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

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CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 153-158

Peripheral ossifying fibroma: A clinical entity in the mandibular incisor region- A case report


1 Department of Periodontology, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India
2 Department of Dentistry, Pandit Raghunath Murmu Government Medical College, Baripada, Odisha, India

Date of Submission28-Feb-2021
Date of Decision23-Apr-2021
Date of Acceptance14-May-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Ira Gupta
3A/206, Flat: 1-A, Ram Kutir Appartments, Azad Nagar, Kanpur - 208 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_11_21

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   Abstract 


Peripheral ossifying fibroma (POF) is one of the inflammatory reactive exophytic nodular growth, commonly occurring on the gingiva. It is seen more often in females, in the interdental papilla and anterior part of the maxilla. It represents unique clinical characteristics and diverse histopathological features. Surgical excision is the treatment of choice but with a reported recurrence rate of 7%–45%. In the present case report, a 15-year-old female patient reported with the chief complaint of painless swelling in the mandibular anterior region. An excisional biopsy was obtained and sent for histopathological diagnosis. On histopathological examination, it was confirmed as POF. The purpose of this article is to present a case of POF and review the current literature on this condition, so that, such condition can be treated through proper diagnosis and treatment planning.

Keywords: Excisional biopsy, gingival hyperplasia, peripheral ossifying fibroma


How to cite this article:
Gupta I, Mishra S, Gupta R, Sarkar S. Peripheral ossifying fibroma: A clinical entity in the mandibular incisor region- A case report. J Int Clin Dent Res Organ 2021;13:153-8

How to cite this URL:
Gupta I, Mishra S, Gupta R, Sarkar S. Peripheral ossifying fibroma: A clinical entity in the mandibular incisor region- A case report. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 May 28];13:153-8. Available from: https://www.jicdro.org/text.asp?2021/13/2/153/335867




   Introduction Top


Gingival reactive lesions are very common.[1] Many types of localized reactive lesions are seen on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma (POF). These lesions present with a diverse spectrum of clinical conditions ranging from dysplastic to neoplastic and from focal to multifocal. One such lesion is POF.[2]

POF is a reactive, solitary, painless slow-growing soft-tissue growth that is usually seen on the interdental papilla. It may be pedunculated or broad-based; usually, smooth surfaced and varies from pale pink to cherry red in color. It is believed to comprise about 9% of all gingival growths and to arise from the gingival corium, periosteum, and the periodontal membrane. It has also been reported that it represents a maturation of a preexisting pyogenic granuloma or a peripheral giant cell granuloma.[3]

POF was first reported by the Shepherd in 1844 as alveolar exostosis. Eversol and Robin later in 1972 coined the term POF. The lesion shows female preponderance with the predilection for the maxillary arch. Although POF represents benign clinical behavior, the recurrence rate can reach up to 20%.[3] The purpose of this article is to present a case of POF and to review the current literature on this condition along with the treatment of such lesion through proper diagnosis and treatment planning.

Following [Table 1] shows the details of various cases of POF documented till date.
Table 1: Details of various cases of POF documented

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   Case Report Top


A 15-year-old female visited the Department of Periodontics, Rama Dental College-Hospital and Research Center with a history of a painless swelling that had gradually increased in size during the previous 1 year. Patient was systemically healthy. Past medical and family history was noncontributory.

Intraoral examination revealed a solitary, pedunculated mass involving buccal interdental papilla and attached gingiva in relation to 41 and 42. Mass was pink in color with a smooth surface, measuring approximately 10 mm × 8 mm. It was nontender and firm inconsistency [Figure 1]. No bleeding on probing was present. Patient was seen to be maintaining considerably good oral hygiene; however, subgingival deposits were seen with respect to the incisors.

Routine blood investigations including complete blood count were found to be within the normal limits. The tests for hepatitis A, B, and C were negative. Periapical radiograph showed normal findings with no bone loss. After elimination of the local etiological factors such as plaque, calculus, and regression of gingival inflammation, excisional biopsy of the growth was done under antibiotic coverage and thorough curettage of the adjacent periodontal ligament (PDL), and the periosteum was carried out to prevent recurrence [Figure 2] and [Figure 3]. The excised tissue was sent for histopathologic examination. The microscopic examination showed parakeratinized stratified squamous epithelium with underlying highly cellular connective tissue stroma. The connective tissue stroma showed both fibrous and mineralized components with abundant endothelial lined edematous proliferating blood vessels of varying shapes and sizes with perivascular inflammation, few areas of dystrophic calcifications and abundance of lymphoplasmacytic inflammatory infiltrate. There was the presence of hyperplastic parakeratinized stratified squamous epithelium with high cellular connective tissue stroma. The epithelium was proliferated with long thin rete pegs coalescing with each other. The stroma was densely fibrocellular with the presence of osteoid in the form of trabecular bone showing osteolytic lacunae and osteoblast rimming. The histopathological features were diagnostic of POF [Figure 4] and [Figure 5]. After the excision of the growth, the healing was uneventful with the restoration of normal gingival contour and in 6 month postoperatively also, the recurrence of the growth was not seen [Figure 6].
Figure 1: clinical appearance of the peripheral ossifying fibroma involving labial mucosa permanent mandibular right central and lateral incisor

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Figure 2: after completion of scaling

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Figure 3: excisional biopsy of peripheral ossifying fibroma involving periodontal ligament and periosteum

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Figure 4: histopathological picture (10×)

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Figure 5: histopathological picture (20×)

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Figure 6: six months postoperative clinical picture

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   Discussion Top


POF occurs mostly in craniofacial bones and categorized into two types central and peripheral. The central type arises from the endosteum or PDL adjacent to the root apex and the peripheral type occurs on the soft tissues overlying the alveolar process.[4] Gingiva is one of those anatomical regions in the oral cavity with the broadest array of lesions occurring, ranging from inflammatory to neoplastic. POF is one such reactive lesion.[5]

The etiology and pathogenesis of POF are unknown though many have suggested that these lesions originate in the cells of the PDL for the following reasons: (a) The lesion occurs exclusively in the gingival tissue, close to the PDL; (b) Oxytalan fibers are reported to be found within the mineralized matrix of some lesions; (c) Due to the fibrocellular response originating in the PDL.[4],[6] Hence, local irritants such as dental plaque, calculus, masticatory forces, ill-fitting dentures, poor quality restorations, and trauma have all been implicated in the etiology along with the hormonal influence because of the high occurrence in females.

The lesion shows predilection toward female and commonly occurs in the second and third decades. Mostly, they are found in the maxilla and anterior to the molars, but numerous variations have been reported in literature. Till date, in the literature, 29 cases have been reported solitary growth of POF in the maxillary anterior region, 13 cases showed solitary growth in the mandibular anterior region; whereas 16 cases have been reported solitary growth in the maxillary posterior region and 15 cases in the mandibular posterior region. Sometimes, POF occurs at rare location and manifests as generalized gingival overgrowth. Till date, three cases have been reported with generalized gingival growth and seven cases showed POF at rare location. The size of POF, as reported in the literature, ranges from 0.4 to 9.0 cm in dimension. Another variant of POF is multicentric POF, observed in genetic associated conditions such as nevoid basal-cell carcinoma syndrome, multiple endocrine neoplasia type II, neurofibromatosis, and Gardner syndrome.[5],[7]

Histologically, the key features of this lesion are:

  • Intact or ulcerated stratified squamous surface epithelium
  • Benign fibrous connective tissue with varying numbers of fibroblasts
  • Mineralized matrix consisting of mature, lamellar or woven osteoid, cementum-like material, lamellar, or dystrophic calcifications with inflammatory cells.[8]


POF has to be differentiated from peripheral giant cell granuloma, peripheral odontogenic fibroma, traumatic fibroma, pyogenic granuloma, osteosarcoma, and chondrosarcoma. Peripheral giant cell granuloma has clinical features similarities with POF however; POF lacks the purple or blue discoloration. Peripheral odontogenic fibroma contains odontogenic epithelium and dysplastic dentin; which are absent in POF. POF is differentiated from traumatic fibroma, as traumatic fibroma occurs on buccal mucosa along the bite line. Pyogenic granuloma presents as soft, friable nodule, small in size with a tendency to hemorrhage, and may or may not show calcifications. Osteosarcoma and chondrosarcoma are usually less frequently seen in the gingival compared to POF. Malignant lesions show more pronounced bony changes and asymmetric widening of the PDL.[9]

Treatment includes proper surgical intervention with deep excision of the lesion including periosteum and affected PDL. Thorough scaling and root planing and/or removal of other sources of irritants should be accomplished. Postoperative follow-ups are required because of high rate of recurrence. Mesquita et al. found higher number of argyrophilic nucleolar organizer region and proliferating cell nuclear antigen-positive cells in POF indicating the high proliferative activity of the lesion. Recurrence of POF can be due to incomplete removal of the lesion, failure to eliminate local irritants, and difficulty in accessing the lesion during surgical manipulation (usually an interdental area).[1],[10] However, considering the recurrence rate of such lesions to be around 8%–20%, so patient should be kept on regular follow-up during the course of time.


   Conclusion Top


A variety of reactive lesions occur in the oral cavity with similar clinical findings and nearly resembling histological features. Among them, of unknown etiology, unpredictable clinical course, and pronicity for recurrence, POF is a clinician's cause for concern. It shares varied clinicopathological presentation. Management of POF needs systematic approach along with regular, long-time follow-up to prevent the recurrence of and to improve the quality of life of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yadav V, Kudva PB, Goswami MR. Peripheral ossifying fibroma diagnosis to treatment plan – A case report. Int J Enhanc Res Med Dent Care 2017;4:1-9.  Back to cited text no. 1
    
2.
Bhasin M, Bhasin V, Bhasin A. Peripheral ossifying fibroma. Case Rep Dent 2013;2013:497234.  Back to cited text no. 2
    
3.
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. 3
    
4.
Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.  Back to cited text no. 4
    
5.
Mohiuddin K, Priya NS, Ravindra S, Murthy S. Peripheral ossifying fibroma. J Indian Soc Periodontol 2013;17:507-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 6
    
7.
John RR, Kandasamy S, Achuthan N. Unusually large-sized peripheral ossifying fibroma. Ann Maxillofac Surg 2016;6:300-3.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Choudary SA, Naik AR, Naik MS, Anvitha D. Multicentric variant of peripheral ossifying fibroma. Indian J Dent Res 2014;25:220-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Rajendran R. Benign and malignant tumors of oral cavity. In: Shafer WG, Hine MK, Levy BM, editors. Shafer's Text Book of Oral Pathology. 5th ed. Philadelphia, PA: W.B. Saunders Co; 2006. p. 113-308.  Back to cited text no. 9
    
10.
Reddy GV, Reddy J, Ramlal G, Ambati M. Peripheral ossifying fibroma: Report of two unusual cases. Indian J Stomatol 2011;2:130-3.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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