Desmoplastic fibroma of the maxilla: report of case

Desmoplastic fibroma of the maxilla: report of case

C L IN IC A L REPORTS Desmoplastic fibroma of the maxilla: report of case Mark Z. Eisen, DDS H arold E. Butler, DDS a wide distribution over the bo...

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Desmoplastic fibroma of the maxilla: report of case Mark Z. Eisen, DDS H arold E. Butler, DDS

a wide distribution over the body but ap­ peared primarily in the shoulder girdle and upper arm. The first description of these tumors in bone was by Jaffe,3 who coined the term desmoplastic fibroma. He reported the occurrence of these lesions This case rep o rt rev ie w s the and presented cases involving the tibia, literatu re an d discusses the scapula, and femur. criteria n ecessa ry fo r Whitesides and Ackerman4 described diagnosing the desm oplastic cases in the head and neck of the humerus and ilium. Scheer and Kuhlman5 pre­ fibrom a. sented another case of a lesion involving the third lumbar vertebra. Dahlin and Hoover6 noted that these tumors were rare, after they reviewed 3,000 cases of bone tumors and found only two desmo­ A 3 esmoplastic fibroma is a rare tumor plastic fibromas. The first case report in­ of the maxilla that has been reported three volving the jaws was published by Grif­ times. It is a benign, locally aggressive fith and Irby.7 Ferguson8 reviewed 14 tumor that is treated conservatively, but cases involving the jaws. The first case of has a tendency to recur. This report dis­ desmoplastic fibroma of the maxilla was cusses the clinical, radiographic, and his­ reported by Sood and Chatterjee.9 A re­ tologic criteria for diagnosing the lesion. view of the literature shows only two ad­ ditional reports of desmoplastic fibroma of the maxilla, Summers and Matz,10 and R eview of the literature Pindborg and Hjorting-Hansen.11 Fibromas are benign tumors that origi­ nate in connective tissue and are found in R eport o f case many areas of the body. MacFarlene1 of Glasgow, Scotland, described a specific The patient, a 46-year-old black man, was seen type of fibroma in the abdominal wall in the office w ith a sw ollen face. The patient stated that the sw elling had been present for m usculature and called it a desmoid approxim ately four years but was more notice­ tum or or “desm om a.” Paget2 reported able in the past tw o m onths. He had no other similar tumors and correlated their his­ symptoms. Exam ination show ed a sw elling in tologic appearance in various areas of the the right lateral nasal region. The sw elling pro­ body. The extra-abdominal desmoids had tru d ed into th e labial vestibule above the

Fig 1 ■ R adiographic appearance: partially radiopaque m ass w ith poorly defined borders on right m axilla. 608 ■ JADA, Vol. 108, A pril 1984

canine and premolars. The m ucosa w as intact a n d n o rm a l in a p p e a ra n c e . R a d io g ra p h s sho w ed a p artially ra d io p aq u e m ass w ith poorly defined borders in the right antral wall (Fig 1). A biopsy was performed w ith the pa­ tient u n d er local anesthesia and a histologic diagnosis of desm oplastic fibroma was made. T he patient was scheduled for adm ission to the hospital for definitive rem oval of the lesion. On adm ission, results of the history and physical exam ination were unrem arkable ex­ cept for m ild hypertension that w as controlled w ith 50 mg hydrochlorthiazide per day. Labo­ ratory blood studies, chest X ray, and EKG were norm al. W ith the patient under general endo­ tracheal anesthesia, a full thickness m ucoperiosteal flap of the buccal gingiva w as ele­ vated to expose the right lateral antral wall. The buccal cortex of bone was notably ex­ panded. After the cortical bone was removed, the lesion w as noted to be grayish-w hite and rubbery in consistency. The borders of the le­ sion were identified and the tum or w as com­ pletely removed. The defect extended from the zygom atic buttress region to the piriform aper­ ture. Grossly, there were several sm all areas of lateral perforation into the antrum and nasal cavity walls. The specim en was sent to the de­ partm ent of surgical pathology for exam ina­ tion. T h e p a tie n t d id w ell after surgery a n d w as d isc h arg e d after th ree days to be fo llo w ed as a n o u tp atien t. T he posto p erativ e course w as u n e ­ v e n tfu l a n d th e tu m o r h a d n o t re c u rre d at the one-year follow -up visit.

The pathology report described a 3.0 x 1.0 x 3.0 cm mass. Microscopically, the lesion con­ sisted of masses of collagenous connective tis­ sue irregularly arranged w ith m oderate cellularity w ith sm all and pyknotic nuclei. Rare areas of calcified tissue were present (Fig 2, 3). The diagnosis was desm oplastic fibroma.

D iscussion Desmoplastic fibroma is a rare benign tumor of bone, separate from other central fibrous bone lesions. It is found more commonly in long bones. In the mandi­ ble, it is often found in the posterior body or ramus region. All four cases reported in the maxilla have been in the right antral wall. These tumors are locally aggressive, but have never been reported to metas­ tasize, although they have a tendency to recur. There is a slight predilection for males. The lesion occurs most commonly during the second decade of life. There is a questionable causal relationship to pre­ vious trauma, but the cause is considered unknown. Pain and pathologic fracture are often the initial symptoms.9 Desmoplastic fibromas are usually dis­ covered when enlargement causes facial asymmetry. They are usually asymp-

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considered appropriate. Radiation is in­ appropriate because of the possibility of sarcomatous transformation.6 Sum m ary Desmoplastic fibroma of the facial areas is a rarely occurring tumor. Characteristi­ cally, it is a benign, locally aggressive le­ sion. The treatment is surgical excision. The case presented is only the fourth one to be reported in the maxillary region. ____________________________ J'ANDA Fig 2 ■ M asses of collagenous connective tissue ir­ regularly arran g ed (H & E, orig m ag x 125).

Fig 3 ■ M oderate cellularity, sm all pyknotic nuclei, in irreg u lar connective tissue (H & E, orig m ag x 250).

tomatic but, if large enough, may cause functional problems. Radiographically, they are radiolucent with well-defined sclerotic borders, some trabeculation, and expansile, thinned cortices. They may appear as unilocular or multilocular le­ sions. Some lesions have been reported w ith ill- d e f in e d b o rd e rs r a d i o ­ graphically, which can suggest malig­ nancy. The gross appearance of the lesion is usually that of a firm unencapsulated fibrous growth of a rubbery consistency. The outer surface is smooth and nodular and the interior surface white or grayish with trabeculae and cyst-like areas.7 Histologically, desmoplastic fibroma is described as a dense hypocellular tissue with large amounts of intercellular col­ la g e n o u s b u n d le s . R are o r sm a ll mononuclear fibroblasts are present and usually bone form ation is not seen. Desmoplastic fibroma may be confused with low-grade well-differentiated fibro­ sarcoma, but the lack of mitotic activity

and nuclear anaplasia facilitates differen­ tiation.6 Central odontogenic fibromas can also be confused with the desmo­ plastic fibroma if odontogenic epithelium is not present. The absence of osteoid dif­ fe re n tia te s th e tu m o r from fib ro u s dysplasia. The lack of giant cells and foam cells distinguishes the lesion from nonossifying fibromas. The classification of this tumor is vari­ able. Sometimes it has been classified as a nonosteogenic or nonodontogenic tumor of bone. It has also been classified as a central fibroma of bone, or as a separate entity. The differential diagnosis should in­ clude low-grade fibrosarcoma, fibro­ matosis, aneurysmal bone cyst, giant cell tum or, fibrous dysplasia, and odon­ togenic tumors. Treatm ent should be conservative in the facial areas to avoid deformity. However, if perforation into soft tissue has occurred, wide resection is required. In other areas of the body, local excision with a margin of normal tissue is

Dr. Eisen is assistant professor, and Dr. Butler was chief resident, departm ent of oral and maxillofacial surgery, U niversity of M aryland. Dr. Butler is now in private practice, Hong Kong, BCC. Address requests for reprints to Dr. Eisen, departm ent of oral and m axillofacial surgery, University of M aryland Dental School, 666 W Baltimore St, Baltimore, 21201. 1. M acFarlene, J. Clinical reports of the surgical practice of the Glasgow Royal Infirmary. Glasgow, Scotland, D. Robertson, 1832, pp 63, 66. 2. Paget, J. Fibronucleated tum or of the abdom en of fourteen years growth; rem oval. Lancet 1:625, 1856. 3. Jaffe, H.L. Tumors and tum orous conditions of the bones and joints. Philadelphia, Lea & Febiger, 1958, p 298. 4. W hitesides, T.E., and Ackerm an, L.V. Desmo­ plastic fibroma. J Bone Joint Surgery 42A:1143,1960. 5. Scheer, G.E., and K uhlm an, R.E. Vertebral in­ volvem ent by desm oplastic fibroma. JAMA 185:669, 1963. 6. Dahlin, D.C., and Hoover, N.W. Desm oplastic fi­ brom a of bone: report of two cases. JAMA 188:685687, 1964. 7. Griffith, J.G., and Irby, W.B. D esm oplastic fi­ broma. Oral Surg 20:269-275, 1965. 8. Ferguson, J.W. Central fibroma of the jaws. Br J Oral Surg 12:205-218, 1974. 9. Sood, V.P., and Chatterjee, A.K. Desmoplastic fibroma of the maxilla. J Laryngol Otol 89:329-333, 1975. 10. Sum mers, L., and Matz, L.R. R ecurrent desm o­ plastic fibroma. Int J Oral Surg 5:100-103,1976. 11. Pindborg, J.J., and Hjorting-Hansen, F. Atlas of the jaws. Copenhagen, M unksgard, 1974, p 64-65.

A possible allergic response to polyether impression material: a case report Richard J. Blankenau, DDS W. Patrick Kelsey, DDS W. Thomas Cavel, DDS

A

The allergenic p o ten tia l and the im m une response to certain im pression m aterials are discussed in this case report.

X j L n awareness of the allergenic poten­ tial and knowledge of the immune re­ sponse to certain impression materials can be useful to the dental practitioner. A case report of an allergic reaction to a

polyether impression material (Impregum) is presented in this paper. A special emphasis is given to clinical applications of the immunologic responses in similar cases of hypersensitive patients.

Blankenau—K elsey-C avel: POSSIBLE ALLERGIC RESPONSE TO IMPRESSION MATERIAL ■ 609