PMC5711670_01
A, Panoramic radiograph acquired over 12 years before surgery. Note the delayed eruption of the first and second left premolars relative to the corresponding teeth on the contralateral side. B, Panoramic radiograph acquired over 91/4 years before surgery. Note the emerging radiolucency in the left lower jaw (regions 35-38). C, Panoramic radiograph acquired approximately 33/4 years before surgery. The radiolucency in the left lower jaw is now clearly visible. D, Preoperative panoramic radiograph. The multilocular radiolucency extends from region 35 far into the left mandibular ramus.
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The patient was a 22-year-old Caucasian woman who was referred to us by her dentist for further diagnostic workup and treatment of a giant radiolucent lesion located in the body and ramus of the left mandible (Fig. 1D). The first orthopantomogram (Fig. 1A) had been acquired during investigation for suspected aplasia of teeth 34 and 35 in 1997 when the patient was about 10 years of age. However, a routine orthopantomogram acquired in 2000 (Fig. 1B) revealed the start of an osteolytic process involving the left mandibular body from positions 36-37, which was unfortunately missed by the attending dentist. Orthopantomograms acquired in 2006 (Fig. 1C) revealed a further increase in the size of the radiolucency, which now extended from region 35 to region 38 and almost reached the coronoid process. Radiologic findings (Fig. 1D) revealed a massive radiolucent lesion extending from the left mandibular body to the ascending ramus, and almost into the coronoid process, as well as a missing tooth at position 37.
A, Preoperative CT image acquired in 2009 (axial view). B, Postoperative CT image acquired in 2009, clearly showing the whole extent of the bony defect after removal of the central odontogenic fibroma. C, Postoperative CT image acquired in 2014. D, Postoperative CT image acquired in 2015. Note the good bony regeneration. CT, computed tomography.
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CT revealed a large hypodensity affecting the left mandibular body and ramus, while the expanding cortical bone appeared intact (Fig. 2A). Radiographs acquired at the most recent visit show blistered ossification at the site of removal of the COF in the left mandibular body along with well-remodeled bone and absence of tooth 27 (Figs. 2 C-D and 6).
Preoperative magnetic resonance images (axial view). A, T1-weighted. B, T2-weighted.
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Magnetic resonance imaging of the lower jaw did not reveal infiltration of the surrounding soft tissue (Fig. 3), suggesting a diagnosis of COF. Radiographs acquired at the most recent visit show blistered ossification at the site of removal of the COF in the left mandibular body along with well-remodeled bone and absence of tooth 27 (Figs. 2 C-D and 6).
Odontogenic fibroma. Scant inactive-appearing odontogenic epithelium embedded in mature fibrous connective tissue (H&E).
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Histologic analysis revealed scant inactive-appearing odontogenic epithelium embedded in mature fibrous connective tissue (Fig. 4). Radiographs acquired at the most recent visit show blistered ossification at the site of removal of the COF in the left mandibular body along with well-remodeled bone and absence of tooth 27 (Figs. 2 C-D and 6).
A, Intraoperative view after mucoperiosteal flap formation. B, Intraoperative view after tumor removal, with the forceps pointing to the left inferior alveolar nerve. C, Homogenous whitish solid tumor, which had to be removed in fragments.
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The tumor was identified as a homogenous whitish solid mass, which was removed in fragments (Fig. 5). Radiographs acquired at the most recent visit show blistered ossification at the site of removal of the COF in the left mandibular body along with well-remodeled bone and absence of tooth 27 (Figs. 2 C-D and 6).
A, Postoperative panoramic radiograph clearly showing the whole extent of the bony defect after removal of the central odontogenic fibroma. Postoperative panoramic radiographs acquired in (B) 2013, (C) 2014, and (D) 2015 (note the remodeled bone structure).
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Since her surgery, the patient has attended our institution for annual follow-up orthopantomography (Fig. 6) and CT (Fig. 2B-D). Radiographs acquired at the most recent visit show blistered ossification at the site of removal of the COF in the left mandibular body along with well-remodeled bone and absence of tooth 27 (Figs. 2 C-D and 6).