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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 47-50

Peripheral ossifying fibroma: An unusual presentation


1 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Ahmedabad, Gujarat, India
2 Department of Oral Medicine and Radiology, I.T.S Dental College, Muradnagar, Ghaziabad, Uttar Pradesh, India

Date of Web Publication9-May-2018

Correspondence Address:
Dr. Sheetal Sharma
G-7, Leela Homes, Vaishali, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_39_17

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  Abstract 


Peripheral ossifying fibroma (POF) is a focal, reactive, non-neoplastic tumor-like growth of the soft tissue occurring frequently in the maxillary anterior region, mainly affects females, predominating in the second decade of life. POF typically presented as a solitary, slow growing nodular mass that is either pedunculated or sessile. POF is commonly associated with poor oral hygiene, trauma, microorganisms etc and majority of cases showing no marked underlying bone involvement radiographically. The definitive diagnosis is based on histology, with identification of cellular connective tissue and focal presence of osseous component or other calcifications. Surgery is the treatment of choice, though it has a recurrence rate of 8-20%. We report an unusual case of a large POF in the posterior mandible region of a male child patient with histopathological correlations and also highlights the differential diagnosis and management.

Keywords: Calcification, central ossifying fibroma, peripheral ossifying fibroma


How to cite this article:
Shah JS, Sharma S. Peripheral ossifying fibroma: An unusual presentation. Int J Oral Health Sci 2018;8:47-50

How to cite this URL:
Shah JS, Sharma S. Peripheral ossifying fibroma: An unusual presentation. Int J Oral Health Sci [serial online] 2018 [cited 2018 May 26];8:47-50. Available from: http://www.ijohsjournal.org/text.asp?2018/8/1/47/232170




  Introduction Top


Peripheral ossifying fibroma (POF) is a focal, reactive, nonneoplastic tumor-like lesion of soft tissue that often arises from the cells of the periodontal ligament, but the etiopathogenesis is obscure.[1],[2],[3] POF is one of the infrequently occurring gingival lesions and represents up to 2% of all oral lesions [1],[2],[3],[4] and 9% of all gingival lesions.[5] It mainly affects females, predominating in the second decade with the anterior maxilla being the most common location of involvement.[1],[2],[3],[4],[5],[6],[7],[8],[9] POF typically presented as a slow-growing solitary, nodular mass that is either pedunculated or sessile. The overlying surface is usually smooth but sometimes ulcerated, and color varies from pink to red. The definitive diagnosis is based on histology, with the presence of cellular connective tissue and focal presence of osseous component or other calcifications. Surgery is the treatment of choice though it has a recurrence rate of 8%–20%.[1],[4],[6],[7]


  Case Report Top


A 14-year-old boy reported with the chief complaint of painless growth on the right lingual mandibular posterior region. The patient noticed the growth 15–20 months before. The growth had progressed gradually and attained the present size. Growth was not associated with any symptoms such as difficulty in swallowing, talking, or pain. The patient did not have any history of trauma. Medical and dental history was noncontributory [Figure 1].
Figure 1: Profile picture

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Intraoral examination revealed a solitary, oval-shaped, sessile, pale pink exophytic growth of size 3 cm × 3 cm present in respect to 44, 45, and 46 regions extending anteroposterior from lingual aspect of 44 to middle of 46 and superoinferiorly from occlusal surface to 3 cm inferiorly. Buccally rotated 44 and carious 46 was present. Growth was bony hard in consistency, noncompressible, nontender, nonfluctuant, and nonreducible with lobulated surface on palpation [Figure 2]. Clinical diagnosis of unilateral mandibular tori was made. The clinical differential diagnoses were POF, traumatic fibroma, and peripheral osteoma.
Figure 2: Well-defined growth on the right lingual mandibular posterior region

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Intraoral periapical radiograph, occlusal and Opg shows a well defined radiopacity superimposed over the middle portion of roots of 44, 45, and 46 having well-defined borders with no effect on the surroundings structures. Computed tomography (CT) scan also showed 2 cm × 3 cm-sized well-defined bony outgrowth with bone matrix with no associated soft-tissue component noted. Based on radiographs, as lesion was homogeneously radiopaque with dense margins, outgrowing from the lingual cortical plate without causing expansion of it, diagnosis of mandibular tori was made [Figure 3]. Further to rule out, biopsy was done which showed proliferating parakeratinized stratified squamous epithelium with underlying dense collagenized fibrous connective tissue composed of spindle-shaped fibroblast. Deeper area shows trabecular bone with entrapped osteocytes and peripheral osteoblastic rimming interspersed with mature fibrous connective tissue and few blood vessels along with chronic inflammatory cell infiltration. Hence, the final diagnosis of POF was considered based on histological findings [Figure 4], [Figure 5], [Figure 6]. The patient was operated under general anesthesia, and on 6-month follow-up, the patient was asymptomatic [Figure 7].
Figure 3: Coronal section of computed tomography scan showing homogeneous hyperdense lesion on lingual aspect

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Figure 4: Bony trabeculae and benign fibroblastic proliferations in fibrous connective tissue (H and E, ×10)

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Figure 5: Parakeratinized stratified squamous epithelium with bony trabeculae, benign fibroblastic proliferations, and collagenization (H and E, ×4)

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Figure 6: Peripheral osteoblastic rimming (H and E, ×40)

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Figure 7: Postoperative picture

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  Discussion Top


Intraoral ossifying fibroma has been described in the literature since the late 1940s.[7] In 1982, Gardner coined the term POF for a lesion that is reactive in nature.[1] There are two types of ossifying fibroma – 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 the medullary cavity. The peripheral type occurs solely on the soft tissues covering the tooth-bearing areas of the jaws.[1],[3] Cemento-ossifying fibroma was found to exhibit increased proliferative activity compared to POF.[9] Eversole and Roving stated that, with the similar sex and site predilection of pyogenic granuloma, peripheral giant-cell granuloma, and POF as well as similar clinical and histological features, these lesions may simply be varied histological responses to irritation.[3],[9]

Although the etiopathogenesis of POF is dubious, some consider it a neoplastic process, whereas other as a reactive process. However, the lesion is thought to arise from the cells of the periodontal ligament due to trauma or local irritants such as by dental plaque, microorganisms, masticatory forces, and ill-fitting and poor quality dentures.[1],[2],[3],[4],[5],[6],[7],[8],[9]

Females were affected more than males (5:1). The lesions occur in the second decade, with declining incidence in later years. Lesions occur slightly more common in the maxilla (60%) and in the incisor-cuspid region (50%).[1],[2],[3],[4],[5],[6],[7],[8],[9] Our reported case was in contradiction to literature as affected patient was a male of 14 years with growth on the right mandibular posterior lingual region.

Clinically, POF appears as a solitary nodular mass that is either pedunculated or sessile. The surface mucosal color ranges from red to pink. Although they are generally <2 cm in diameter, size can vary depending on duration. Tooth migration and bone destruction also reported but not common.[1],[3],[4],[5],[6],[7],[8],[9] Similar presentation was seen in our case as a solitary, oval-shaped, sessile, exophytic growth of size 3 × 3 cm with pale pink mucosa with no superficial ulcerations but of significantly larger size than the average lesion. Growth was bony hard in consistency and not associated with bleeding tendency. The clinical differential diagnosis includes bony exostosis, traumatic fibroma, and peripheral osteoma.

POF should be differentiated from these lesions which share similar clinical features. POF has predilection for the anterior maxilla [1],[2],[3],[4],[5],[6],[7],[8],[9] in females of 2–3 decades, unilateral presentation, asymptomatic, solitary nodular mass that is either pedunculated or sessile, and the color of overlying mucosa ranges from red to pink [1],[2],[3],[4],[5] while bony exostosis most commonly present on lingual aspect of mandible with normal overlying mucosa, traumatic fibroma can be seen anywhere in the oral cavity, but most common site is buccal mucosa along the occlusal line having sessile base and peripheral osteoma present on the lower border of mandible having bony hard consistency with normal mucosa. Thus, unusual presentation was seen in reported case, i.e., lesion was present in male of 14 years with growth on the right mandibular posterior lingual region which is contradictory to literature.

Radiographically, the lesion represents varying stages of ossification; however, ossification or calcification is not elucidated in all cases, particularly in the earlier stages of the lesion. Occasionally foci of radiopaque material may be seen, particularly in larger lesions or mild cupping defect of adjacent alveolar bone.[1],[5],[6],[8] The present case demonstrated complete calcification within the lesion with no soft-tissue component as seen in CT scan.

POF is confirmed by histopathological examination. It is nonencapsulated mass of cellular connective tissue of mesenchymal origin characterized by fibrous connective tissue with varying fibroblast, myofibroblast, and collagen content, sparse to profuse endothelial proliferation. Mineralization can vary between cementum-like material, bone (woven and lamellar), and dystrophic calcification.[1],[4],[6],[9] Similar presentation was seen in our reported case.

The treatment of choice for POF is the elimination of local irritating factors such as plaque and calculus along with local resection including both the periodontal ligament and the affected periosteal component.[2],[4],[8],[9] The rate of recurrence varies from 8.9% to 20%, due to its reactive nature. It probably occurs due to incomplete removal, repeated injury, or persistence of local irritants. The prognosis is good.[1],[5],[8],[9]


  Conclusion Top


POF is a nonneoplastic, slowly progressing lesion of the gingiva with randomly distributed calcifications, immature bone, and osteoid. As POF share similar clinical presentation to mandibular tori, makes it difficult to diagnose and differentiate. Thus, the histopathological investigation is essential for definitive diagnosis and treatment planning of such lesion. POF is reactive in nature, so complete surgical excision down to the periosteum is the preferred treatment as the recurrence rate is as high; while tori are development condition, it does not require aggressive management and chances of recurrence are negligible. Hence, POF should be considered in differential diagnosis of tori and confirmed only by histopathological examination.

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 Top

1.
Pal S, Hegde S, Ajila V. The varying clinical presentations of peripheral ossifying fibroma: A report of three cases. Rev Odonto Ciência 2012;27:251-5.  Back to cited text no. 1
    
2.
Joshi S, Mazumdar S, Pandit MK. Peripheral ossifying fibroma on edentulous mandibular alveolar mucosa. J Maxillofac Oral Surg 2015;14:84-6.  Back to cited text no. 2
    
3.
Bhushan B, Bhushan A, Moirangthem E, Sharma N, Bhargava N, Sethi T, et al. Peripheral ossifying fibroma in mandible: A rare case report. J Pharm Biomed Sci 2015;5:475-9.  Back to cited text no. 3
    
4.
Chhina S, Rathore AS, Ahuja P. Peripheral ossifying fibroma of gingiva: A case report. Int J Case Rep Images 2012;2:21-4.  Back to cited text no. 4
    
5.
Bhasin M, Bhasin V, Bhasin A. Peripheral ossifying fibroma. Case Rep Dent 2013;2013:497234.  Back to cited text no. 5
    
6.
Sunitha K, Geetha P, Reddy KV, Maloth KN, Shetty N, Nayyar AS. Peripheral ossifying fibroma of posterior mandible: A rare case report. Int J Clin Case Rep 2015;5:1-5.  Back to cited text no. 6
    
7.
Farquhar T, MacLellan J, Dyment H, Anderson RD. Peripheral ossifying fibroma: A case report. J Can Dent Assoc 2008;74:809-12.  Back to cited text no. 7
    
8.
Yadav R, Gulati A. Peripheral ossifying fibroma: A case report. J Oral Sci 2009;51:151-4.  Back to cited text no. 8
    
9.
Kale L, Khambete N, Sodhi S, Sonawane S. Peripheral ossifying fibroma: Series of five cases. J Indian Soc Periodontol 2014;18:527-30.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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