What is ossifying fibroma?

Among the wider spectrum of tumours called osteo-fibrous dysplasia, which are rare benign tumours that mainly affect the long bones in children, a variant of them that affects adults and can damage the bones of the head and neck, primarily the mandible, is ossifying fibroma. Other bones that may be involved are the nasal cavities, the orbit and the skull.¹

These tumours are benign but they grow slowly and are locally invasive. They don’t spread to other tissues but can cause serious damage in the surrounding areas. As they occur in the head and neck they pose an even greater risk since sensitive organs like the eyes and brain surround them.^1,2

 Understanding the term “ossifying fibroma” can help better grasp the condition.

"Ossifying" refers to the process of turning into bone, and in ossifying fibroma, bone forms within fibrous connective tissue where it shouldn't. This affects your musculoskeletal system, involving bones and connective tissues."Fibroma" denotes the fibrous tissue composing the tumour. Healthcare professionals use the suffix "-oma" to describe all tumours, regardless of their cancerous nature.⁴

Understanding ossifying fibroma - how do they form, and what is it like to have one?

The exact cause and origin of osteofibrous dysplasia remain unclear. Instances of familial cases are rare.

It's suggested that these tumours may stem from an abnormality involving fibrous tissues and blood vessels. According to this theory, osteofibrous dysplasia may result from problems with haversian canals (canals in the bones that the blood vessels run through).¹ Although it has not been confirmed, there are suggestions that some issues like dental plaque build up, gum irritation, dental procedures or trauma to the face or jaw can contribute to the development of this condition.⁴

Ossifying fibroma typically doesn't cause symptoms and is commonly detected during routine dental checkups. It's more prevalent in females and can develop at any age, but it's most frequently seen in people between their twenties and forties.³ It is possible for the tumour to grow slowly and silently, not causing any symptoms until it becomes large enough to cause facial deformity.²

Diagnosis of ossifying fibroma

Ossifying fibroma may be an incidental finding in a dental clinic, or the patient may notice something wrong while brushing their teeth. The doctor will first take a history and explore everything and anything that is related to this newly developed lump, and gather a few more personal data e.g. age and sex. 

However, since this tumour typically presents as a lump without any symptoms and no clear causation, clinical history will not hint at too much and, for this reason, the diagnosis of ossifying fibroma relies heavily on imaging and biopsy for confirmation.

 The initial investigation of choice is usually an X-ray, although this may not be enough for radiologists to diagnose an ossifying fibroma. The appearance may be either as a cyst or something of a mixed density (thin and thick bone).³ Doctors may then proceed to more elaborate imaging modalities like CT scans or MRI, although the criteria for diagnosing this condition is not yet clearly established.¹

 In adults, a tissue biopsy of the tumour is the only method for confirming the diagnosis, which is usually taken during surgery to remove the existing tumour.⁴

Treatment options: what will happen after getting diagnosed?

Treatment of ossifying fibroma is usually treated with surgery. Medication is typically not needed for this condition, other than painkillers after the surgery, or antibiotics if there is suspicion of an infection

Surgery to remove the tumour takes various approaches, ranging from less invasive methods to more aggressive ones. Among the less invasive options is a two-stage treatment, where the cyst or tumour is decompressed first, then removed. Another method employs endodontic microsurgery techniques in a single step.⁵ These advanced techniques, using specialised tools and operating microscopes, allow for precise treatment without excessive tissue removal.

New materials and devices, like ultrasonic tools and retrograde filling materials, aid in effective treatment by preparing the tooth's canal and filling it properly.⁵

Doctors are debating whether to fill the surgical site with bone graft material or allow natural clot formation. While some argue for natural healing, others advocate for osseous grafting to accelerate bone regeneration, particularly in cases with larger lesions. Various graft materials are available, including synthetic options, which offer advantages in cost and have comparable clinical outcomes.⁵

Prognosis and complications

Understanding the future outlook and potential challenges of ossifying fibroma, including its long-term effects, helps medical professionals to plan the best treatments while minimising the risks.

Factors predicting the outcome of endodontic microsurgery include variables such as the size and nature of the lesion, alongside the selection of surgical approach.⁵

Potential complications of post-endodontic microsurgery are similar to those of any surgical procedure and include nerve damage, infections, and the chance of incomplete recovery or recurrence of the tumour.⁵

Follow-up and long-term management

The battle does not end after surgery, in fact, post-surgical follow-up is important to ensure success of the treatment and can help to provide reassurance if needed.

People with ossifying fibroma need to return frequently for check-ups to make sure the problem doesn't come back or cause any new issues. They will usually have X-rays regularly to see how things are healing and to catch any signs of the problem returning. Doctors also need to check for any new symptoms or changes in the area. If there's a chance the problem might have returned, they might need more detailed scans, like CT scans or MRIs, to figure out what's going on and decide on the best treatment.⁶

As for long-term care, the main focus is keeping an eye out for any signs that the tumour might come back. Patients need to understand how important it is to keep going to check-ups regularly and let their doctors know right away if they notice anything new or different. Sometimes they may need regular scans, especially if they've had serious issues in the past. Working together with different kinds of specialists, such as jaw surgeons, imaging experts, and tissue experts, can be very helpful in managing the condition, especially if it's been tough to treat in the past.⁶

Summary

In understanding ossifying fibroma, a rare benign tumour affecting the bones of the head and neck, several key points emerge:

• Ossifying fibroma is a variant of osteofibrous dysplasia, primarily affecting adults and damaging bones in the head and neck, particularly the mandible
• Typically asymptomatic, ossifying fibroma is often detected incidentally during routine dental check-ups, with a higher prevalence in females and commonly appearing between the twenties and forties
• Diagnosis heavily relies on imaging modalities like X-rays, CT scans, and MRI, along with tissue biopsy during surgery for confirmation
• Surgical removal is the primary treatment approach, ranging from less invasive methods like decompression to more aggressive techniques. Advanced tools and materials aid in precise treatment and promote effective healing
• Factors influencing treatment outcomes include lesion size, nature, and the chosen surgical approach. Potential complications include nerve damage, infections, and the risk of recurrence
• Post-surgery, regular follow-up visits and imaging scans are essential to monitor for recurrence and ensure proper healing. Long-term care focuses on vigilance for any signs of recurrence or worsening symptoms, with interdisciplinary collaboration among specialists to optimise management

Moving forward, advancements in diagnostic techniques and treatment modalities hold promise for improving outcomes in the diagnosis and management of ossifying fibroma. Enhanced imaging technologies and novel surgical approaches may offer more precise diagnosis and effective treatment options, ultimately improving patient care and prognosis.