PMC5804290_01
Preoperative orthopantomogram revealing a mixed (radiolucent-radiopaque) lesion, the inferior border of the mandible in the right angle region.
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Orthopantomogram showed a large mixed well-circumscribed bony lesion along the angle of the right mandible that extended approximately 1 cm beyond the inferior border of the mandible (Figure 1).
(a) CT axial cross section and (b) CT coronal cross section of an expansile mixed lesion of the right angle region of the mandible.
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Computed tomography (CT) scan of the maxillofacial region identified a 22 mm x 24 mm mixed (radiolucent-radiopaque), well-circumscribed, expansive lesion at the right mandibular angle region, not involving the dentition (Figures 2 and 2).
Virtual surgical plan allowing for 5 mm surgical bony margin surrounding the tumor, indicating overlap between surgical margin and mandibular canal.
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However, such a margin was noted to overlap with the mandibular canal placing the patient at high risk for transection of the inferior alveolar nerve during tumor extirpation (Figure 3).
(a) Intraoperative photograph following exposure of tumor and application of custom tumor cutting guide. (b) Piezoelectric handpiece used to perform osteotomy. (c) Resection specimen. (d) View of the inferior alveolar nerve following completion of resection. (e) Autogenous anterior iliac crest bone graft in place.
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The patient subsequently underwent right marginal mandibulectomy with 5 mm surgical margin via transcervical route utilizing a customized cutting guide for guidance of osteotomy (Figure 4). Piezoelectric surgical system was used to perform the osteotomy (Figure 4), and following its completion the inferior alveolar nerve was noted to be intact (Figure 4). Following tumor extirpation (Figure 4), a 2.0 mm reconstruction plate was secured to the mandible, and an autogenous anterior iliac crest bone graft was used to reconstruct the mandibular defect (Figure 4).
Histologic imaging of gross specimen. Histopathology of the tumor comprised numerous small, round ossicles embedded in cellular fibrous stroma, and occasional osteoclast-like giant cells are identified. The lesion is well demarcated from the surrounding bone. No increased mitotic figures or necrosis is seen. Benign fibro-osseous lesion, consistent with ossifying fibroma of the jaw (hematoxylin and eosin, 100x).
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Final histologic analysis indicated a diagnosis of ossifying fibroma (fibrous connective tissue with islands of calcifications similar to bone and cementum) (Figure 5).