DOI: 10.5272/jimab.

1642010_10-13
Journal of IMAB - Annual Proceeding (Scientific Papers) vol. 16, book 4, 2010

FIBROUS DYSPLASIA IN THE MAXILLO-

MANDIBULAR REGION – CASE REPORT
Cholakova R., P. Kanasirska*, N. Kanasirski, Iv. Chenchev, A. Dinkova
Department of Oral Surgery, Faculty of dental medicine
*Department of Allergology, Physiotherapy and Clinical radiology
Medical University, Plovdiv, Bulgaria

ABSTRACT related to a mutation in the gene that encodes the subunit

Craniofacial fibrous dysplasia is 1 of 3 types of of a stimulatory G protein (Gsα) located on chromosome
fibrous dysplasia that can affect the bones of the craniofacial 20.1,2 As a consequence of this mutation, there is a
complex, including the mandible and maxilla. substitution of the cysteine or the histidine-amino acids of
Fibrous displasia is a skeletal developmental disorder the genomic DNA in the osteoblastic cells-by another amino
of the bone-forming mesenchyme that manifests as a defect acid, arginine.3 Consequently, the osteoblastic cells will
in osteoblastic differentiation and maturation. elaborate a fibrous tissue in the bone marrow instead of
It is a lesion of unknown etiology, uncertain normal bone. (8, 9, 10).
pathogenesis, and diverse histopathology. It is a benign bone disorder of an unknown etiology,
Fibrous dysplasia represents about 2, 5% of all bone uncertain pathogenesis and diverse histopathology (2).
tumors and over 7% of all benign tumours. Fibrous dysplasia represents about 2, 5% of all bone
The aim of this article is to represent a rare case of tumors and over 7% of all benign tumours
bilateral fibrous dysplasia of the upper and lower jaws, in Cranial or facial bones are affected approximately in
combination with Intellectual disability (previously called 30% of the patients. (3, 4). The average age of the patients
mental retardation). The clinical diagnostic approach with FD is 25, 8 years (from 5 to 67) without sex
including imaging studies: Orthopantomogram (OPG) and preference(46, 7% male) and usually manifests before the
3D tomography is described. Histological examination was 3rd decade of life. (4, 5)
also essential for obtaining a definitive diagnosis. Fibrous dysplasia is described in terms of three
major types: monostotic, involving a single bone;
Key words: fibrous dysplasia, Lichtenstein-Jaffe’s polyostotic, having multiple lesions involving multiple
disease, Maxillofacial, McCune-Albright’s disease, bones; and McCune Albright syndrome, a polyostotic form
osteodystrophia fibrosa, osteitis fibrosa disseminata, of fibrous dysplasia that also involves endocrine
monostotic form, polyostotic form, craniofacial form, abnormalities.
cherubism, 3D tomography, Intellectual disability. The monostotic form of fibrous dysplasia is the most
common, comprising 70% of cases, most likely to quiesce
INTRODUCTION at puberty. A typical monostotic lesion, usually presented
Fibrous dysplasia (FD) is a bone development unilateral, will involve the femur, tibia or ribs, with 25%
anomaly characterized by hamartoma proliferation of fibrous occurring in the bones of the skull. Affection of the
tissue within the medullary bone, with secondary bony craniofacial bone is observed with 10% of the patients
metaplasia, producing immature, newly formed and weakly suffering from monostotic FD (6, 7).
calcified bone, without maturation of the osteoblast which Twenty-five percent of fibrous dysplasia involves two
appears radiolucent on radiographs, with the classically or more bones. These lesions may be localized to one region
described ground-glass appearance.(1). of the body or they may be disseminated, involving virtually
In 1937, McCune and Bruch first suggested that every bone. There is a female predilection in polyostotic
among all of the abnormalities of bone formation, this fibrous dysplasia, and up to 50% may involve bones in the
disorder should have its own place as a distinct clinical head and neck. These lesions are more likely to continue to
entity. The following year, Lichtenstein introduced the term progress even after puberty.
“fibrous dysplasia” Deformity is progressive and by mass effect there
Reed’s definition states that fibrous dysplasia is an may be impingement on other structures and functional
arrest of bone maturation, woven bone with ossification impairment.
resulting from metaplasia of a nonspecific fibro osseous These lesions tend to be structurally weak and are
type. (3). The etiology of this abnormal growth process is therefore prone to pathologic fracture. Alkaline phosphatase

10 / JofIMAB; Issue: vol. 16, book 4, 2010 /

may be elevated in up to 30% of patients with polyostotic
fibrous dysplasia, and a dramatic rise may herald malignant
degeneration.
Malignant degeneration occurs in less than 1% of
cases of fibrous dysplasia. Malignancies are almost
exclusively osteosarcoma. For unknown reasons, monostotic
and craniofacial lesions have the greatest potential for
malignant degeneration. Pain, rapid growth of a lesion and
a dramatic elevation of alkaline phosphatase may herald
malignant transformation.

CASE REPORT
A 28-year-old male presented at the Oral surgery
department, Medical university, Plovdiv six years ago with
complaining of mild pain in the lower jaw without precise
localization.
The past medical history includes skin disorder -
Picture 2.
rosacea and medium Intellectual disability manifesting with
emotional-volitional instability prolonged neurotic
decompensation.
There was no family history with similar findings.
The general physical examination revealed a
moderately built patient with satisfactory vital signs and
mental retardation.
Extraorally no facial deformity was ascertained.

Picture 3.

The covering and surrounding mucosa was normal in

color, without any clinical manifestation of inflammation or
ulceration.
On palpation affected areas was painless, with hard
consistence and plane surface.
The initial diagnosis based on the clinical
examination was fibrous dysplasia of the upper and lower
jaws.
Further Imaging Studies with X-ray and 3D
tomography was undertaken for accurately definition of the
bone density and for obtaining the definite diagnosis.
They confirmed lesion confined to the interior of
bone with no soft-tissue involvement witch was helpful in
distinguishing fibrous dysplasia from a malignancy.
Maxillary and mandibular involvement had a mixed
Picture 1.
radiolucent and radiopaque pattern.
Orthopantomo graph revealed diffusive radiolucent
Oral examination revealed the presence of bilateral
areas in the posterior areas of upper and lower jaws.
symmetrical expansion in the distal part of the alveolar ridge
of lower and upper jaws.

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 DISCUSSION
Fibrous dysplasia of the cranium is a rare disorder
of unknown etiology in which normal bone is replaced by
abnormal fibro-connective tissue proliferation.
In 36, 3% of the cases of FD the clinical beginning
is hidden, there is no clear symptoms and obtaining the
diagnosis is complicated. The rest of the patients (63, 6%)
are with diverse symptoms depending on location, swelling,
deformation and presence of pain (8, 11).
Polyostotic fibrous dysplasia affects multitude
skeletal bones usually unilateral.
The patient at present is in quiescence and no bone
increase is detected during following years.
Sudden increase in the level of alkaline phosphatase
Picture 4. is one of the symptoms for malignant transformation and for
that reason its amount should be periodically observed.
In the area of the lower left first molar above the At present alkaline phosphatase level is normal and
mandubular canal was observed radio opacity measuring maintains a constant level.
around 10 mm with obliteration of two third of the left The pain in the lower jaw, being the main complaint
maxillary sinus. of the patient, is considered to be caused by compression
of the mandible nerve of the enlarged fibrous tissue.
The main aim of the treatment is correction of the
functionality in combination with aesthetic effects.
Surgical excision of the affected bone tissue is usually
a successful way of treatment. However it leeds to a huge
functional and aesthetic deficit, as well as long-term post-
operative complications.
The conservative therapeutical approach with limited
reduction in the size of these lesions is enough to manage
the symptoms. Because patients with FD may be at risk of
malignant transformation, periodic follow-up is mandatory
to detect such transformation. (2, 13). Although the
conservative approach in case of FD, affecting the jaws, is
widespread, ortognatic surgery is used in many cases in
order to restore the occlusion and to correct the dentofacial
deformity, caused by the disorder.
Surgical approach aims: stable occlusion, facial
aesthetics and evasion of post-operative relapse. The
Picture 5.
radiotherapy is contra indicated (14, 15).
Biphosphonates are used in cases when an
During the extraction of the lower left first molar a
intervention is necessary but the surgery can not be
bone and soft tissue was taken for histological examination.
performed (8). Some authors suggest applying calcitonin in
The histological findings (¹ 12924/ 7. 05. 2007)
combination with surgical treatment. Calcitonin treatment
showed fibrous modification of the bone tissue without soft
aims local bone calcification which leads to reduction in
tissue involvement. This led to the definite diagnosis Fibrous
bleeding during the bone remodeling (16).
dysplasia.
Usually the prognosis is good although the bad
The patient was advised to visit his dentist regularly
outcomes occur more frequently among young patients or
for ongoing re-examination and to observe and inform for
those with polyostotic forms of the disorder (8). The
any change in growth formation and appearance of pain.
interval between the diagnosis of FD and the development
In the re-examine periodically is measured the level
of malignity is 13,5 years. The risk of malignant
of alkaline phosphatase.

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transformation is 0, 5%, if the patient with FD does not differentiate from other benign and malignant bone
undergo treatment (1, 8). The malignant transformation is disorders.
higher among male with polyostotic FD, craniofacial lesions The general dental practitioner can be the first to
and monostotic FD. The clinical signs of malignity detect such conditions especially when the only affected
development are: pain, immediate swelling and an increase areas are in maxillo-mandibular region so sufficient
in the alkaline phosphatase. The radiotherapy increased knowledge on this condition is important for the proper
malignant transformations more than 400 times (1, 3). diagnosis, treatment and prevention of further complications.
For obtaining the definite diagnosis, treatment and
CONCLUSIONS further management of fibrous displasia is mandatory to be
Isolated cases of fibrous displasia in maxillo- carried out imaging studies, histological and laboratory tests.
mandibular region are rare and can be difficult to

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Address for correspondence:

Radka Cholakova, DMD
3 Hristo Botev blvd, Plovdiv 4002 , Bulgaria
tel: +359/889 268 581, +359/895 716 612
E-mail: [email protected]
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