Peripheral ossifying fibroma: A case report

Peripheral Ossifying Fibroma - A Case Report Chirag Shah*, Surabhi Joshi**, Chintan Joshi**, Sameer Zope**

Abstract Peripheral ossifying fibroma is a reactive gingival overgrowth whose pathogenesis is uncertain. It is more prevelant in women and usually located in maxilla. Here we are reporting a case where it was diagnosed as peripheral ossifying fibroma after complete intra/extra oral examination, radiographic analysis, hematologic and histopathologic examination, and its surgical management with post operative follow up. Key Words : Peripheral ossifying fibroma, Oral cavity, Epulis, Pyogenic granuloma, Oral tumors

INTRODUCTION

B

enign fibrous overgrowths arising from the mucous membrane are termed as fibromas and are frequent growths in the oral cavity. Many of the fibrous growths originate from underneath the periodontium, similar to peripheral ossifying fibroma (POF). POF is an occasional growth of the anterior region of mandible and accounts for 3.1% of all oral tumors and 9.6% of the gingival lesions. About 60% of these tumors occur in maxilla and more than 50% of all cases of maxillary POF are found in the incisors and canine areas. The peripheral ossifying fibrom is a localized reactive enlargement of the gingiva that typically measures less than 1.5 cm at its greatest diameter.1 Other names of the lesion are Peripheral odontogenic fibroma, Peripheral cementifying fibroma, Calcifying or Ossifying fibroid epulis, Peripheral fibroma with calcification, Calcifying fibroblastic granuloma, Peripheral fibroma with cementogenesis.2 Prognosis is good, but some instances of recurrence have been reported regularly in various studies. Incidence of recurrence has been put at 16-20% by various studies. Reasons for recurrence include a) incomplete removal of lesion, b) failure to eliminate local irritants and c) difficulty in access during surgical manipulation due to intricate location of POF being present usually at interdental areas. Deep excisions have been preferred as interjection to these recurrences.3

CASE REPORT A 44 year old female patient reported with the chief complaint of growth on her gums around upper front teeth since 6 months. Patient gave the history of excision of the similar kind of growth involving the same site about 6 months back. After the excision, the growth came back to original size in about 1 month, after which it *Professor and Head; **Lecturer; Department of Periodontics, KSD, Gandhinagar. 1002

stopped growing further. Her medical history revealed high Total Cholesterol of 260 mg/dl since four months. She was not taking any medication for the same. Family history was negative. No Significant Extra - oral findings were present On Intra - oral examiniation interdental papillae between 22 & 23 was enlarged, erythematous, lobular & had ulcerative surface which was inflamed. There was no history of tooth brush trauma. On palpation swelling was fibrous, no pitting and tender loss of stippling between 22 & 23. Size: Width about 8 mm. There was probing depth of 6mm distal to 22. Bleeding on probing was present. No other abnormality detected in oral cavity except for shallow pockets in relation to 36 & 46. Radiographic findings showed slight crestal bone loss with no any periapical lesion and no other abnormality detected. Hematology report Random Blood Sugar : 136 mg/dl, Haemoglobin : 13.1gm%., Total WBC Count : 8,600/cu.mm, Bleeding time (Dukes) : 2 min 10 sec, Clotting time (Capillary tube method) : 4 min 30 sec. Procedure After the phase I therapy, the gingival overgrowth was excised under local anaesthesia. The excision was followed by gingivoplasty. The tissue was sent for histopathologic diagnosis. Histopathology report The given H & E section show parakeratinised stratified squamous epithelium overlying the stroma and delicate collagen fibers with numerous proliferating fibroblasts within connective tissue. Diffuse distribution of osteoid tissue in the form of globules and trabecular pattern with osteoblasts rimming in few areas. Endothelial lined blood vessels with RBC’s were seen (Fig. 5). Depending upon clinical finding and histological features, a final diagnosis of peripheral ossifying fibroma JIDA, Vol. 5, No. 9, September 2011

Fig. 1a & b : Preoperative intra oral view.

Fig. 2 c : Dimensions of the growth.

Fig. 3 : Intra - oral periapical radiograph.

Fig. 4 c & d : Imtraoperative photos.

was made. Post - operative care A periodontal dressing was placed which was removed post operatively after 1 week. Patient was placed on 0.12 % Chlorhexidine mouthrinse twice daily for two weeks. Healing occurred uneventfully and shallow probing depths were noted 6 months after surgery and the lesion did not reappear during this 6 month follow up period (Fig. 6).

DISCUSSION The etiology and pathogenesis of Peripheral ossifying fibromas are not known. It has been suggested that these lesions originate in the cells of the periodontal ligament for the following reasons: Peripheral ossifying fibroma exclusively appears in the gingival tissue, closed to the periodontal ligmanent; oxytalan fibers are found within the mineralized matrix of some lesions; the age distribution of the lesions in inversely proportional to the number of permanent teeth lost; and the fibrocellular response of peripheral ossifying fibroma is similar to that of other reactive gingival lesions originating in hte periodontal ligament.4 When presented clinically with a gingival lesion, it is important to establish a differential diagnosis. In this case, the clinical features led to a differential diagnosis of irritation fibroma, pyogenic granuloma or PGCG. The JIDA, Vol. 5, No. 9, September 2011

Fig. 2a, b : Dimensions of the growth.

Fig. 4 a, b : Intra operative photos.

Fig. 5 : Histopathologic photo.

Fig. 6 : Post operative.

POF must be differentiated from the peripheral odontogenic fibroma (PODF) described by the World Health Organization. Histologically, the PODF has been defined as a fibroblastic neoplasm containing odontogenic epithelium. Despite a preponderance of literature supporting differentiation, some authors continue to argue that the POF (or peripheral cementoossifying fibroma) is the peripheral counterpart of the central cemento-ossifying fibroma.5 Histopathologically, several variations were observed, with equal number of cases showing ulcerated epithelium and others showing hyperplastic epithelium. In the current study, three-fourth of the cases showed fibrocellular connective tissue stroma with fibroblast showing moderate-high activity. Occurrence of plump fibroblasts with vesicular nucleus was a common feature. The plump fibroblasts can be considered to be representative of the undifferentiated mesenchymal cells arising from periodontal ligament, whereas, if the fibroblasts are spindle shaped, they may represent a metaplastic change as seen in pyogenic granuloma. A very characteristic feature of peripheral ossifying fibroma is the presence of high cellularity around the mineralized tissue, which helps in differentiating the connective tissue stroma from other peripheral lesions like pyogenic granuloma. Buchner and Hansen reported that there are three types of mineralized tissue in POF: dystrophic 1003

calcification, bone (woven or lamellar) and cementum like material. The distinction between these mineralized masses is quite arbitrary in routine H and E sections. With the advent of polarizing microscopy, its efficacy in accurately identifying these mineralized masses is advocated.6 Radiographic features of the periapical ossifying fibroma 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. Underlying bone involvement is usually not visible on a radiograph. In rare instances, superficial erosion of bone is noted.8 The recurrence rate of the POF has been considered high for reactive lesions and it probably occurs due to incomplete initial removal, repeated injury, or persistence of the local irritants.7 The rate of recurrence has been reported at 8.9%, 9%, 14%, 16% and 20%. Therefore, regular follow-up is required.5 The treatment of choice for peripheral ossifying fibroma is local resection with peripheral and deep margins including both the peridontal ligament and the affected periosteal component. In addition, elimination of local etiological factors such as bacterial plaque and tartar is required. The teeth associated with peripheral ossifying fibroma are generally not mobile, though there have been reports of dental migration secondary to bone loss. Extratction of the neighbouring teeth is usually not considered necessary.4

CONCLUSION

gingival enlargement which has to be differentiated from neoplastic growth and other gingival growth forms. In the case presented above we can conclude that with proper intra/extraoral, radiographic, haematologic examination and confirmatory histopathologic examination the firm diagnosis of the lesion can be made. Surgical excision of the lesion is the advised management with timely follow up to counter any chances of recurrences.

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Peripheral ossifying fibroma is slowly progressing

Contd. from page 992

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