective. However, more cases and a longer period of follow-up are required to define its long-term therapeutic effect.

Psammomatoid juvenile ossifying fibroma: case study and a review

BACKGROUND

The group of fibro-osseous lesions from the maxillofacial region is very heterogeneous, but what they all have in common is the substitution of normal bone by fibroblasts with the consequent formation of collagen fibers, as well as substitution by different types of mineralized tissues which may be similar to bone or cement. Within this group of lesions, the juvenile ossifying fibroma is found, considered a rare and recurrent benign fibro-osseous neoplasia. The term juvenile ossifying fibroma has been used in the literature to describe two histopathological variations of conventional ossifying fibroma. These variations are trabecular juvenile ossifying fibroma and psammomatoid juvenile ossifying fibroma. Psammomatoid juvenile ossifying fibroma is an uncommon bone-forming neoplasm with aggressive local growth. Diagnostic of this lesion occurs after the correlation of clinical, imaging, and histopathological findings. Proposed treatments range from enucleation and curettage to resection of the tumor.

OBJECTIVES

The present article has as its objectives to report an uncommon case of a 4-year-old male patient treated by conservative approach and revise the literature on juvenile ossifying fibroma.

CONCLUSIONS

Psammomatoid juvenile ossifying fibroma, for its being very uncommon, warrants further investigation in order to establish the best treatment, principally in children, with a view to minimizing mutilating treatments. In the case examined, a conservative treatment was chosen, where the surgeon established curette and cryotherapy, and the reintegration of the child in his social environment, without relapse during the first year of therapy.

Juvenile ossifying fibroma of mandible: a case report

Fibro osseous lesions are benign mesenchymal skeletal tumours in which mineralized tissue, blood vessels and giant cells, in varied proportions replace normal bone. Included in this group are fibrous dysplasia (FD), cherubism, ossifying fibroma and osteoblastoma. Although fibro osseous lesions have similar histologic and radiographic features, they may exhibit a wide range of biological behaviours. Because the histologic appearance does not predict the rate of growth or prognosis, treatment is based on the clinical and biologic behaviour of the tumour. The term "Juvenile active ossifying fibroma"(JAOF) has been given to a less common, more aggressive variant of the central ossifying fibroma which occurs primarily in children and young adults. This lesion has been described in literature under variety of terms like "aggressive psammomatoid ossifying fibroma" or "juvenile ossifying fibroma". We are presenting a case of Juvenile aggressive ossifying fibroma in a 17 years old girl who reported to our institute.

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.

Cherubism: best clinical practice

Cherubism is a skeletal dysplasia characterized by bilateral and symmetric fibro-osseous lesions limited to the mandible and maxilla. In most patients, cherubism is due to dominant mutations in the SH3BP2 gene on chromosome 4p16.3. Affected children appear normal at birth. Swelling of the jaws usually appears between 2 and 7 years of age, after which, lesions proliferate and increase in size until puberty. The lesions subsequently begin to regress, fill with bone and remodel until age 30, when they are frequently not detectable.

Fibro-osseous lesions, including those in cherubism have been classified as quiescent, non-aggressive and aggressive on the basis of clinical behavior and radiographic findings. Quiescent cherubic lesions are usually seen in older patients and do not demonstrate progressive growth. Non-aggressive lesions are most frequently present in teenagers. Lesions in the aggressive form of cherubism occur in young children and are large, rapidly growing and may cause tooth displacement, root resorption, thinning and perforation of cortical bone.

Because cherubism is usually self-limiting, operative treatment may not be necessary. Longitudinal observation and follow-up is the initial management in most cases. Surgical intervention with curettage, contouring or resection may be indicated for functional or aesthetic reasons. Surgical procedures are usually performed when the disease becomes quiescent. Aggressive lesions that cause severe functional problems such as airway obstruction justify early surgical intervention.

Paranasal sinus and skull base fibro-osseous lesions: when is biopsy indicated for diagnosis?

BACKGROUND

Paranasal sinus fibro-osseous (FO) lesions represent a heterogeneous group, often sharing overlapping radiographic and pathologic features posing a dilemma in accurate diagnosis. The objective of this study was to correlate preoperative radiologic and postoperative histologic diagnosis to help guide a diagnostic algorithm.

METHODS

Retrospective analysis of 60 FO lesions between 1994 and 2010.

RESULTS

The mean age was 42.3 years with average follow-up of 12.5 months. The preliminary radiologic diagnosis was osteoma in 22 (36.7%), fibrous dysplasia (FD) in 9 (15%), ossifying fibroma (OF) vs FD in 5 (8.3%), and OF in 3 (5%) cases. The diagnosis was indeterminate in 21 (35%) cases. Management consisted of excision in 29 (48.3%), observation in 17 (28.3%), and biopsy in 14 (23.3%) patients. For patients undergoing resection or biopsy, positive predictive value of preoperative radiology was 100% (10/10) for osteoma, 85.7% (6/7) for FD, and 33.3% (1/3) for OF cases. For the indeterminate lesions, most common pathologic diagnoses for 21 patients included osteoma in 4 (17.4%), arrested pneumatization in 3 (14.3%), OF in 3 (14.3%), and FD in 2 (9.5%). For FD vs OF cases, 3 underwent surgery, revealing osteoma, FD, and OF in 1 patient each.

CONCLUSION

In this series, radiologic-histopathologic correlation was high for osteoma and FD and low for OF and OF vs FD. This data suggests that patients with classic radiologic characteristics of osteoma and FD may be observed, unless resection is warranted based on clinical symptomatology. Preoperative diagnosis of OF, OF vs FD, or indeterminate lesions may warrant a biopsy to establish firm diagnosis to guide definitive management, especially if preoperative computed tomography (CT) imaging is concerning for an aggressive FO neoplasm.

Management of juvenile ossifying fibroma in the maxilla and mandible

We present three cases with juvenile ossifying fibroma. Two occurring in the maxilla, and one in the mandible. All three cases presented with a major swelling in the face. After clinical and radiological evaluation the lesions were surgically excised and sent for histopathological evaluation. Two histological types of juvenile ossifying fibroma were found, the psammatous type in two cases and the trabecular pattern in one case. Although juvenile ossifying fibroma is an uncommon clinical entity, its aggressive local behaviour and high recurrence rate mean that it is important to make an early diagnosis. It is also important to apply the appropriate treatment and to follow-up the patient closely over the long term. This report describes the diagnosis and treatment of juvenile ossifying fibroma in the maxilla and the mandible. It also emphasizes the importance of considering the less aggressive options as a first line of treatment before choosing the aggressive approach when dealing with children.