Reconstruction of maxillary cemento-ossifying fibroma defect with buccal pad of fat.

A cemento-ossifying fibroma (COF) is a rare benign neoplasm of maxilla when compared with mandible (World Health Organization, 1992). COF of maxilla may be quite large and locally very aggressive lesion. These tumor mass was peeled out by en-bloc excision using gentle blunt dissection. This paper presents 35-year-old male patient who had a gradually expanding lobular mass in the left maxillary posterior region for past 1 year. He has been treated successfully by surgical en-bloc resection. Various techniques were used to reconstruction the defect. Buccal pad of fat is a simple technique having advantages like good vascularity, adaptability, good closure of the defect with favorable prognosis.

Cemento-ossifying fibroma (COF) is a rare benign neoplasm of the maxillary region where growth is extensive in to the maxillary sinus extending into the orbital walls.[1] Cementum containing lesions are theoretically of periodontal membrane origin, which may spread to maxillary sinus from upper premolar or molar teeth. These lesions are very slow-growing, asymptomatic, intraosseous masses, most frequent in females compared to males aged between 35 and 40 years. Surgical resection of the lesion is the only treatment option.[2] Following surgical resection maxillary defect closure was carried out using various techniques such as primary closure, split thickness skin grafting, regional flap and free flap. The type and size of the defect determine the technique to be used. Buccal pad of flap is a type of reconstruction technique gained much popularity in oral and maxillofacial surgery[3] because of its rich blood supply.

Case Report

A 35-year, 10 month-old male patient presented to department of oral surgery with a chief complaint of swelling in the left side of the face with visual disturbances [Figure 1]. Further, he complaints of a huge mass in the upper left dental arch region for past 1 year, which gradually increasing in size with difficulty in mastication and bleeding on touch without any difficulty in pain and swallowing. Past medical history reveals he was affecting nasal obstruction for past 6 months. Visual evaluation shows he was suffering from diplopia. Extra oral examination showed along with swelling in the left region off the face an altered infra orbital bony contour and proptosis. On intra oral examination, a large circumscribed mass involving the left posterior region of hard palate from midline and extended bilaterally displacing the left upper molars and premolars [Figure 2]. Swelling was firm and well-demarcated margin. 2nd and 3rd molar teeth was having grade 3 mobility, displaced, extruded severely below the occlusal plane, bleeding on probing without pain and tenderness.

Figure 1

Extra oral photograph- frontal view

Figure 2

Intraoral photograph showing displaced teeth

Orthopantomogram and contrast enhanced computed tomography scan showed expansible lytic lesion with osseous fragments involving the posterior 1/3 of the hard palate and alveolar ridge corresponding to premolar and molar regions [Figures 3 and 4]. Further, it invades the left maxillary sinus involving the floor of the orbit and part of ethmoid. Anteriorly, it involves the right nasal passage abutting the inferior turbinate and blocking the airway. Histopathology report confirmed as COF.

Figure 3

Orthopantomogram showing the lesion

Figure 4

Computed tomography image showing the extension of the lesion

Treatment and prognosis

Weber-Fergusson approach was carried out with en-bloc resection of the tumor [Figures 5 and 6]. Following resection closure of palatal defect was carried out using ipsilateral buccal pad of fat by careful, gentle dissection and reconstruction [Figure 7]. Remaining portion was packed with Bismuth Iodoform Paraffin Paste pack and secured with an acrylic stent. Post-operative period was uneventful and healing was favorable and good [Figure 8].

Figure 5

Intraoperative view after excision of mass

Figure 6

Specimen of the lesion

Figure 7

Intra operative buccal fat of pad harvesting

Figure 8

Post-operative surgical site after 6 months of healing

Discussion

COF was a well-circumscribed expansible lesion with calcified matrices involving both maxilla and mandible and it was considered as an aggressive lesion when it involves the maxillary antrum. When the extension of the lesion was favorable enucleation was done. However, surgical resection was done when lesion was very wide with involvement of adjacent structures. Recurrence following complete excision is generally considered to be uncommon.[2] In case of bone erosion, it may requires bone grafting or reconstructive surgery. Reconstruction of the defect also is simple with primary closure, split thickness skin grafting, regional flap, Skin graft, tongue flap and buccal pad of fat. Studies suggested that the buccal fat of pad with its high vascularity and easy harvesting technique has a very high success rate in the reconstruction of oral defects.[34]

Conclusion

COF a rare kind of lesion in maxilla even in aggressive extensive form can be managed surgically with least recurrence. Reconstruction of the defect with buccal fat pad helps the surgeon to reduce the size of the defect with favorable prognosis thereby avoiding the need to opt for extensive flaps or other reconstructive options.