Journal of Interdisciplinary Dentistry

CASE REPORT
Year
: 2021  |  Volume : 11  |  Issue : 2  |  Page : 93--96

Peripheral ossifying fibroma


Sangeeetha Subramaniam1, Sakthi Vino Bala2, Prakash Ponnudurai Samuel Gnana1, Dhayanand John Victor1, Devapriya Appukuttan1,  
1 Department of Periodontics, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu, India
2 Department of periodontics, Asan Memorial Dental College and Hospital, Chengalpet, Tamil Nadu, India

Correspondence Address:
Dr. Sakthi Vino Bala
No. 85/2, Annai Lakshmi Illam, 5th Street Kothari Nagar, Annai Sathya Main Road, Nessapakam, Chennai - 600 089, Tamil Nadu
India

Abstract

There are many reports showing localized gingival overgrowth which is most commonly reactive rather than neoplastic. The reactive type of lesion includes pyogenic granuloma, irritation fibroma, peripheral giant cell granuloma, and peripheral ossifying fibroma (POF). Among those, POF is a rare reactive gingival type of lesion. Eversole and Rovin in 1972 first described the POF. The main etiology may be due to trauma, local factors such as plaque and calculus, impingement by dental appliance or restorations. This case report shows a clinical presentation of a 40-year-old male reported with the gingival over growth in the lower front teeth region. The patient was provisionally diagnosed as pyogenic granuloma. Management of the lesion included nonsurgical therapy followed by excisional biopsy. Histologic sections were made and confirmed as POF. The patient was followed up to 6 months with no other complication.



How to cite this article:
Subramaniam S, Bala SV, Gnana PP, Victor DJ, Appukuttan D. Peripheral ossifying fibroma.J Interdiscip Dentistry 2021;11:93-96


How to cite this URL:
Subramaniam S, Bala SV, Gnana PP, Victor DJ, Appukuttan D. Peripheral ossifying fibroma. J Interdiscip Dentistry [serial online] 2021 [cited 2021 Dec 3 ];11:93-96
Available from: https://www.jidonline.com/text.asp?2021/11/2/93/325109


Full Text



 Clinical Relevance to Interdisciplinary Dentistry



Clinical findings of this lesion resembles many other benign and malignant lesions of gingiva; histopathological findings is mandatory to provide the patient with final diagnosis. Although surgical excision of the lesion can be done by the periodontist; it should be correlated with the histopathologic findings which can be given by the oral pathologist.

 Introduction



Benign lesions that manifest as gingival overgrowth in the oral cavity are peripheral giant cell granuloma, pyogenic granuloma, epulis, peripheral giant cell fibroma, and peripheral ossifying fibroma (POF). Eversole and Rovin in 1972 first described the POF as a reactive gingival type of lesions.[1] The etiology may be attributed to trauma, local factors such as plaque and calculus, and impingement by dental appliance or restorations.[2],[3] POFs are more common in gingiva and alveolar mucosa with more than 50% of occurrence in incisor and cuspid region.[4] POF lesion was reported in all age groups with slight predilection in the second decades of life, and the average age group of POF occurrence is about 25 years[5] with the most commonly reported cases among females.[6] It is presented as a sessile or pedunculated nodular mass that usually emanates from the interdental papilla.[4] Rarely, POFs can cause migration and loosening of adjacent teeth.[7] The color is usually pink to red and is >2 cm in diameter; however, larger lesions may also occur. Histologically, a POF is a gingival mass composed of islands or trabeculae of woven or lamellar bone in a cellular fibrous connective tissue stroma. Chronic inflammatory cells tend to be seen around the periphery of the lesion. Surgical excision is the treatment of choice, and the lesion should be excised down to the periosteum to prevent recurrence.[4]

 Case Report



A 40-year-old male reported to the department of periodontics with the chief complaint of growth in the lower front teeth region for the duration of the past 6 months. The growth was initially observed as small and gradually progressed over a period of time and attained the present size. The patient had no discomfort or pain in relation to the growth. Medical history revealed that the patient was diabetic and hypertensive for the past 5 years, and he was under medications. The patient was found to be a smoker for the past 20 years.

Intraoral examination revealed generalized accumulation of subgingival plaque and calculus depicting poor oral hygiene. An erythematous gingival growth was evident in the labial aspect of 31, 32, and 33 teeth region measuring 3 cm × 3 cm approximately, extending superiorly up to middle third of the crown portion, inferiorly to the lower labial vestibule, and anteroposteriorly from mesial aspect of 31 to distal aspect of 33 [Figure 1]. On palpation, the growth was firm, lobulated, with pedunculated base and appeared to be nontender without any discharge. However, on periodontal examination, bleeding on probing was positive and Grade 1 mobility was evident around 31, 32, 33, and 34. Based on the clinical appearance of the lesion, the patient was put up with the provisional diagnosis as pyogenic granuloma and the differential diagnosis that included are POF, peripheral giant cell granuloma, giant cell fibroma, and fibroma.{Figure 1}

Complete hemogram indicated that all blood counts were within normal limits, and glycemic level was under control. Oral prophylaxis was accomplished, and excisional biopsy was planned. The patient was explained about the nature of the lesion as well as recommended treatment plan. A written consent was obtained from the patient before surgery. Under local anesthesia, external bevel incision using scalpel was performed around the lesion [Figure 2] and [Figure 3]; the growth was removed, and gingivoplasty was done in the lateral aspect of 31, 32, and 33 to establish the normal contour. The tissue was sent for histopathologic examination. Histopathological finding showed a mass of connective tissue covered partly by hyperplastic stratified squamous epithelium and partly by fibropurulent membrane. The connective tissue was highly cellular and was made of loosely arranged collagen fibers, endothelial cell proliferation, numerous capillaries of various sizes and shapes engorged with red blood cells, and moderate inflammatory cell infiltration. In the deeper portion, irregular trabeculae of bone interposed with globules of osteoid material were found to be scattered [Figure 4]. The histological findings were suggestive of POF. The patient was recalled after 1 week, and the wound healing was found to be satisfactory. Further, the patient was recalled at 3 and 6 months postoperatively, and no evidence of recurrence was seen [Figure 5].{Figure 2}{Figure 3}{Figure 4}{Figure 5}

 Discussion



The lesion “ossifying fibroma” was first clinically described by Menzel in the year 1972, and its term was put forth by Montgomery in 1927.[8] Ossifying fibromas are broadly categorized into two types; one is central ossifying fibroma which arises intraosseusly, other is POF that arises extraosseusly from the soft tissues.[9] Gardner in the year 1982 stated that the term “POF or peripheral odontogenic fibroma” has to be restricted to extraosseus counterpart of central odontogenic fibroma.[5] POF is solitary, reactive rather than nonneoplastic type of lesion most commonly localized to gingival papilla.[2] Other terms of POFs are ossifying fibrous epulis, calcifying fibroblastic granuloma, peripheral cementifying fibroma, and peripheral odontogenic fibroma.[5]

The pathogenesis of POF is unclear, but it was suggested to arise from periodontal ligament cells. The reason why POF is thought to arise from PDL cells are (1) its exclusive occurrence in gingiva, (2) presence of oxytalan fibers within mineralized matrix in some lesions, (3) close proximity of gingiva to periodontal ligament, (4) age distribution of the lesions is inversely proportional to the number of permanent teeth lost, (5) fibrocellular response of POF is similar to that of other reactive gingival lesions that originate from PDL.[1],[9],[10],[11],[12]

Clinically, POF is slow-growing, asymptomatic type of lesion with smooth or lobulated surface and sessile or pedunculated base. The color of POF varies from pink to red, and in some cases, tooth migration along with interdental bone loss is also seen.[7],[13] Radiographically, involved tooth shows widening of periodontal ligament, thickened lamina dura, central area shows radiopaque foci of scattered calcifications, and superficial erosion of bone is also noted in some instances.[1],[9],[14],[15]

The differential diagnosis for POF includes peripheral giant cell granuloma, the giant cell fibroma, pyogenic granuloma, epulis, lipoma, and capillary hemangioma.[16] Histopathologic findings are critical for the diagnosis of POF as the clinical picture resembles many other benign and malignant conditions of gingiva. The present case showed highly cellular connective tissue with loosely arranged collagen fibers, irregular trabeculae of bone interposed with globules of scattered osteoid material. These findings are quite characteristic of POF. Hence, the correlation of the clinical and histopathologic finding has led to the diagnosis of this case as POF. Recurrence rate of POFs is between 7% and 45%.[17] Recurrence is believed to result from incomplete excision, failure to remove etiologic factors. Conservative surgical excision is considered as the treatment of choice along with oral prophylaxis, and the excision should include the removal of underlying periosteum.[4],[17],[18]

 Conclusion



A slow-growing soft tissue mass with speckled calcification in anterior region should raise a suspicion of reactive lesion such as POF. Histopathological findings help in accurate diagnosis, once diagnosed POF should be treated with total excision. The patient should be instructed with proper oral hygiene care and maintenance and they should be involved under rigorous supportive periodontal therapy to prevent recurrence of the lesion.

Declaration of patient consent

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 cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.
2Bhasin M, Bhasin V, Bhasin A. Peripheral ossifying fibroma. Case Rep Dent Vol 2013;1-3.
3Farquhar T, Maclellan J, Dyment H, Anderson RD. Peripheral ossifying fibroma: A case report. J Can Dent Assoc 2008;74:809-12.
4Hung HY, Chang CC, Chang JY, Yu CH, Wang YP, Liu BY, et al. Peripheral ossifying fibroma: A clinicopathological study of 27 cases. J Dent Sci 2007;2:171-5.
5Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-8.
6Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: Report of 376 cases. J Am Dent Assoc 1966;73:1312-20.
7Mergoni G, Meleti M, Magnolo S, Giovannacci I, Corcione L, Vescovi P. Peripheral ossifying fibroma: A clinicopathologic study of 27 cases and review of the literature with emphasis on histomorphologic features. J Indian Soc Periodontol 2015;19:83-7.
8Sujatha G, Sivakumar G, Muruganandhan J, Selvakumar J, Ramasamy M. Peripheral ossifying fibroma: Report of a case. Indian J Multidiscip Dent 2011;2:415-8.
9Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.
10Cuisia ZE, Brannon RB. Peripheral ossifying fibroma--A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8.
11de Marcos JA, de Marcos MJ, Rodríguez SA, Rodrigo JC, Poblet E. Peripheral ossifying fibroma: A clinical and immunohistochemical study of four cases. J Oral Sci 2010;52:95-9.
12Rallan M, Pathivada L, Rallan NS, Grover N. Peripheral ossifying fibroma. Case Reports 2013;1-3.
13Sairam V, Padmaja K, Praveen KB, Naresh G, Vikas RG. Peripheral ossifying fibroma: A case report. Adv Dent and Oral Health 2016;1:74-6.
14Yadav R, Gulati A. Peripheral ossifying fibroma: A case report. J Oral Sci 2009;51:151-4.
15Poon CK, Kwan PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: Report of a case. J Oral Maxillofac Surg 1995;53:695-8.
16Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Philadelphia, Pa, USA: Saunders; 1995.
17Zain RB, Fei YJ. Fibrous lesions of the gingiva: A histopathologic analysis of 204 cases. Oral Surg Oral Med Oral Pathol 1990;70:466-70.
18Clínico FO. Peripheral ossifying fibroma: A clinical report. Int J Odontostomatol 2011;5:153-6.