Presenting a case of central giant cell granuloma

1. ODONTOGENIC FIBROMYXOMA
OF MAXILLA A RARE CASE
REPORT
DR.REHANA SULTANA
Panineeya mahavidyalaya institute of dental
sciences & research centre
1

2. CASE REPORT
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3.  45 yr old female with painful swelling in the upper
left back teeth region since 4 months.
 Dull aching pain radiating occasionally to ear on
same side.
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CHIEF COMPLAINT

4. PAST DENTAL HISTORY
 Removal of upper left back tooth and a small portion
of the swelling was surgically removed and sent for lab
examination in a local dental hospital about 4
months back . The reports of which were not available
with patient.
4

5. EXTRAORAL FINDINGS
 Solitary, diffuse and firm swelling on left side of the face
 Approx 40x40 mm causing mild facial asymmetry.
 A-P extending from tragus to the ala of the nose
 S-I extending from lower eye lid till the zygomatic buttress
 No signs of any inflammation or sinus opening.
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6. PRE OP
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7. INTRA ORAL FINDINGS
 3×2 cm diffuse swelling from 25-28 .
 Oval and covered with diffuse erythematous areas of mucosa.
 Obliteration of the buccal sulcus.
 The palatal aspect, was unremarkable.
 Teeth #27 and #28 were clinically missing.
 Lymph nodes : palpable
 Mouth opening : 28mm and restricted movements.
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8. INVESTIGATIONS
ORTHOPANTOMOGRAM
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9. CT SCAN
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10. • PROVISIONAL DIAGNOSIS :
Fibro osseous lesion of the jaw
• DIFFERENTIAL DIAGNOSIS:
Central giant cell tumour
Central hemangioma
Odontogenic keratocyst
Maxillary sinus tumor
10

11. HISTO PATHOLOGY
• Incisional biopsy was performed showed loosely arranged
stellate, spindle-shaped and round cells in an abundant
loose myxoid stroma with collagen fibres and islands of
odontogenic epithelium
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odontogenic
FIBROMYXOMA

12. DIAGNOSIS:
ODONTOGENIC FIBRO MYXOMA
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13. TREATMENT PLAN
• Partial maxillectomy under general anaesthesia was
planned.
• Preoperative impressions and study casts were
made.
• Obturator was made with short labial bow and
Adams clasp on 16 and 26.
13

14. INTRA OP
• Excision of the lesion along with partial maxillectomy was
performed through intra oral approach under general
anaesthesia.
• Buccal fat pad was mobilized for closure and soframycin
ribbon gauze was placed through nasal antrostomy for next
two days.
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15. SPECIMEN
• Complete excision of the lesion was done and sent for histo
pathological examination.
• Obturator was placed next day after surgery to prevent
hematoma formation.Postoperative hospital stay was
uneventful except an episode of vomiting after 8hrs of
surgery. 15

16. POST OP
At follow up of 1week, 1month and 2months & 6 months patient was
comfortable without any complaints follow up OPG and PNS view was
unremarkable.
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17. Post op P.N.S VIEW
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18. POST OP O.P.G
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19. DISCUSSION
• Fibromyxoma is a benign tumour of ectomesenchymal
origin with or without odontogenic epithelium
• The term “Myxoma” -Virchow in 1863
• “Fibromyxoma” - Dietrich et al
• In 1947, Thoma and Goldman first described myxomas
of the jaws.
19

20. James DR,Lucas VS: maxillary myxoma in a child of 11 months age- a case report-
J.cranio max facial surgery,15:42 -44,1987
• Slow growing expansile and locally destructive.
• Solitary growths.
• Occur in soft and bony tissues.
• Subclassified into osteogenic and odontogenic entities .
• Heart, skin, and subcutaneous tissue and centrally in the
bone.
• 1% to 3% of all cysts and tumors of the jaws .
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21. *Abiose BO,ajagbe HA,thomas O: fibromyxoma of jawbones-a study of ten cases. Br j oral
maxillofac surgery, 25:415-421,1987
*Adamo AK,Locricchio RC, Freedman P: Myxoma of mandible treated by peripheral ostectomy
and immediate reconstruction- Report of a case, J oral surg, 38:530-533,1980
• Mandible > maxilla*
• Displacement of dentition*
• 2nd and 3rd decades of life.
• Females > Males.
• Children < 12 years- rare
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INCIDENCE

22. ETIOLOGY
• Odontogenic ectomesenchymal origin.
(Goldblatt LI Ultrastructural study of an odontogenic oral surg
oral med oral pathol 1976 Aug;42(2):206-20.)
• Odontogenic fibroma that has undergone myxomatous
changes
(Willis RA: Pathology of tumors. St Louis, MO, Mosby,1948, pp
642-655)
• From remnants of embryonic mesenchyme
(Ewing J: Neoplastic disease: A treatise on tumors, (ed4).
Philadelphia, PA, Saunders, 1940, pp 182-189
22

23. • True mesenchymal neoplasm
(Ghosh BC, Huvos AG, Gerold FP, et al: Myxoma of the jaw bones.
Cancer 31:237-240, 1973)
• Infectious origin
(Glazunov MF, Puchkov JG: Human muscular myxoma and
intracellnlar inclusions. Vopr Onkol 6:11- 27, 1960)
• Antecedent trauma is also considered as an inciting event
(Whitman RA, Stewart S, Stoopack JG, et al: Myxoma of the
mandible: Report of a case. J Oral Surg 28:63-70, 1971)
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24. CLINICAL PRESENTATION
• Main sign -swelling of the affected region
• With pain occurring less frequently mostly in cases of
soft tissue myxomas.
• Paresthesia, hyperesthesia, anesthesia- very rare
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25. • More aggressive in maxilla than in mandible
( Reichart PA, Philipsen HP. Odontogenic tumors and allied
lesions. London: Quintessence Publishing Co Ltd; 2004)
• Exophthalmus &obliteration of nasolabial fold
(Sasidhar Singaraju, Sangeetha P Wanjari, Rajkumar N Parwani.
Odontogenic myxoma of the maxilla: A report of a rare case
and review of the literature. January-June 2010, 14(1):19-23
• Tooth displacement and cortical bone expansion
25

26. Radiographic features
 Unilocular radiolucency: common in anterior region
 Multilocular radiolucency: posterior region
 Gracile septae may be found giving rise to tennis rachet /
honey combed/ soap bubble appearance
 Diffuse calcifications
(Chuchurru JA, Luberti R, Cornicelli JC, Dominguez FV. Myxoma
of the mandible with unusual radiographic appearance. J
Oral Maxillofac Surg 1985;43:987-90)
26

27. • Tooth displacement is common
• Root resorption is rare
• Scalloping of tumor between roots
(Farman AG, Nortje CJ, Grotepass FW, Farman FJ, Van Zyl JA.
Myxofibroma of the jaws. Br J Oral Surg 1977;15:3-18.)
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28. Differential diagnosis
• When unilocular and without septae : peri apical cyst,
traumatic bone cyst
• When multilocular: Ameloblastoma ,, central hemangioma,
central giant cell granuloma and odontogenic keratocyst
and certain non-neoplastic lesions (fibrous dysplasia)
Peltola, B Magnusson, RP Happonen and H Borrman,
Odontogenic myxoma—a radiographic study of 21 tumours,
Br J Oral Maxillofac Surg 32 (1994), pp. 298–302
28

29. Dezoti MSG et al: Odontogenic myxoma -a case report and clinico radiographic study of
seven tumuors. J.contemp dent prac 7,107,2006
• Small tumours- Curettage followed by cauterization.
• Larger tumours - Extensive resection.
• Recurrence rates as high as 10 %to 33% and average 25%
have been reported.*
• Prognosis of fibromyxoma (jaw) > fibromyxoma (long
bones)
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MANAGEMENT

30. 30

31. • Abiose et al. reported that fibromyxomas constituted
3.73% of all benign and malignant oral tumors and 20%
of tumors of dental origin second in incidence to
ameloblastoma.
• However, James etal. reported the case of a maxillary
myxoma in a child of 11 months.
REVIEW OF LITERATURE
31

32. • Keszler et al. (10) found that myxoma in childhood
represented 12.5% of the 80 cases of this tumor and stated
that fibromyxoma must be taken into account in the
differential diagnosis of intraosseous radiolucencies in
young patients.
• In their review of fibromyxomas, Farman et al. stated that
three mandibular cases were found for every two maxillary
cases and that fibromyxomas were more common in the
premolar and molar regions.
REVIEW OF LITERATURE
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33. REVIEW OF LITERATURE
• Wide resection with preservation of vital structures and
simultaneous autogenous bone graft reconstruction.
Chen CT, Chen YR, Lai JP, Tung TC. Maxillary myxoma treated
with wide resection and immediate reconstruction: a case
report. Ann Plast Surg. 1997; 39(1): 87-93
• More aggressive surgical treatment should be reserved for
lesions for which there is a strong suspicion of malignant
transformation.
Frezzini C, Maglione M, Rizzardi C, Melato M. Odontogenic
myxoma recurring after 11 years: case report and
observations on this unusual neoplasm. Minnerva Stomatol.
2003; 52(5): 247-51.
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34. REVIEW OF LITERATURE
• A very rare malignant form of the lesion showing marked
cellularity and cellular atypism has been designated as
MYXOSARCOMAS
Lamberg MA, Calonius BP, Makinen JE, Paavolainen MP,
Syrjanen KJ. A case of malignant myxoma (myxosarcoma) of
the maxilla. Scand J Dent Res 1984; 92: 352-57.
• Cytogenetic analysis of malignant myxosarcoma has
revealed an unexpectedly aberrant hypertetraploid
chromosome complement that was considered as
incompatible with the usual karyotypic patterns of benign
tumours.
Pahl S, Henn W, Binger T, Stein U, Remberger K. Malignant
odontogenic myxoma of the maxilla: case with cytogenetic
34

35. TAKE HOME MESSAGE
• Benign tumour of ectomesenchymal origin with
or without odontogenic epithelium
• 1% to 3% of all cysts and tumors of the jaws .
• Mandible
• 2nd and 3rd decades of life.
• Females
• Small tumours- Curettage followed by
cauterization.
• Larger tumours - Extensive resection.
• Recurrence rates as high as 25% have been
reported.
• Prognosis of fibromyxoma (jaw) > fibromyxoma
(long bones)
• Malignant transformation of fibromyxoma
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36. ACKNOWLEDGEMENTS
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37. 37
THANK YOU