Table of Contents      
CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 2  |  Page : 159-161

Peripheral ossifying fibroma


Department of Periodontics, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India

Date of Web Publication3-Sep-2015

Correspondence Address:
Neha M Mirchandani
202, Kunj Vihar, Opp. Bk No. 181 A, Dholuram Darbar Road, Ulhasnagar - 421 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.164400

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   Abstract 

Reactive lesions found on the gingiva are common and tend to be nonneoplastic growths. They are usually not painful and are often overlooked by the patient until they become symptomatic or are identified by their dentists. Peripheral ossifying fibroma (POF) is a lesion of the gingival tissues that predominantly affects women and is usually located in the maxilla anterior to the molars. The definitive diagnosis though is established by histological examination, which reveals the presence of cellular connective tissue with focal calcifications. Surgery is the treatment of choice, though the recurrence rate can reach 20%. This article presents a case of POF in a 21-year-old male in the mandibular posterior region, diagnosed and treated at our hospital.

Keywords: Reactive lesions of gingiva and epulis, peripheral ossifying fibroma (POF), recurrence


How to cite this article:
Mirchandani NM, Agrawal AA, Kale TA, Pardeshi KV. Peripheral ossifying fibroma. J Int Clin Dent Res Organ 2015;7:159-61

How to cite this URL:
Mirchandani NM, Agrawal AA, Kale TA, Pardeshi KV. Peripheral ossifying fibroma. J Int Clin Dent Res Organ [serial online] 2015 [cited 2017 Sep 21];7:159-61. Available from: http://www.jicdro.org/text.asp?2015/7/2/159/164400


   Introduction Top


The study of tumors of the oral cavity and adjacent structures constitutes an important phase of dentistry because of the role which the dentist plays in the diagnosis and treatment of these lesions. Although tumors constitute only a small number of the pathologic conditions seen by dentists, they are of great significance since they have the potential ability to jeopardize the health and longevity of the patient. [1]

On the basis of the site involved, reactive lesions can be classified as follows:

  1. Lesions predominantly affecting gingiva:
    1. Peripheral fibroma (fibrous hyperplasia, fibrous epulis).
    2. Pyogenic granuloma.
    3. Peripheral giant cell granuloma.
    4. Peripheral ossifying fibroma (POF).
  2. Lesions affecting tongue:
    1. Hairy tongue.
    2. Hairy leukoplakia.
  3. Lesions affecting palate:
    1. Nicotine stomatitis.
  4. Lesions affecting buccal mucosa and vestibule:
    1. White lesions associated with smokeless tobacco.
    2. Dentifrice associated slough.
  5. Lesions involving any site of oral cavity:
    1. Traumatic ulcerations (acute and chronic).



   Case Report Top


A 21-year-old male reported to the department of periodontics with the chief complaint of swelling in the lower right back tooth region since 3 months. The swelling was initially small and gradually increased to the present size over the period of 3 months. There was no contributory past dental and medical history. Extraoral examination revealed no significant findings. On intraoral examination, a solitary pedunculated growth (1.1 cm × 0.8 cm × 1.0 cm) was seen in relation to buccal aspect of tooth 30 [Figure 1]a. The lesion was reddish pink in color, firm, and erythematous having a smooth, nonulcerated surface [Figure 1]b. However, the lesion was asymptomatic. On palpation, the growth was nodular, movable, and nontender with the absence of discharge. Bleeding on provocation was present.
Figure 1: (a) An intraoral solitary pedunculated growth seen on buccal aspect of the mandibular right posterior teeth; (b) reddish pink, firm, nonulcerated surface of the lesion; (c) intraoral periapical of site showing no significant findings; (d) occlusal radiograph showing no significant finding


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   Investigation Top


Complete hemogram was performed that showed all blood counts to be within normal limits.

An intraoral periapical and occlusal radiograph revealed no relevant significant findings [Figure 1]c and d.


   Treatment Top


Full mouth scaling was done to remove local irritants. Excision and microscopic examination were planned, and the patient's consent for the same was taken.

Adequate local anesthesia and aseptic techniques were employed. A silk suture was passed through the lesion to assist in retraction [Figure 2]a. A No. 11 blade was used to excise the lesion to its base following which a periodontal dressing was adapted [Figure 2]b-d. No suturing was done. The excised lesion (1.1 cm × 0.8 cm × 1.0 cm) was stored in formalin for histopathologic examination.
Figure 2: (a) Excision of lesion; (b) after excision; (c) periodontal dressing given; (d) excised tissue


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   Follow-Up Top


The patient presented for follow-up examination 7 days, 15 days, 30 days, 60 days, and 12.5 months postoperatively [Figure 3]a and b. The surgical site appeared to be healing well. There was no evidence of recurrence of the lesion, and the patient had no complaints pertaining to the site of lesion.
Figure 3: (a) Healing: (A) after 2 months; (b) Healing: (B) after 12.5 months


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   Histopathology Report Top


Microscopically, parakeratinized stratified squamous epithelium underlined by highly cellular connective tissue with plump fibroblast arranged in interlacing fascicles was seen. Numerous bony trabeculae lined by osteoblast, containing osteocytes in lacunae were also noted. Numerous bony trabeculae lined by osteoblast, containing osteocytes in lacunae were noted. Osteoid rim was seen around few bony trabeculae along with numerous blood vessels [Figure 4]a and b. The histopathological findings confirmed the lesion as POF.
Figure 4: (a) Hematoxylin and eosin (H and E) stain showing (A) parakeratinized stratified squamous epithelium (10×); (b) H and E stain showing (B) bony trabeculae (40×)


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   Discussion Top


POF is typically a solitary and slow-growing nodular mass that is either pedunculated or sessile, and has been cited in the literature under various names such as peripheral fibroma with osteogenesis, calcifying fibroblastic granuloma, and peripheral cementifying fibroma. [2],[3]

Clinically, POF usually manifests as a well-defined and slow-growing gingival mass <2 cm in size and located in the interdental papilla region. The color is identical to that of the gingiva or slightly reddish and the surface may appear ulcerated. It mainly affects women in the second decade of life. The lesions are most often found in the gingiva, located anterior to the molars and in the maxilla. The definitive diagnosis is based on the histological examination, with the identification of cellular connective tissue and the focal presence of bone or other calcifications. [4] The present case did not show typical characters, as the lesion was seen affecting the male patient in the posterior tooth region involving the buccal aspect in the mandible.

Surgical excision is the treatment of choice for POF; however, recurrence can be frequently noted. In a case series by Cundiff [5] 16% of the cases recurred, whereas Eversole and Rovin [3] reported a recurrence rate of 20%. Reexcision might be necessary in such cases.

Pyogenic granuloma, POF, peripheral giant cell granuloma, and fibroma were proposed to be the differential diagnosis due to the similarities in clinical presentation. Pyogenic granuloma arises most frequently on the gingiva accounting 75% of all cases. It is predominantly seen in the second decade of life that is either pedunculated or sessile with smooth, lobulated, or even a warty surface. It shows tendency for hemorrhage, and it is painless and soft in consistency. No radiographic abnormality is seen. POF is more common in children and young adults. It is either sessile or pedunculated with same color as normal mucosa or slightly reddened. Surface may be intact or ulcerated. No apparent underlying bone involvement is seen on the radiograph. Peripheral giant cell granuloma is asymptomatic. It shows a relatively rapid growth that is most often dark red, vascular, or hemorrhagic in appearance with surface ulceration. Fibroma occurs at any site in oral cavity. It is a well-defined and slow-growing lesion with normal color and smooth surface that is usually sessile or very rarely pedunculated.

For a definitive diagnosis, the biopsy specimen was subjected to histopathological examination and a final diagnosis of POF was made.

The first description of a variant of ossifying fibroma - cement-ossifying fibroma (COF) - was made by Menzel in 1872. But it was first reported in the jaw by Montgomery in 1927. Bhasker et al. in 1984 [6] described this lesion as peripheral fibroma with calcification, and the term "peripheral ossifying fibroma" was coined by Eversole and Rovin in 1972. [3] POF tends to occur in the second and third decades of life. Almost two-thirds of all cases occur in females with a predilection for the anterior maxilla. [7] In the present case, lesion was seen in a male patient involving the posterior mandible. The size of POF ranged 0.4-4 cm. [8]

Radiographic features of POF vary. Radiopaque foci of calcifications have been reported to be scattered in the central area of the lesion but not all lesions demonstrate radiographic calcifications. [7]

A confirmatory diagnosis is made by histopathologic examination of biopsy specimens. All the specific histologic features of POF were seen in the present case. Gardner et al. [9] stated that the cellular connective tissue of POF is so characteristic that a histological diagnosis can be made with confidence, regardless of the presence or absence of calcification.

Although POF is a benign reactive lesion, the recurrence rate is relatively high. According to the 134 cases of POFs analyzed by Cuisia and Brannon, [10] the average time interval for the first recurrence is 12 months. Thus, a regular follow-up of the patient is necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Shafer WG, Hine MK, Levy BM. Benign and malignant tumors of the oral cavity. Textbook of Oral Pathology, 6 th ed. India: Elsevier; 2009. p. 80-219.  Back to cited text no. 1
    
2.
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. 2
    
3.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 3
[PUBMED]    
4.
García de Marcos JA, García de Marcos MJ, Arroyo Rodríguez S, Chiarri Rodrigo J, Poblet E. Peripheral ossifying fibroma: A clinical and immunohistochemical study of four cases. J Oral Sci 2010;52:95-9.  Back to cited text no. 4
    
5.
Cundiff EJ. Peripheral ossifying fibroma: A review of 365 cases. MSD Thesis Indiana University, 1972. In: Shafer WG, Hine MK, Levy BM, editors. A Textbook of Oral Pathology, 6 th ed. Philadelphia: WB Saunders; 1974. p. 128.  Back to cited text no. 5
    
6.
Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcifications: Report of 376 cases. J Am Dent Assoc 1966;73:1312-20.  Back to cited text no. 6
[PUBMED]    
7.
Kenney JN, Kaugars GE, Abbey LM. Comparison between peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-82.  Back to cited text no. 7
    
8.
Kendrick F, Waggoner WF. Managing a peripheral ossifying fibroma. ASDC J Dent Child 1996;63:135-8.  Back to cited text no. 8
    
9.
Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-8.   Back to cited text no. 9
[PUBMED]    
10.
Cuisia ZE, Brannon RB. Peripheral ossifying fibroma-a clinical evaluation of 134 pediatrics cases. Pediatr Dent 2001;23:245-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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