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| CASE REPORT |
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| Year : 2013 | Volume
: 3
| Issue : 2 | Page : 101-104 |
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Peripheral ossifying fibroma
Adhiraj Roy, S Shivaprasad, L Ashok
Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
| Date of Web Publication | 4-Jul-2014 |
Correspondence Address:
Adhiraj Roy
Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2231-6027.135986
Many types of localized reactive lesions may occur on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma and peripheral ossifying fibroma (POF). POF is a gingival growth, usually arising from interdental papilla. Other terms used to describe this lesion include peripheral cementifying fibroma, peripheral fibroma with cementogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis and calcified fibroblastic granuloma. POF usually occurs at a mean age of 30 years and as the age advances incidence reduces. Here in this article, we present a case report of POF occurring in a 55-year-old female patient. Keywords: Calcifying fibroblastic granuloma, epulis, gingiva, peripheral cementifying fibroma, peripheral fibroma with calcification, peripheral fibroma with cementogenesis and peripheral cemento-ossifying fibroma, peripheral ossifying fibroma
How to cite this article:
Roy A, Shivaprasad S, Ashok L. Peripheral ossifying fibroma. Int J Oral Health Sci 2013;3:101-4 |
| Introduction | |  |
Peripheral ossifying fibroma (POF) is a lesion that occurs exclusively on the gingiva, and with a female predilection it is more common in children and young adults. More than 50% of cases occur in the region of the incisors and canine teeth. It presents as a well-defined, firm mass, sessile or pedunculated, the size varies from 0.5 cm to 2 cm in diameter. Usually covered by smooth normal epithelium. The surface is frequently ulcerated due to mechanical trauma. It can be easily confirmed by histopathological examination and treated by surgical excision. POF usually occurs at a mean age of 30 years and as the age advances incidence reduces. Here in this article we present a case report of POF occurring in a 55 year old female patient.
| Case report | | |
A 55 year old female patient comes with a chief complain of painless swelling [Figure 1] and [Figure 2] on her upper gums since 6 months. The swelling was present since 6 months which was of gradual onset. Swelling initially started small in size in the upper front gums which gradually progressed to the present size. Swelling was painless since its origin and was associated with bleeding while brushing or eating. Patient also reported that swelling felt the same since its start. Intra oral examination revealed a solitary sessile growth present on the upper labial gingiva in relation to 21, 22 extending up to the attached gingiva measuring 3 cm × 3 cm, roughly oval in shape. Surface is red shiny with paleness on the anterior surface with irregular borders. Borders of the swelling were well defined. On palpation inspectory findings confirmed. Swelling [Figure 2] was soft to firm in consistency non tender, fixed to the gingiva [Figure 3]. Mobility of the tooth in adjacent to the swelling was present. No bleeding on provocation. There was a full complement of upper and lower teeth with mobility in relation to 11, 21, 31, 32, 41, 42 and discoloration of 21. Gingiva was soft and edematous with generalized attrition present. Considering all the relevant clinical findings we gave a working diagnosis of benign soft tissue tumor on the gingiva was given. Benign soft tissue tumor encompass a diverse range of lesions, so a probable clinical differential diagnosis for the same was given. They were pyogenic granuloma, peripheral ossifying fibroma or peripheral giant cell granuloma.
An intraoral periapical radiograph was taken in relation to 21 which revealed loss of lamina dura on the distal aspect with thickened periodontal membrane space. Anterior maxillary topographic occlusal radiograph revealed a soft tissue swelling present anteriorly with flecks of calcification present centrally in the uniform radio dense soft tissue shadow. Thus narrowing down the differential diagnosis to peripheral ossifying fibroma. The lesion was subjected for excisional biopsy [Figure 4] and the patient was kept under follow up.
| Histopathology | | |
Soft tissue specimen [Figure 4] revealed the presence of hyperplastic parakeratinzation with focal connective tissue entrapment underlying connective tissue shows presence of dense bundles of collagen fibres. There are engorged areas of blood vessels with evidence of ossification in the deeper parts of the connective tissue [Figure 5].
The histopathological features there by confirms the diagnosis of peripheral ossifying fibroma.
| Discussion | | |
Since the late 1940s intra oral ossifying fibromas have been studied and encountered in the literature. Many names have been given to similar lesions, such as epulis, peripheral fibroma with calcification, peripheral ossifying fibroma, calcifying fibroblastic granuloma, peripheral cementifying fibroma, peripheral fibroma with cementogenesis and peripheral cemento-ossifying fibroma. [1]
Gracia de Marcos et al. (2010) [2] stated that the etiology and pathogenesis of POF was not clear. Kumar et al. {2006}; [3] suggested that these lesions originated in the cells of the periodontal ligament as it exclusively appears in the gingival tissue close to the periodontal ligament. Wright and Jennings, {1979} [4] stated that oxytalan fibres were found within the mineralized matrix of some lesions. Kumar et al., {2006} [3] stated that the fibrocellular response of POF is similar to that of other reactive gingival lesions originating in the periodontal ligament.
Cuisia and Brannon {2001}; [4] Gracia de Marcos et al. {2010}; [2] Moon et al. {2007} [5] stated that other factors that have been implicated in the etiopathogenesis of POF were trauma and local irritants such as plaque, calculus, ill-fitting dental appliances and microorganisms.
Peripheral ossifying manifest as a pedunculated or sessile nodule. The color of these lesions can be red to pink with areas of ulceration, and their surface may be smooth or irregular. Although they are generally <2 cm in diameter, [6] size can vary with reports ranging from 0.2-3.0 cm to 8 cm and some lesions may be as large as 9 cm in diameter. [6] Cases of tooth migration and bone destruction have been reported, but these are not common findings. [7]
The female to male ratio reported in the literature varies from 22:1 and 1.7:1 to 4.3:1. [8]
The majority of the lesions occur by the second decade of life, with a declining incidence in later years. [2],[6],[8],[9],[10],[11] and there are 2 reported cases of peripheral ossifying fibroma present at birth, presenting clinically as congenital epulis. [6]
Cuisia and Brannon {2001} [4] reported that only 134 out of 657 diagnosed POFs (20%) were in the pediatric population (0-19 years), with 8% in the first decade. Zhang {2007} [11] conducted a retrospective study of 431 cases in the Chinese population by and deduced the mean age of incidence of POF to be 44 years.
POFs are believed to arise from gingival fibres of the periodontal ligament as hyperplastic growth of tissue that is unique to the gingival mucosa. [8],[9],[10],[12],[13] This hypothesis is based on the fact that POFs arise exclusively on the gingiva, the subsequent proximity of the gingiva to the periodontal ligament and the inverse correlation between age distribution of patients presenting with POF and the number of missing teeth with associated periodontal ligament.
Hormonal influences may play a role, given the higher incidence of POF among females, increasing occurrence in the second decade and declining incidence after the third decade. [11] Kumar et al.[3] noted in an isolated case of multicentric POF, the presence of a lesion at an edentulous site in a 49-year-old woman, which once again raises questions regarding the pathogenesis of this type of lesion.
Gardner [8] stated that POF cellular connective tissue is so characteristic that a histologic diagnosis can be made with confidence, regardless of the presence or absence of calcification.
Histologically, the POF appears to be a non-encapsulated mass of cellular fibroblastic connective tissue3 of mesenchymal origin, covered with stratified squamous epithelium, which is ulcerated in 23%-66% of cases. [6],[9] 3 Most ulcerated lesions occur in patients in the second decade. [6],[8] POFs contain areas of fibrous connective tissue, endothelial proliferation and mineralization. Endothelial proliferation can be profuse in the areas of ulceration, which can be misleading in clinical diagnosis, as the lesion may appear to be a pyogenic granuloma. [9],[13] Mineralization can vary between cementum-like material, bone (woven and lamellar) and dystrophic calcification. [6],[9],[14]
Gracia et al. {2010} [11] conducted an immuno histochemical study to determine the nature of the proliferating fusiform cells. All the lesions presented a cellular component in the form of fusiform cells, without significant atypias. This proliferation was accompanied by an inflammatory component of lymphocytes, plasma cells, CD68 positive histiocytes, and multinucleated giant cells. The study showed the cells to be of a myofibroblastic nature (vimentin + , actin HHF35 + ). The proliferating component did not express estrogen or progesterone receptors. [2]
The POF lesion is generally small and does not require imaging beyond radiographs. [12]
| Conclusion | | |
POF is a slowly progressing lesion, the growth of which is generally limited. Many cases will progress for long periods before patients seek treatment because of the lack of symptoms associated with the lesion. A slowly growing pink soft tissue nodule in the anterior maxilla of an adolescent should raise suspicion of a POF. Discussion of the differential diagnosis should be done tactfully to prevent unnecessary distress to the patient and family. Zhang and others 16 noted that cancer was included in the differential diagnosis in only 2% of cases. Treatment consists of surgical excision, including the periosteum, and scaling of adjacent teeth. Close postoperative follow-up is required because of the growth potential of incompletely removed lesions and the 8%-20% recurrence rate.
| References | | |
| 1. | Feller L, Buskin A, Raubenheimer EJ. Cemento-ossifying fibroma: Case report and review of the literature. J Int Acad Periodontol 2004;6:131-5. 
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| 2. | 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.
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| 3. | Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43.
|
| 4. | Pushparaja S, Soniya A. Peripheral ossifying fibroma: A clinical and histological evaluation of 51 cases. PJSR 2012;5:9-14.
|
| 5. | Moon WJ, Choi SY, Chung EC, Kwon KH, Chae SW. Peripheral ossifying fibroma in the oral cavity: CT and MR findings. Dentomaxillofac Radiol 2007;36:180-2.
|
| 6. | Farquhar T, MacLellan J, Dyment H, Anderson RD. Peripheral ossifying fibroma: A case report. J Can Dent Assoc 2008;74:809-12.
|
| 7. | Poon CK, Kwan PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: Report of a case. J Oral Maxillofac Surg 1995;53:695-8.
|
| 8. | Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.
|
| 9. | Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: Report of 376 cases. J Am Dent Assoc 1966;73:1312-20.
|
| 10. | Lee KW. The fibrous epulis and related lesions. Granuloma pyogenicum, ′Pregnancy tumour′, fibro-epithelial polyp and calcifying fibroblastic granuloma: A clinico-pathological study. Periodontics 1968;6:277-92.
|
| 11. | Zhang W, Chen Y, An Z, Geng N, Bao D. Reactive gingival lesions: A retrospective study of 2,439 cases. Quintessence Int 2007;38:103-10.
|
| 12. | Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-8.
|
| 13. | Cuisia ZE, Brannon RB. Peripheral ossifying fibroma: A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8.
|
| 14. | Zain RB, Fei YJ. Fibrous lesions of the gingiva: A histopathologic analysis of 204 cases. Oral Surg Oral Med Oral Pathol 1990;70:466-70.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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