juvenile ossifying fibroma ( jof ) is an actively growing aggressive lesion containing cells rich in the fibrous stroma containing cellular osteoid , trabeculae of woven bone without osteoblastic lining , with or without clusters of giant cells .
el - mofty first identified the two histopathological variants of jof : trabecular and psammomatoid .
rare cases of mandibular jof have been reported . clinical examination reveals it as asymptomatic slow growing swelling causing facial asymmetry , extending to a substantial size and behaving as an aggressive lesion .
it has higher male predominance with the mean age of occurrence ranging from 2 to 15 years .
the radiographic features show unilocular or multilocular radiolucency with well - delineated borders and few opacification in the center .
the suggestive features of the aggressive variant are the presence of the perforation , cortical thinning , tooth displacement , and root resorption .
the advanced imaging studies show more invasive and destructive features apart from conventional radiographic features .
histopathologically both the entities are nonencapsulated , well demarcated from the surrounding bone consisting of neoplastic cellular stroma formed by spindle shape fibroblast .
in contrast , the psammomatoid pattern forms concentrically laminated ossicles that vary in shape and having peripheral eosinophilic osteoid rims with basophilic centers typically .
the overall clinical features , histopathological features , and advanced imaging were indispensable to provide the diagnosis as jof . a nonaggressive form of this lesion is managed by curettage and local excision whereas aggressive form is managed by complete surgical excision , en - bloc resection or hemimaxillectomy to prevent recurrences .
reported here is a case of a trabecular variant of jof in a 17-year - old female patient .
a 17-year - old female represented with a chief complaint of pain and slowly progressive swelling of the left side of face along with reduced mouth opening for the last 2 months .
initially , the swelling was smaller in size and increased progressively to attain final size causing facial asymmetry with reduced mouth opening .
extraoral examination revealed an ill - defined , diffuse , and bony hard swelling of approximately measuring about 6 cm  4 cm on the left side of the face , extending superior - inferiorly from left zygomatic arch till angle of the mandible and anteroposteriorly from nasolabial fold till tragus of the left ear with normal overlying skin [ figure 1a and b ] intraorally , swelling was solitary , slightly tender with the expansion of buccal and lingual cortical plates with no pathological changes to the overlying mucosa .
there was reduce mouth opening measuring about 15 mm in the greatest dimension [ figure 2a ] .
orthopantomogram revealed a large well - bordered , well - defined unilocular , circular , mixed lesion ( calcification specks ) approximately , 2 cm in size involving the ramus , coronoid , and angle of the mandible [ figure 3 ] posteroanterior view of mandible showed a well - defined , mixed lesion involving the coronoid process , ramus and the angle of the left side of the mandible [ figure 4 ] .
axial and sagittal view of computed tomography confirmed the routine radiographic features and further showed a heterogeneously enhancing mixed lytic - sclerotic lesion with a sclerotic rim extending into adjacent soft tissue measuring 5.12 cm  3.83 cm with exterior and superior extension into the left infratemporal fossa and medial extension up to pterygoid muscle [ figure 5a and b ] .
biopsy was taken from the involved site , and the h and e section showed the presence of trabeculae of fibrillar osteoid and woven bone . in few areas , multinucleated giant cells were also noted .
based on clinical , radiographic , advanced imaging studies and histopathological report provided the diagnosis of the trabecular variant of jof affecting left mandible with differential diagnosis of cement - ossifying fibroma , osteoblastoma , and osteogenic sarcoma .
the lesion was excised by segmental resection using transmandibular approach and reconstruction was done [ figure 7a and b ] .
postoperative healing was uneventful ; mouth opening was increased to the value of 30 mm [ figure 2b ] .
postoperatively , the esthetics , oral function of the patient such as speaking , and chewing were intact and normal [ figure 8a and b ] .
the patient is still under regular follow - up as the lesion has high recurrence rate .
( a and b ) preoperative extraoral view of the patient showing swelling on the left side of face ( a ) preoperative mouth opening , ( b ) postoperative mouth opening preoperative panoramic view of the patient preoperative posteroanterior view of the patient ( a ) axial view of computed tomography , ( b ) sagittal view of computed tomography histopathological section ( a ) postoperative panoremic view of the patient , ( b ) postoperative posteroanterior view of the patient ( a and b ) postoperative extraoral view of the patient with intact facial symmetry
jof mostly strikes children with slightly male predominance with a mean age of 11 years .
clinically , it is asymptomatic , however rarely it is aggressive and symptomatic . in the present case ,
both maxilla and mandible are affected with more prevalence for maxilla . in the present case , the duration of swelling noted was 2 months .
the characteristic radiographic features reveal a central opacification with well - defined unilocular to multilocular pattern giving it a ground glass appearance .
the 50% of cases of jof are recorded in multiple sinuses with few occurring in the single sinus .
the duration , clinical and radiographic features and extension of the lesion into the adjacent soft tissue favors the aggressive type of jof as previously reported .
the features like resorption and perforation of cortices , tooth displacement and aggressive growth of the lesion favor the diagnosis as an aggressive variety of jof . in this case , except for tooth resorption all other features like perforation of the cortices and extension into the surrounding tissue was noted .
because of the high recurrence rate , there is no follow - up protocol mentioned in the literature and immediate reconstruction is not advised .
resection is considered where there is recurrence , invasion into surrounding tissues , or when preserving the inferior border is not feasible .
jof is an uncommon clinical entity , because of its aggressiveness and high recurrence rate it is necessary to arrive at an early diagnosis , applying the appropriate clinical , diagnostic approaches , and appropriate treatment for effective results and long - standing follow - up .
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has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed there are no conflicts of interest .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed
 one of the rarest entities of fibro - osseous lesions that arise within the craniofacial bones is juvenile ossifying fibroma ( jof ) . 
 it is an intraosseous expansile lesion of the jaw that imitate odontogenic lesions . who has described two distinct histopathological variants of jof ; trabecular and psammomatoid . 
 histologically , they are characterized by the presence of fibrous connective tissue stroma along with osteoblastic and osteoclastic cells . 
 clinical , characteristics show an early age of onset , typical histological patterns , high rate of aggressive behavior and recurrence . 
 this article presents a rare clinical case of the trabecular variant of jof , its clinical , radiological , histological , and treatment aspects . 
Introduction
Case Report
Discussion
Conclusion
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