Multiple fibro-osseous lesions of the jaws: A report of a rare case with a literature review
A 14-year-old girl from eastern Nepal reported to the authors' clinic with progressive facial disfigurement in the past 3 years due to swelling in the left maxilla. No history of associated trauma or systemic or local infectious conditions was elicited. The associated symptoms of left nasal stuffiness and difficulty in breathing were noted starting 6 months ago. The patient's family and medical history were non-contributory. Upon physical examination, a solitary diffuse, non-tender, bony hard swelling measuring 4×3 cm was noted in the left maxilla. An intraoral examination revealed a swelling in the left maxillary alveolar region that was non-tender and bony-hard on palpation (). The adjacent dentition and oral mucosa showed no abnormalities. A provisional diagnosis of fibrous dysplasia was given, with ossifying fibroma, central giant cell granuloma, and benign odontogenic tumour considered as differential diagnoses.\nPanoramic radiography revealed radiopaque discrete lesions in all 4 quadrants with a peripheral radiolucent rim. The right maxillary alveolus presented with a smaller lesion measuring 1×2 cm that raised the floor of the maxillary sinus in a dome-shaped manner. The mandibular lesions were localized on both the right and left second premolar to first molar regions, and measured 3×2 cm. The most radiopaque area was located centrally, particularly in the mandibular lesions. The lesions showed displacement of the adjacent tooth roots, the mandibular canal, and maxillary sinus floor (). A maxillary occlusal topographic radiograph revealed an expansile radiopaque lesion measuring 4×3 cm extending to the mid-palatine suture in the left maxillary quadrant (). A lateral oblique radiograph of the left mandibular body showed a radiopaque lesion with a peripheral radiolucent rim (). Computed tomography (CT) coronal and axial images revealed expansile osteogenic lesions in the 4 quadrants (), with the lesion in the left maxilla being the largest. No evident breach was noted in the antral walls except for the left lateral nasal wall. Radiographic diagnoses of fibrous dysplasia, ossifying fibroma, and osseous dysplasia including florid osseous dysplasia were considered.\nThe patient was advised to receive an evaluation of serum calcium and alkaline phosphatase levels along with routine hematological investigations, which were within the normal limits. Biopsies of the maxillary lesions and both mandibular lesions were performed under local anaesthesia. The histological examination revealed predominant fibrous tissue with ossifications and cementum-like material suggestive of fibro-osseous lesions. The presence of cementum-like material and ossifications strongly suggested ossifying fibromas (). Surgery was then planned in a phased manner. Considering the age of the patient, a conservative approach with aggressive curettage was performed under general anaesthesia. The most extensive and symptomatic of the lesions in the left and right maxilla were aggressively curetted after obtaining bony access into the maxillary sinus by intraoral approaches on 2 separate occasions.\nOn gross appearance, the left maxillary lesion was friable and obtained as multiple fragmented bits of fibrous tissue (). Histopathology with routine haematoxylin and eosin staining showed a predominantly fibrous stroma with plump spindle-shaped fibroblasts arranged in whorled patterns (). Areas of ossification and irregularly shaped immature cellular bony trabeculae representing woven bone were noted dispersed throughout the lesion. Some areas of spherical eosinophilic calcifications with basophilic concentric reversal lines, suggestive of psammoma bodies, were noted. The histological features were strongly suggestive of ossifying fibroma.\nThe patient remained asymptomatic for 2 years of follow-up. However, she was reluctant to undergo further surgery for the mandibular lesions or any further investigations.