JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 1  |  Page : 59-63

Peripheral ossifying fibroma with an underlying exophytic bony mass


1 Department of Periodontology, Jagadguru Sri Shivarathreeswara Dental College and Hospital, Jagadguru Sri Shivarathreeswara University, Mysore, Karnataka, India
2 Department of Oral Pathology and Microbiology, Jagadguru Sri Shivarathreeswara Dental College and Hospital, Jagadguru Sri Shivarathreeswara University, Mysore, Karnataka, India

Date of Web Publication18-Mar-2015

Correspondence Address:
Dr. Y V Nagarjuna Reddy
Department of Periodontology, [Room No. 9, First Floor], Jagadguru Sri Shivarathreeswara Dental College and Hospital, JSS University, Sri Shivarathreeshwara Nagar, Mysore - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.153510

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   Abstract 

The peripheral ossifying fibroma (POF) is a benign reactive gingival overgrowth occurring mainly in the anterior maxilla in young adults, predominantly among females. The definitive diagnosis is established by histological examination. Surgery is the treatment of choice, though the recurrence rate can reach up to 20%. The purpose of this article is to present a case of POF in a 50-year-old female with an abnormal size and an exophytic bony mass associated with it.

Keywords: Calcifications, local irritants, peripheral ossifying fibroma, reactive response


How to cite this article:
Nagarjuna Reddy Y V, Chandrashekara Rao DP, Hegde U, Vivek HA. Peripheral ossifying fibroma with an underlying exophytic bony mass . J Int Clin Dent Res Organ 2015;7:59-63

How to cite this URL:
Nagarjuna Reddy Y V, Chandrashekara Rao DP, Hegde U, Vivek HA. Peripheral ossifying fibroma with an underlying exophytic bony mass . J Int Clin Dent Res Organ [serial online] 2015 [cited 2019 Dec 6];7:59-63. Available from: http://www.jicdro.org/text.asp?2015/7/1/59/153510


   Introduction Top


Solitary gingival enlargements are relatively common findings and usually the result of reactive response to local irritation. [1] One such reactive non-neoplastic enlargement of the gingiva is peripheral ossifying fibroma (POF) which was first described by Eversole and Rovin in 1972. [2] There are two types of ossifying fibromas, the central type and the peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes the expansion of medullary cavity. The peripheral types occur solely on the soft tissues covering tooth bearing areas of the jaws, i. e., it occurs solely on gingiva. [3] It is widely considered that the lesion is often associated with trauma or local irritants such as subgingival plaque and calculus, dental appliances, and poor quality dental restorations. [2] The cells of the periodontal ligament are considered to be important in the histogenesis of POF. [4]

Clinically, POFs are sessile or pedunclated, usually ulcerated and erythematous or exhibit a color similar to the surrounding gingiva. [5] The POF may occur at any age but exhibits a peak incidence between the second and third decades with female preponderance and more frequently in maxillary anterior region. [3] Most lesions are less than 2 cm in size, although larger ones occasionally occur, and in the vast majority of cases, there is no apparent underlying bone involvement visible on the radiographs. However, on rare occasions, POF appears to show superficial erosion of bone. [6] Therapy for POF includes surgical excision which includes periosteum and periodontal ligament as well as removal of etiology. [7] Recurrence rate as high as 20% has been reported. [2]

The purpose of this article is to present a case of POF with few uncommon findings.


   Case Report Top


A 50-year-old female patient reported with the chief complaint of a growth in gums between the upper front teeth since 7 months. The swelling was initially small and gradually increased in size. There was no sudden increase or regression in size of the swelling and no relevant past medical or dental history. It was not painful but there was history of bleeding from gums on digital manipulation. Intra-oral examination revealed a solitary, sessile, oval growth on labial side [Figure 1] in between the upper central incisors involving marginal and attached gingiva and alveolar mucosa. It measured 3 × 2 × 1.5 cm. It was extending from depth of the vestibule to the incisal edges. Mesiodisatally, it extended from distal margin of 11 to distal margin of 21. The swelling crossed the alveolar ridge and extended palatally up to the incisive papilla. The surface of the swelling was lobulated. On palpation, lesion was firm to hard in consistency and was non-reducible, non-compressible, non-tender, and non-fluctuant. It was non-ulcerated but showed multiple erythematous areas. Other intra-oral findings were grade 1 mobility of 11, generalized calculus, inflammation, and attrition, pathologic migration in relation to 11 and 21, root stump of 16 and decayed 27. Patient ' s overall oral hygiene status was poor. Extraorally, it was noticed that because of the swelling, patient ' s nasolabial angle was decreased, compromising her esthetics. Radiographic examination showed radio-opaque mass present between 11 and 21 that was attached to alveolar process and distal migration of the same, causing midline diastema [Figure 2]. Blood investigations showed no abnormal findings. Based on all the above findings, differential diagnosis of irritational fibroma, pyogenic granuloma, POF, and peripheral giant cell granuloma were considered.
Figure 1: Pre operative facial fiew

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Figure 2: Calcification batween 11 and 21 attached to alveolar process causing midline diastema

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Full mouth scaling was done to remove local irritants and oral hygiene instructions were given. Patient was recalled after 2 weeks for excision. After anesthetizing the area with 2% Lignocaine hydrochloride, transgingival probing was done with UNC15 probe and it was found that only 4 mm of probe could penetrate the lesion, after which resistance from hard tissue was felt. Thus, anticipating a bony swelling, it was decided to raise a full thickness flap. Crevicular incisions were given facially to teeth 11, 12, 21, 22 with No. 12 Bard parker blade, and a full thickness mucoperiosteal flap was raised. Upon reflection, a calcified mass was seen in between 11 and 21 which was attached to alveolar process facially and closer to mesial surface of 11 [Figure 3]. It measured 11 mm anterioposteriorly [Figure 4], 7 mm mesiodistally and superioinferiorly. Also, there were deposits of calculus seen on the incisors, labially. The hard tissue was excised to the base with a straight fissure bur and micro motor under saline irrigation [Figure 5]. After this, the enlarged soft tissue was excised with No.15 Bard Parker blade [Figure 6]. Thorough subgingival scaling and root planning was done to eliminate all etiologic factors and the excised hard and soft tissues [Figure 7] were sent for histopathologic examination. The flap was repositioned and sutured, area was covered with tinfoil and periodontal dressing was placed. Patient was motivated for proper oral hygiene maintenance and oral hygiene instructions were reinforced. Patient was put on Chlorhexidine mouthwash, Amoxicillin 500mg (t. i. d, 5 days) and combination of Aceclofenac 100 mg and Paracetamol 500 mg (b. i. d, 3 days) and recalled after 10 days for suture removal and check-up.
Figure 3: Calcified bony mass between 11 and 21, subgingival calculus on facial surface 11 and 21

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Figure 4: Anterioposterior extent

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Figure 5: Surgical excision of Hard tissue

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Figure 6: Soft tissue excission

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Figure 7: Excised hard and soft tissues

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The Hematoxylin and Eosin-stained sections from soft tissue showed superficial stratified squamous epithelium and underlying fibrocellular connective tissue with areas of calcification [Figure 8]. The connective tissue stroma was highly cellular with plump proliferating fibroblasts and calcifications resembling bone were seen [Figure 9]. The hard tissue findings were of normal trabecular bone. Based on these findings, it was diagnosed as POF.
Figure 8: Hematoxylin and Eosin pictomicrograph (×10)

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Figure 9: Hematoxylin and Eosin section in high power (×40)

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Ten-days follow-up of patient showed healing of soft tissue and mild inflammation. Patient was asymptomatic and there was no sign of infection or any abnormal findings. After 1.5 month and 3 month follow-up, the patient showed satisfactory healing of gingiva and nasolabial angle was normal. The patient recall after 6 months was uneventful [Figure 10]a and b.
Figure 10: (a) Six months post operative clinical picture, (b) 6 months post operative radiographs

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   Discussion Top


Gingiva is often the site of localized growths that are considered to be reactive rather than neoplastic in nature. [8] Intra-oral ossifying fibromas have been described in the literature since the late 1940s. Many names have been given to similar lesions, such as epulis, peripheral fibroma with calcification, peripheral ossifying fibroma, calcifying fibroblastic granuloma, peripheral cementifying fibroma, and peripheral fibroma with cementogenesis and peripheral cemento-ossifying fibroma. [2] The sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions. [4]

Because of their clinical and histopathologic similarities, some peripheral ossifying fibromas are thought to develop initially as pyogenic granulomas that undergo fibrous maturation and subsequent calcification. However, not all POFs may develop in this manner.

Though the exact etiopathogenesis of POFs is uncertain, an origin from cells of the periodontal ligament has been suggested. The reasons for considering periodontal ligament origin for POF include exclusive occurrence of peripheral ossifying fibroma in the gingiva (interdental papilla), the proximity of gingiva to the periodontal ligament and the presence of oxytalan fibers within the mineralized matrix of some lesions. [9] The excessive proliferation of mature fibrous connective tissue is a response to gingival injury, gingival irritation, subgingival calculus, or a foreign body in the gingival sulcus. Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue and resultant initiation of formation of bone and dystrophic calcification. [7]

In the present case, patients overall oral hygiene status was poor with generalized calculus. Subgingival calculus was evident after reflection of full thickness flap; this could be the most probable etiologic factor here. Although a case report of POF in post menopausal woman has been reported in literature, there is no explanation for its occurrence in this group. [10] Extensive literature search has not revealed the association of bony mass in POF in post menopausal woman. The underlying bony mass could be reactive change associated with menopausal status of women.

Irritational fibroma presents clinically as a firm nodular growth associated with a source of irritation. Pyogenic granuloma presents as a soft, friable nodule that bleeds with minimal manipulation, but tooth displacement and resorption of alveolar bone are not observed. Although peripheral giant cell granuloma has clinical features similar to those of POF, the latter lacks the purple or blue discoloration commonly associated with peripheral giant cell granuloma and radiographically shows small flecks of calcification. Thus, the diagnosis based only on clinical aspects can be difficult, and histopathologic examination of the surgical specimen obtained by excisional biopsy is mandatory for an accurate diagnosis of POF. [11]

In the case reported here, the histopathologic picture was diagnostic of POF as it was characterized by the presence of fibrous connective tissue with plump proliferating fibroblasts, calcifications, dense bundles of collagen fibers and blood vessels covered by stratified squamous parakeratinized epithelium.

The treatment of choice for the peripheral ossifying fibroma is local surgical excision. In the present case, the lesion was excised down to periosteum because recurrence is more likely if the base of the lesion is allowed to remain. Our 6-months follow-up showed no recurrence.

The interesting part of this case is that patient was in 5 th decade with lesion measuring 3 × 2 × 1.5 cm, unlike the usual cases of POF which occur in 2 nd or 3 rd decade and measure <2 cm. It was coincidental finding that POF was associated with an exophytic bone mass arising from the alveolar process.


   Conclusion Top


Clinically, a number of lesions associated with offending agents such as calculus present as sessile or pedunclated solitary growths on gingiva. However, each lesion behaves differently. Hence, definitive histopathologic diagnosis aids in the better management, prognosis, and follow-up of the lesion.

 
   References Top

1.
Flaitz CM. Peripheral giant cell granuloma: A potentially aggressive lesion in children. Pediatr Dent 2000;22:232-3.  Back to cited text no. 1
    
2.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 2
    
3.
Neville BW, Damm DD, Allen CM, Bouquot JE. Text book of Oral and Maxillofacial Pathology, 2 nd edition. Saunders Elsevier Philadelphia 2004. p. 451-2.  Back to cited text no. 3
    
4.
Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43.  Back to cited text no. 4
    
5.
Poon CK, Kwan PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: Report of a case. J Oral Maxillofac Surg 1995;53:695-8.  Back to cited text no. 5
    
6.
Kenney JN, Kaugara GE, Abbey LM. Comparison between the peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-82.  Back to cited text no. 6
    
7.
Pendyla G, Joshi S, Marawar PP, Pawar B, Mani A. Peripheral ossifying fibroma - A case report. Pravara Med Rev 2012;4.  Back to cited text no. 7
    
8.
Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1987;63:452-61.  Back to cited text no. 8
    
9.
Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: Report of 376 cases. J Am Dent Assoc 1966;73:1312-20.  Back to cited text no. 9
    
10.
Gugnani S, Pandit N, Gugnani N. Peripheral Ossifying Fibroma in post menopausal woman with generalized chronic periodontitis: A rare case report. Indian J Dent Sci 2014; 6:69-71.  Back to cited text no. 10
    
11.
Chaturvedy V, Gupta AK, Gupta HL, Chaturvedy S. Peripheral ossifying fibroma, some rare findings. J Indian Soc Periodontol 2014;18:88-91.  Back to cited text no. 11
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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