Giant cemento-ossifying fibroma of the mandible
A 34 year old female patient reported to Department of Oral Medicine and Radiology, with a chief complaint of swelling of the lower jaw since six years. She stated that a small swelling on the left side of jaw was noticed six years ago, measuring about 1cm in diameter, which gradually increased to the present size, involving both sides of the face. There were no subjective symptoms, except for difficulty in chewing food.\nGross facial asymmetry was noticed due to a swelling involving the middle and lower one third region of the face []. Bilaterally fullness of the cheeks and lower lip with obliteration of the mentolabial sulcus and nasolabial fold was noticed. A well demarcated swelling was noticed over the left cheek region and a diffuse swelling over the right side, which extended from the left ramus of the mandible to the right body of the mandible with obliteration of inferior border of the mandible. Swelling on the left side was roughly ovoid in shape, measuring about 8 × 6 × 5 cm[]. Skin over the swelling was stretched. On palpation the swelling is hard in consistency, lobulated and nontender; with no accompanying cervical lymphadenopathy.\nOn intraoral examination [], a diffuse swelling was seen extending from the left to right retromolar region. Bilaterally, vestibular obliteration was noticed due to buccal labial and lingual cortical plate expansion with normal appearing mucosa. Swelling was hard, lobulated and nontender. Correlating the history and clinical findings, a provisional diagnosis of benign fibro-osseous lesion of mandible was given and differential diagnosis of fibrous dysplasia, ossifying/cementifying fibroma and central giant cell granuloma (non- aggressive lesion) was given. Patient was further subjected to hematological, radiological and histopathological investigations. Routine hematological examination, serum protein, calcium, phosphorus and alkaline phophatase levels were estimated and the values obtained were within the normal range.\nPanoramic radiograph [] revealed a well defined mixed radiopaque and radiolucent lesion, extending from left ramus region to the right angle of the mandible, measuring about 11 × 7 cms. Internal architecture exhibited a cotton-wool pattern of calcification. Centrifugal growth fashion is appreciable, which causes a ball-like circular lesion and bowing of the inferior border of mandible. The inferior cortex is parallel to the tumor mass above with no evidence of erosion. Occlusal radiograph [], revealed irregular expansion of both bucco-lingual cortical plates and lingual displacement of involved teeth. Posterior-Anterior (PA) mandible view [] revealed a mixed radiopaque, radiolucent lesion involving the left ramus region and extending up to the right angle of the mandible.\nPlain axial view and 3D-CT scan [Figures and ] revealed a large expansile lesion within the mandible, which involves right and left body and left ramus of mandible, which exhibits mixed sclerotic and lucent areas measuring 11.8 × 7.0 × 7.3 cm.[]\nAn incisional biopsy was performed and the tissue was sent for histopathological evaluation [] which irregularly shaped bony trabaculae interspersed in connective tissue stroma which is fibrocellular. Trabaculae contains osteocytes in lacunae within them. Several spherical masses of a cellular calcified material resembling cementum were seen through the fibrous tissue. Fibroblasts in the stroma are numerous and spindle shaped with prominent nuclei which were suggestive of cemento- ossifying fibroma. Based on clinical, radiographic and histopathological findings a final diagnosis of giant cemento-ossifying fibroma of the mandible was made.