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Ossifying Fibroma–Cementoma of Jaw. Differences in Histopathological

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Ossifying Fibroma–Cementoma of Jaw. Differences in Histopathological otolaryngologia polska 66 (2012) 359–362 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/otpol Case report/Kazuistyka Ossifying fibroma–cementoma of jaw. Differences in histopathological nomenclature Wło´kniak kostnieja˛cy – cementoma szcze˛ki. Ro´z˙nice w nomenklaturze histopatologicznej Wiesław Konopka 1,2,*,Małgorzata S´ miechura 1,Małgorzata Struz˙ycka 1, Marcin Kozakiewicz 3, Monika Dzieniecka 4 1 Department of Otolaryngology Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland 2 Department of Audiology, Phoniatry and Paediatric Otolaryngology Medical University of Lodz, Poland Head: Wiesław Konopka 3 Department of Maxillar and Facial Surgery Medical University of Lodz, Poland Head: Marcin Kozakiewicz 4 Department of Patomorphology Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland Head: Andrzej Kulig article info abstract Article history: Ossifying fibroma (cementoma) is a tumor of mesenchymal origin which represents about Received: 25.05.2012 1% of odontogenic tumors. It is commonly found in patients under 25, more often so in Accepted: 26.06.2012 women. As its growth is slow and painless, it is usually accidentally detected by dental Published on line: 04.07.2012 radiological examination. The aim of our study was to present the histopathological dilemma concerning the naming of a rare odontogenic tumor of the jaw. The authors Keywords: present a rare jaw tumor, a benign ossifying fibroma, in the maxilla of a 12-year-old girl Cementoma treated surgically, and they discuss the difficulty in making a definitive histopathological Histopathological nomenclature diagnosis. The clinical and histological criteria for identifying this type of tumor are still Jaw tumor uncertain, as the most common sites, that is the tooth-bearing areas of the mandible, are very rare in the maxilla. The differentiation from the central fibro-osseous lesions in the maxilla bones is discussed. The final diagnosis of ossifying fibroma was based on the WHO Słowa kluczowe: classification. A literature search reveals a fundamental flaw in defining a unified classi- wło´ kniak kostnieja˛cy fication for this type of change. As there is no clear diagnostic criterion, few repeatable nomenklatura histopatologiczna diagnoses can be found. Although individual researchers tend to use their own means of guz szcze˛ki classification in their routine work, the WHO classification should be applied. © 2012 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved. * Corresponding author at: Department of Otolaryngology Polish Mother’s Memorial Hospital-Research Institute Rzgowska 281/289, 93-338 Ło´ dz´, Poland. Tel.: +48 502510083/422711701. E-mail address: [email protected] (W. Konopka). 0030-6657/$ – see front matter © 2012 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved. http://dx.doi.org/10.1016/j.otpol.2012.06.027 360 otolaryngologia polska 66 (2012) 359–362 alveolus and hard and soft palate. She had already been Introduction operated on twice at the ages of 6 and 18 months. The disease was observed for several months, gradually Ossifying fibroma (cementoma) is a slow-growing benign expanding and causing a marked asymmetry of the face. neoplasm composed of fibroblastic and osseous components, Enlargement of the tumor caused pain in the area. The child did which occurs throughout the skull but most commonly, in the not report facial sensory disturbances. Laryngological exami- mandible and maxilla. It is of mesenchymal origin and arises nation found facial asymmetry with a lump on the left cheek, from the cementum, one of the tissues forming the root of the asymmetry of the external nose and curvature of the nasal tooth, and represents about 1% of odontogenic tumors [1].It septum on the right side, which partially impaired patency. In occurs most often in young people under 25 years of age, more the vestibule of the mouth, a hard swelling was found on the often in women than in men. According to Eversole [2] in 75– alveolar process on the left side of the maxilla. In the oral cavity 89% of cases, the tumor occurs in the mandible, especially in and pharynx, scars from numerous reconstructive surgeries of its rear section, near the premolars and molars. It rarely occurs the palate were visible; the soft palate was short and in episodes or in the vicinity of the front teeth. The tumor asymmetric. The results of laboratory tests were normal. grows very slowly, about 0.5 cm per year, and does not present A CT scan of the sinuses showed that the left maxillary sinus any clinical symptoms for a long time. It is often detected by was filled mostly by sclerotic tissue with numerous calcifica- chance on teeth after a radiological inspection; the greatest tions, without evidence of malignant bone and without diagnostic value can be attributed to the pantomographic the presence of periosteal reactions. The lesion measured X-rays often requested by dentists. The jaw bones, paranasal 45 Â 43 mm. sinuses, nasopharynx, and orbit are frequently found to be The front part of the normal sinus aeration was separated more active and demonstrate a juvenile variety of ossifying from the tumor by a bone lamella. Hypoplasia of the lower fibroma (juvenile cemento-ossifying fibroma). The juvenile right nasal concha was present, as were signs of a history of variant of the tumor is prone to grow much more rapidly, plastic surgery for cleft palate. The patient was qualified to tending toward the destruction of surrounding tissue and provide material for histopathological examination. penetration of the surrounding space, leading to alveolar Under general anesthesia, the left maxillary sinus was distension and displacement of bone resorption, as well as opened according to standard procedure through the vestibule paresthesia, pain, swollen facial bones and loose teeth [1]. of the oral cavity. The anterior wall of the sinus was thin and Although the etiopathogenesis of cementoma is not comple- brittle. A white tumor fragment was removed; it had a gray, tely understood, injuries, genetic disorders, hormonal disor- solid consistency and did not bleed when touched. The tumor ders and calcium-phosphate are among the likely factors that easily separated from the wall bone. An initial histological contribute to its development. Four types can be distinguished examination (2098/11) indicated that the tumor was an based on tissue type: cementoma ossificans – the most odontogenic fibroma. common form, benign cementoma, giant cementoma and The girl was qualified for surgical treatment. The tumor periapical cement dysplasia. was reached through the side of the oral vestibule; it was The characteristic histopathologic features of the structure dissected from the surrounding tissues and removed. Revision is the presence of a tumor capsule, a rich cellular connective of the postoperative cavity was performed by removing the tissue stroma, spindle cells and an immature trabecular remaining tumor fragments penetrating further into the sinus bone and masses which looks like cement. Radiological images space. The bony walls of the cavity were smooth and did not of cementomas, especially the larger ones, display highly display any signs of postoperative destruction or malignant characteristic features. The typical radiological image is invasion. A visual inspection of the excised tissue revealed composed of dense bone structure around the tooth root in a gray–white, smooth, springy tumor measuring 60 Â 60 mm a relatively regular circular shape, around which bone with no bleeding. An anterior osteoplasty was then performed. rarefaction can be seen, due to resorption, and rather ‘‘fuzzy’’ The size of the postoperative cavity in the upper and lower surrounding tissue. Cementomas should be treated surgically sinus cavity wall and the degree of facial asymmetry were by radical resection of the tumor along with the neighboring minimized by moving the peripheral bone lamellae toward healthy tissue. Although large tumors require the use of the center of the opening in the wall of the maxillary sinus. diagnostic computed tomography (CT), a variation of conical The tumor mass was submitted for histopathological exami- computed tomography, with a much higher resolution than CT, nation. The treatment was well tolerated. is available for use in this type of examination. The postoperative treatment included analgesics and anti- inflammatory drugs. On the seventh postoperative day, a CT scan was performed which showed the increased mucosal Aim edema in the medial upper-left maxillary sinus and the area of more intense contrast on the lateral side, which derived from The aim of our study was to present the histopathological the local postoperative edema. The continuity of the bone wall difficulty faced in naming a rare odontogenic tumor of the jaw. of the left maxillary sinus was broken in a number of places This study addresses the case of an 11-year-old girl who was and unattached fragments of bone left after angioplasty were admitted to the Department of Otolaryngology with a suspected visible. On the eighth day, the girl, being in good overall tumor in the left maxillary sinus, forming a lump in the cheek. condition was discharged and allowed to go home. From the interview, it was known that the child was born with According to the histopathological examination (3681/11), a congenital malformation in the form of median cleft upper lip, the dominant element in the specimen was a proliferation of otolaryngologia polska 66 (2012) 359–362 361 [(Fig._1)TD$FIG] revealed areas of round or ovoid, strongly alkaline, calcic non- cellular structures which, according to some authors [3–5], resemble bodies of the cement. A small percentage of the tumor texture was also made up of pseudo-cystic field structures (regressive changes), around which clusters of giant polynuc- lear osteoclast cells were present. Mitotic figures were not found in the examined tumor specimens (Fig.
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