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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
  Table of Contents    
CASE REPORT  
Year : 2018  |  Volume : 22  |  Issue : 3  |  Page : 406-409
 

A rare case report of craniofacial fibrous dysplasia


1 Department of Oral Pathology and Microbiology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
2 Department of Oral Surgery, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
3 Department of Oral Pathology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission24-Aug-2018
Date of Acceptance01-Oct-2018
Date of Web Publication14-Dec-2018

Correspondence Address:
Vidyadevi Chandavarkar
Department of Oral Pathology and Microbiology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.JOMFP_211_18

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   Abstract 


Fibrous dysplasia (FD) is a fibro-osseous lesion of the osseous structures of the body. The exact cause is unknown; however, recently, the cause has been reported to be postzygomatic somatic mutation in guanine nucleotide-binding protein, alpha stimulating 1 gene located at chromosome 20q13.2. The three subtypes of FD are monostotic, polyostotic and craniofacial. The term craniofacial FD (CFD) is used to describe FD where the lesions are confined to contiguous bones of the craniofacial skeleton. This report describes the case of CFD of a 20-year-old male patient who had unusual presentation involving right maxilla and frontal bone of the left side of the face. The clinical features, radiological findings and treatment have been discussed.


Keywords: Craniofacial fibrous dysplasia, frontal, maxilla


How to cite this article:
Chandavarkar V, Patil PM, Bhargava D, Mishra MN. A rare case report of craniofacial fibrous dysplasia. J Oral Maxillofac Pathol 2018;22:406-9

How to cite this URL:
Chandavarkar V, Patil PM, Bhargava D, Mishra MN. A rare case report of craniofacial fibrous dysplasia. J Oral Maxillofac Pathol [serial online] 2018 [cited 2019 Mar 26];22:406-9. Available from: http://www.jomfp.in/text.asp?2018/22/3/406/247373





   Introduction Top


Fibrous dysplasia (FD) is an uncommon nonhereditary, skeletal developmental anomaly where normal bone is replaced by an excessive proliferation of cellular fibrous connective tissue intermixed with irregular bony trabeculae. It may arise as a single lesion referred to as monostotic or can occur with multiple lesions that affect many bones also known as polyostotic. A small set of polyostotic FD can also occur as a component of a multisystem developmental disorder known as  McCune-Albright syndrome More Details that is also associated with endocrine hyperfunction and cafe au lait cutaneous macules.[1] With an incidence of 1:4000–1:10,000, it seems to be a rare disease.[2] Craniofacial FD (CFD) affects the bones of the craniofacial complex, including the mandible and maxilla, cranial base and vault. It is one of the three types of FD.[3] FD of bone evolve from activating missense mutations in Gs alpha gene in pluripotent embryonic stem cells. The inheritance of these mutations remains in a population of postnatal skeletal stem cells or mesenchymal stem cells which direct the formation of atypical bone in FD.[4] These conditions have a slight female predilection.[2] The bones commonly involved are maxilla (12%) and mandible (12%), involvement of the ethmoid, sphenoid, frontal and temporal bones are infrequent. The affected bones show expansion, thickening and sclerosis. Depending on the involved bone patients may have visual abnormalities, hearing disturbances, facial asymmetry and tooth displacement.[5] We report a case of CFD in a 20-year-old male patient.


   Case Report Top


A 20-year-old male patient presented with a painless swelling of the right maxilla and frontal bone of the left side of the face for the past 2 years [Figure 1]. Clinically, the patient presented with facial asymmetry. There was no history of trauma, trismus, diminished vision, loosening of teeth or epistaxis. Extraoral examination revealed well-defined bony hard swelling in the right maxillary region. There was involvement of the left frontal bone which showed the prominence in that region. Intraorally, there was enlargement of the right side of palate and expansion of alveolar buccal plate was present extending from 11 to 17 [Figure 2]. There was no swelling present elsewhere in the body, and café-au-lait spots were absent. Routine investigations such as hemogram, serum calcium and serum alkaline phosphatase (ALP) were performed. All parameters were within normal limits except ALP. ALP was raised to 300 U/L. The computed tomography (CT) scan showed a radiodense mass with ground-glass appearance involving left frontal and right maxillary bone and its expansion causing facial asymmetry [Figure 3]. CT scan showed thickening of the frontal region with loss of anterior wall of frontal sinus and dense ossifications of the maxilla and its antrum [Figure 4]. An incisional biopsy was obtained from the lesion in the maxilla and histopathological analysis was done. Macroscopy showed two pieces of bony hard-tissue greyish white in color measuring 1 cm × 0.5 cm and 0.5 cm × 0.5 cm approximately [Figure 5]. Microscopic examination showed irregular bony trabeculae in Chinese script pattern scattered within fibrous stroma [Figure 6]. Bony trabeculae showed no osteoblastic rimming [Figure 7]. Poorly formed metaplastic bone was separated by cellular fibrous connective tissue stroma. The bone appeared woven rather than lamellar. Based on the clinical history, radiographic assessment and histological features of the lesion, a diagnosis of craniofacial FD was deduced. Surgical recontouring was restricted only to maxilla. Contour correction of the alveolar bone was performed using stainless steel drill and soft-tissue reduction was also performed [Figure 8]. No treatment of frontal bone was done because there were no ocular symptoms and patient was unwilling too.
Figure 1: Clinical appearance of the patient

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Figure 2: Enlargement of the right side of the palate and expanded alveolar plate extending from 11 to 17

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Figure 3: Axial computed tomography image shows increased dimensions of the zygoma and obliteration of the right maxillary sinus

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Figure 4: Axial computed tomography image shows expansion of left frontal bone

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Figure 5: Incisional biopsy specimen showing two bits of hard tissue

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Figure 6: Decalcified section showing C-shaped bony trabeculae (H&E, ×100)

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Figure 7: Decalcified section showing no osteoblastic rimming (H&E, ×400)

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Figure 8: Surgical recontouring of the maxilla

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   Discussion Top


FD is a fibro-osseous lesion characterized by developmental hamartoma by blending of fibrous and osseous tissue, with resultant secondary bony metaplasia, without osteoblast maturation producing immature, newly formed and weakly calcified bone. It can be monostotic or polyostotic. The craniofacial bones are affected in 10%–25% of cases in monostotic forms and in 50% of cases in polyostotic forms. FD essentially affects children and young adult[6] such as in the present case, a 20-year-old male. CFD is a benign, slowly progressive bone disorder in which normal craniofacial bones are replaced by fibrous tissue in which secondary metaplastic bone formation occurs.[7] FD is relatively rare in the craniofacial region, (only 20% of all locations).[8] Involvement of frontal, sphenoid, nasoethmoid and maxillary bones may result in nasal obstruction, sinus obliteration mainly frontal and maxillary sinus and subsequent sinusitis. Other features associated with CFD are dystopia, dysesthesias in the distribution of the trigeminal nerve, epiphora and also headaches.[9] Latest researchers suggest that the activated G-protein Wnt/B-catenin signaling pathway is involved in modulation of bone formation. Patients with activating guanine nucleotide-binding protein, alpha stimulating mutations specifically showed activated Wnt/B-catenin signaling. The typical radiographic feature of FD is a radiolucent, hazy or ground-glass, pattern. The patterns are due to defective mineralization of immature abnormal bone and it is usually different from the radiographic appearance of normal bone.[1] There are three types of computed tomography (CT images described as ground glass (56%), homogeneous dense (sclerotic) (23%) and radiolucent (cystic) (21%). These findings are characteristic of FD.[10] Magnetic resonance imaging (MRI) also may help in assessing cranial nerve involvement and soft-tissue structures adjacent to the lesion. Bone scintigraphy is usually recommended to rule out the polyostotic variant of FD.[11] On MRI, FD shows homogenous, moderately low signal intensity on T1-weighted images. On T2-weighted images, the tissue usually exhibits very high signal intensity. After intravenous Gd-diethylenetriaminepentaacetic acid, lesions display moderate to significant central contrast enhancement with some rim enhancement. The degree of contrast enhancement on T1-weighted images depends on amount and degree of bone trabeculae and collagen present. Both CT and MRI are excellent imaging modalities in defining the compressive effect of CFD on the orbit, optic canals and adjacent paranasal sinuses.[5] Serum ALP is significantly high in FD. Elevated Serum ALP is usually a reliable marker for predicting the prognosis of patients with FD.[12] There is no specific treatment exists for FD. Radical resection is the only technique to obtain complete resolution of FD. Wait-and-see is indicated in cases of stable lesions and ceases to grow once the patient reaches puberty. Reconstructive techniques allow obtaining adequate aesthetical and functional results. Aggressive lesions are treated by radical resection, except in pediatric patients with residual large defects in which it can be acceptable to try to resolve symptoms through bone shaving, reserving more aggressive treatments in cases of relapse or after skeletal maturity.[13] Bisphosphonates are often used as medical treatment as they may reduce the increased bone resorption. They may alleviate bone pain in FD; however, the effect of medical therapy on skeletal destruction is not clear.[14] To conclude, most of the cases of FD can be treated by conservative recontouring. The surgical procedure is indicated only after active growth phase of bones and a follow-up should be done to check for flare-ups.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lietman SA, Levine MA. Fibrous dysplasia. Pediatr Endocrinol Rev2 013;2:389-96.  Back to cited text no. 1
    
2.
Menon S, Venkatswamy S, Ramu V, Banu K, Ehtaih S, Kashyap VM, et al. Craniofacial fibrous dysplasia: Surgery and literature review. Ann Maxillofac Surg 2013;3:66-71.  Back to cited text no. 2
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3.
Abdelkarim A, Green R, Startzell J, Preece J. Craniofacial polyostotic fibrous dysplasia: A case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e49-55.  Back to cited text no. 3
    
4.
Robey PG, Kuznetsov S, Riminucci M, Bianco P. The role of stem cells in fibrous dysplasia of bone and the Mccune-Albright syndrome. Pediatr Endocrinol Rev 2007;4 Suppl 4:386-94.  Back to cited text no. 4
    
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Guruprasad Y, Prabhakar C. Craniofacial polyostotic fibrous dysplasia. Contemp Clin Dent 2010;1:177-9.  Back to cited text no. 5
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Ben hadj Hamida F, Jlaiel R, Ben Rayana N, Mahjoub H, Mellouli T, Ghorbel M, et al. Craniofacial fibrous dysplasia: A case report. J Fr Ophtalmol 2005;28:e6.  Back to cited text no. 6
    
7.
Leong LT, Ming BJ. Craniofacial fibrous dysplasia involving the orbit: A case report and literature review. Asia Pac J Ophthalmol (Phila) 2015;4:151-4.  Back to cited text no. 7
    
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Ziadi S, Trimeche M, Mokni M, Sriha B, Khochtali H, Korbi S. Eighteen cases of craniofacial fibrous dysplasia. Rev Stomatol Chir Maxillofac 2009;110:318-22.  Back to cited text no. 8
    
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Gupta D, Garg P, Mittal A. Computed tomography in craniofacial fibrous dysplasia: A case series with review of literature and classification update. Open Dent J 2017;11:384-403.  Back to cited text no. 9
    
10.
Bulakbaşi N, Bozlar U, Karademir I, Kocaoğlu M, Somuncu I. CT and MRI in the evaluation of craniospinal involvement with polyostotic fibrous dysplasia in McCune-Albright syndrome. Diagn Interv Radiol 2008;14:177-81.  Back to cited text no. 10
    
11.
Deshpande A, Naidu GS, Dara BG, Gupta M. Craniofacial fibrous dysplasia: A summary of findings with radiological emphasis. J Indian Acad Oral Med Radiol 2016;28:403-8.  Back to cited text no. 11
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12.
Park BY, Cheon YW, Kim YO, Pae NS, Lee WJ. Prognosis for craniofacial fibrous dysplasia after incomplete resection: Age and serum alkaline phosphatase. Int J Oral Maxillofac Surg 2010;39:221-6.  Back to cited text no. 12
    
13.
Valentini V, Cassoni A, Terenzi V, Della Monaca M, Fadda MT, Rajabtork Zadeh O, et al. Our experience in the surgical management of craniofacial fibrous dysplasia: What has changed in the last 10 years? Acta Otorhinolaryngol Ital 2017;37:436-43.  Back to cited text no. 13
    
14.
Ozdemir Kutbay N, Sarer Yurekli B, Kartal Baykan E, Sahin S, Saygili F. Characteristics and treatment results of 5 patients with fibrous dysplasia and review of the literature. Case Rep Endocrinol 2015;2015:670809.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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