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Odontogenic fibroma (OF) is a rare nonepithelial benign tumor arising from the odontogenic mesenchymal tissue in
the jawbone. OFs are topographically categorized into 2 types, the central type and peripheral type, and are
histopathologically divided into the epithelium-poor type and epithelium-rich type. The radiological findings of central OF
commonly include a uni- or multilocular radiolucent area with a well-defined margin, which are similar to those of cysts and
other benign tumors of the jawbone. Therefore, it is difficult to distinguish OF from these jawbone lesions on radiographs
because of their noncharacteristic radiological findings. In this article, we report the cases of 2 patients with central OF who
underwent magnetic resonance (MR) examinations and describe the usefulness of dynamic contrast-enhanced MR imaging for
diagnosing OF. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:e51-e58)
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Figure 1. Panoramic and periapical radiographs (case 1). Panoramic and periapical radiographs showing a multilocular radiolucent area with a well-defined margin extending from the upper left lateral incisor to the first premolar region and root resorption
of the first premolar (A, B).
acquired with a spin-echo sequence, and short TI inversion recovery (STIR) images were acquired with a
turbo-spin-echo sequence. We performed DCE-MRI
via 3-dimensional fast imaging using a steady-state
precession sequence. The DCE-MRI series were composed of 14 consecutive scans performed at 1-second
intervals (acquisition time for each scan: 14 seconds).
The total scan time of this series was 210 seconds.
Then, contrast-enhanced T1WIs (CE-T1WIs) with fat
suppression were acquired using the same parameters
as the unenhanced T1WIs after the administration of
contrast medium.
TICs were created using dynamic images, regions of
interest (ROIs) were drawn on a computer monitor, and
the mean signal intensity in the ROI of each lesion was
calculated using a workstation (Synapse Vincent, Fujifilm, Medical Co., Tokyo, Japan).
Case 1
In October 2003, a 24-year-old woman was referred to
our hospital because a radiolucent lesion that extended
from the upper left lateral incisor to the premolar region
had been detected on a periapical radiograph by her
general dental practitioner. She had not noticed any
symptoms and did not have a relevant medical history.
Conventional radiographs showed a multilocular radiolucent area with a well-defined margin extending
from the upper left lateral incisor to the first premolar
region and root resorption of the first premolar (Figure
1, A and B). Computed tomography (CT) images (bone
window) showed similar findings to those of the conventional radiographs, and palatal bony expansion was
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DISCUSSION
OF is a benign odontogenic neoplasm arising from the
jawbone that is categorized into various types, i.e., it is
histologically divided into 2 types: the epithelium-poor
type (simple type) and the epithelium-rich type (complex or WHO type) and is topographically classified
into 2 types: the intraosseous or central type and the
extraosseous or peripheral type, according to WHO.1 In
this study, both cases involved the central type of OF.
The central and peripheral types of OF represent
approximately 0.1% and 1% to 2% of all odontogenic
tumors, respectively.6 OFs can appear at any age, although they display a predilection for females, and both
of our patients were females (in their first and second
decade, respectively).4,9,10,12 OFs most commonly occur in the anterior region of the maxilla and the posterior region of the mandible.4,5,7,9 In our cases, one OF
was found in the anterior region of the maxilla, and the
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Figure 3. MR images (case 1). The MR images of this case show a tumor (arrows) that displays homogeneous isointensity on
T1WI (A) and heterogeneous iso- to hyperintensity on STIR images (B). On CE-T1WI, the tumor shows strong heterogeneous
enhancement (C).
Figure 4. Histopathological findings (case 1). The surgical specimen was composed of dense fibrous connective tissue, which
showed a minimal cellular appearance accompanied by a partial inflammatory reaction (A; hematoxylin-eosin stain, 100). In the
connective tissue, scattered islands or chords of odontogenic epithelium were observed (B; hematoxylin-eosin stain, 200).
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Figure 5. Panoramic radiograph and posterior-anterior projection (case 2). A panoramic radiograph and posterior-anterior
projection showing a unilocular radiolucent lesion with a well-defined margin together with second molar impaction and third
molar displacement in the lower right molar region (A, B).
Figure 6. CT images (case 2). The axial (bone-window) image shows a unilocular mass with a well-defined margin together with
bony expansion in the lower right molar region (A). A reconstructed sagittal image obtained with the bone window showing a
lesion involving the second molar crown that has displaced the third molar tooth germ (B).
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Figure 7. MR images (case 2). The MR images show a tumor displaying heterogeneous isointensity on T1WI (A) and heterogeneous
hypoisointensity on STIR images (B). Part of the tumor appeared hyperintense on T1WI and STIR images (A, B). On CE-T1WI, the
tumor showed strong heterogeneous enhancement outside of the area that appeared hyperintense on T1WI and STIR images (C).
Figure 8. Histopathological findings (case 2). A tumor mass was observed in the deep areas of connective tissue (A; hematoxylin-eosin
stain, 20). The tumor mass consisted of comparatively acellular fibrous connective tissue, which was admixed with myxomatous tissue
(B; hematoxylin-eosin stain, 100). The odontogenic epithelium in the tumor mass formed small islandlike nests (C; hematoxylin-eosin
stain, 200).
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togenic myxomas described in our previous article displayed a pattern involving gradually increasing enhancement without washout of the contrast medium
until 500 to 600 seconds, which was different from that
of OF, which involved rapidly increasing enhancement
until 200 seconds.17 We consider that DCE-MRI makes
it possible to differentiate central OF from odontogenic
myxomas.
The TIC of our OF showed increasing signal intensities until 800 seconds, indicating that the inflow of
contrast medium was greater than its washout during
this period. Various authors have reported that the rich
fibrous tissues in the extracellular spaces of some tumors reduce the washout of contrast medium.26,27 OFs
are nonepithelial benign tumors arising from odontogenic mesenchymal tissue; however, our OFs were of
the simple type, and lesions of this type contain small
amounts of epithelial tissue.1,5,7,9,28,29 The histopathological findings of our OFs, which contained more rich
fibrous tissue than epithelial tissue, agreed with the
results of previous articles. Therefore, we consider that
a TIC that increases for a long time after the administration of contrast medium is a characteristic finding of
OF arising from odontogenic mesenchymal tissue.
Ossifying fibromas also arise from mesenchymal tissue and are one of the differential diagnoses of central
OF. Ossifying fibromas display various histopathological and radiographic features depending on the contributions of their soft and hard tissue components.1,30 In
ossifying fibromas with hard tissue components, it is
possible to differentiate between ossifying fibromas and
central OF on conventional radiographs and CT images. On the other hand, when the lesion is composed
of mesenchymal soft tissue, it is difficult to distinguish
ossifying fibromas from OF, not only on conventional
radiographs and CT images, but also on MRI, including
DCE-MRI. Therefore, we had to compare the TIC of
our cases with those of ossifying fibromas, but there are
no reports about the DCE-MRI characteristics of OF.
CONCLUSIONS
We have reported 2 cases of central OF of the jawbone.
It was difficult to diagnose these lesions as OF because
they did not display characteristic radiological features.
MRIs of OF show a mass that displays homogeneous
isointensity on T1WIs, heterogeneous iso- to hyperintensity on STIR images, and heterogeneous strong enhancement on CE-T1WIs. The MRI findings of these
cases were different from those of jawbone cysts, although they were similar to those of odontogenic tumors. The TIC of OF rapidly increased in the early
phase and gradually increased without contrast medium
washout in the late phase. The TIC pattern of OF is
different from those of other odontogenic tumors of the
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16.
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