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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 38-41

Peripheral ossifying fibroma of the anterior maxilla: A case report and brief review


Department of Periodontics, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India

Date of Submission23-Aug-2019
Date of Acceptance30-Oct-2019
Date of Web Publication24-Jan-2020

Correspondence Address:
Aishwarya Madhukar Kale
Flat No. 1, Sancheti Towers, Opposite Milind College of Science, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_27_19

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  Abstract 


Peripheral ossifying fibroma (POF) presents as a tumor-like growth of the soft tissue and is often associated with sharp teeth, rough restoration, and ill-fitting denture. POF is fibro-osseous in origin and is commonly found in the maxillary region. It is a slow-growing benign tumor and usually asymptomatic. However, it may induce facial asymmetry. A 29-year-old male patient who reported to the Department of Periodontology with the chief complaint of slow-growing painless mass over the anterior palatal region underwent surgical excision of the mass using electrocautery. Fifteen days follow-up showed uneventful and satisfactory healing of the excised region.

Keywords: Calcification, gingiva, ossifying fibroma, peripheral ossifying fibroma


How to cite this article:
Kale AM, Sethi KS, Karde PA. Peripheral ossifying fibroma of the anterior maxilla: A case report and brief review. J Oral Res Rev 2020;12:38-41

How to cite this URL:
Kale AM, Sethi KS, Karde PA. Peripheral ossifying fibroma of the anterior maxilla: A case report and brief review. J Oral Res Rev [serial online] 2020 [cited 2020 May 30];12:38-41. Available from: http://www.jorr.org/text.asp?2020/12/1/38/276706




  Introduction Top


Peripheral ossifying fibroma (POF) is one of the inflammatory reactive hyperplasias of the gingiva. Menzel (1872) was among the first to describe ossifying fibroma whereas Montgomery (1927)[1] first specified this term. It is a nonneoplastic entity, which may arise as a result of trauma, microorganisms, plaque, calculus, restorations, or dental appliances.[2],[3] It usually presents as a slow-growing solitary sessile or pedunculated mass on the gingiva or alveolar mucosa with a smooth or ulcerated surface. Adjacent teeth are usually unaffected, but in some cases, migration, mobility, and delayed eruption of permanent teeth may occur.[4] They may be also referred as ossifying fibroma with calcification, peripheral cement-ossifying fibroma, or calcifying fibroma.[5]

POF was first reported by the Shepherd (1844) as alveolar exostosis. Eversol and Rovin later coined the term POF.[6] In 1982, Gardner coined the term “POF” for a lesion that is reactive in nature and is not the extraosseous counterpart of a central ossifying fibroma of the maxilla and mandible.[3] The literature shows a higher incidence rate among infants and young adults, mainly in the age range of 10–19 years, affecting especially females (2–4 times higher than males). It is typically seen involving the interdental papilla and is believed to comprise about 9% of all gingival growths. POF occurs mostly on the gingiva and its origin is thought to be from the periodontal ligament (PDL). The purpose of this article is to present a case of POF and highlight its features.


  Case Report Top


A 29-year-old brown-skinned, male patient reported to our Department of Periodontology with a chief complaint of a slow-growing painless mass over the anterior palatal region for around 3 months. It caused discomfort during mastication and speech. The patient had no history of previous swelling within the rima. Past medical and family history was not relevant. Intraoral examination revealed a well-defined growth in relation to tooth number 11, 21 measuring about 2 cm × 2 cm in diameter extending from the distal aspect of 11 to 21 along the occlusal anterior maxillary palatal surface [Figure 1]. On palpation, the swelling was nontender, sessile, and soft in consistency. The dental indentations of the incisal surfaces of the lower teeth were visible on the tumor. The presence of mass led to teeth displacement and tongue position deviation. Plaque and calculus deposits were noted on the teeth. Intraoral periapical radiographic examination in the regions of 11, 21 revealed the presence of horizontal bone loss [Figure 2]. A shadow of the lesion could also be noticed in the radiograph. The differential diagnosis was peripheral giant-cell granuloma (PGCG) and pyogenic granuloma based on clinical appearance, and therapy approach consisted of excision of the lesion and removal of any irritating factors.
Figure 1: Preoperative (a) Occlusal view, (b) width of the lesion, and (c) length of the lesion

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Figure 2: Preoperative radiograph (red arrows indicate radio-opaque shadow of peripheral ossifying fibroma)

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Under local anesthesia, initially, an excisional biopsy of the lesion was performed using a scalpel. The excised tissue was submitted to the Department of Oral Pathology for histopathological investigations. Histologically, hematoxylin and eosin-stained section showed lesional tissue containing highly cellular stroma with plump fibroblast [Figure 3]. Few areas of the osteoid are seen in the areas of increased cellularity. Bony trabaculae containing osteocytes in lacunae with osteoblastic rimming was seen. Few bony spherules were noted. Dense chronic inflammatory cell infiltrate, chiefly lymphocytes and plasma cells, was seen. Numerous blood vessels were noted. Overlying parakeratinized stratified squamous epithelium was also seen.
Figure 3: Histological (a) ×4, (b) ×10, (c) ×40

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Based on the history, clinical examination, and histological analysis of biopsy, the case was diagnosed with POF. The lesion was totally excised using electrocautery [Figure 4] and [Figure 5]. For this, the incision was given below the pedicle area of the lesion which was on incisive foramen. During the postoperative follow-up, the surgical site showed uneventfully healing [Figures 6].
Figure 4: (a) Excision using electrocautery and (b) immediate postoperative

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Figure 5: Excised tissue (a) length and (b) width

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Figure 6: 15-days' follow-up

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  Discussion Top


Various types of localized reactive lesions might occur on the gingiva such as focal fibrous hyperplasia, pathology tumors, pyogenic granuloma, PGCG, and POF benign tumors. POF is a nonneoplastic enlargement of the gingiva that is classified as a reactive hyperplastic inflammatory lesion, a common gingival growth, which is typically seen on the interdental papilla.

Histologically, there are two school of thoughts:First, POF may initially develop as a pyogenic granuloma that undergoes subsequent fibrous maturation and calcification. It represents the progressive stage of the same spectrum of pathosis.[7] Second, POF is due to inflammatory hyperplasia of cells of PDL/periosteum. Metaplasia of the connective tissue leads to dystrophic calcification and bone formation.[8] Eversole and Rovin[2] explicit that with the similar sex and site predilection of pyogenic granuloma, PGCG and POF, as well as similar clinical and histologic features, these lesions may simply be varied histologic responses to irritation. Gardner[3] 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. Buchner and Hansen[9] hypothesized that early POF presents as ulcerated nodules with little calcification, allowing easy misdiagnosis as a pyogenic granuloma. When bone- and cementum-like tissues are observed, the lesions have been referred to as cement-ossifying fibroma. Cementifying fibromas may be clinically and radiographically impossible to separate from ossifying fibromas.[10]

Although the etiopathogenesis of POF is uncertain, an origin from the cells of PDL has been suggested. The reasons for considering PDL origin for POF include the exclusive occurrence of POF in the gingival (PDL), the proximity of the gingiva to the PDL, and the presence of oxytalan fibers within the mineralized matrix of some lesions. Excessive proliferation of mature fibrous connective tissue is a response to gingival injury, gingival irritation, subgingival sulcus, or a foreign body in the gingival sulcus. Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue with resultant initiation of bone formation and dystrophic calcification.

A rare manifestation of multicentric lesion in recent times points toward a possible role of genetics in the etiopathogenesis of this disease.[11] Multicentric lesions present in the oral cavity are not typical but have been observed in the conditions such as the nevoid basal cell carcinoma syndrome (multiple odontogenic keratocysts), multiple endocrine neoplasia type II (multiple neuromas), neurofibromatosis (multiple neurofibromas), and Gardner's syndrome (multiple neoplasms), all of these conditions have been associated with inherited genetic mutations so the potential exists that POF can also be due to genetic mutations that predisposes to gingival soft-tissue overgrowths that contain mineralized product or ossification.[12]

POF tends to occur in the first and second decades of life, with peak prevalence between the ages of 10 and 19 years. The female-to-male ratio varies from 1.22:1 to 1.7:1–4.3:1[13] 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.[14]

Radiographically, POF may not show significant changes in certain cases. However, some cases show varying radiodensity within the lesion, depending on the degree of mineralization. Superficial bone loss, cupping defect, and focal areas calcification have been rarely reported.

Clinical differential diagnosis for gingival growths includes fibroma, PGCG, pyogenic granuloma, peripheral odontogenic fibroma, and POF. The definitive diagnosis of POF is made by the histologic evaluation of biopsy specimens. Histologically, the key feature of this lesion is exceedingly cellular mass of connective tissue comprising large number of plump, proliferating fibroblasts intermingled throughout with delicate fibrillar stroma.

Treatment of these lesions is a complete surgical excision, as was performed in the present case.


  Conclusion Top


Many cases will progress for a long period before patients seek treatment due to its asymptomatic nature as in our case. Due to their clinical and histopathological similarities, it is thought that some POFs develop as a pyogenic granuloma, which undergoes fibrous maturation and then ossification. Clinicopathological characteristics may vary. These lesions are often mistaken and removed by superficial incision. It is important to remove lesion completely in order to reduce recurrences by including subjacent periosteum and PDL besides their possible causes.

The recurrence rate (8%–20%) of 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.[14],[15]

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name 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.
Eversole LR, Sabes WR, Rovin S. Fibrous dysplasia: A nosologic problem in the diagnosis of fibro-osseous lesions of the jaws. J Oral Pathol 1972;1:189-220.  Back to cited text no. 1
    
2.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 2
    
3.
Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-8.  Back to cited text no. 3
    
4.
Kumar RS, Sateesh CP, Shreedhar A. Peripheral ossifying fibroma: A rarity in elderly males. J Dent Sci Res 2017;2:1-5.  Back to cited text no. 4
    
5.
Baumgartner JC, Stanley HR, Salomone JL. Zebra hunt. Peripheral ossifying fibroma. J Endod 1991;17:182-5.  Back to cited text no. 5
    
6.
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. 6
    
7.
Prasad S, Reddy SB, Patil SR, Kalburgi NB, Puranik RS. Peripheral ossifying fibroma and pyogenic granuloma. Are they interrelated? N Y State Dent J 2008;74:50-2.  Back to cited text no. 7
    
8.
Satish BN, Kumar P. Peripheral ossifying fibroma of hard palate: A case report. Int J Dent Clin 2010;2:30-4.  Back to cited text no. 8
    
9.
Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1987;63:452-61.  Back to cited text no. 9
    
10.
Martín-Granizo R, Sanchez-Cuellar A, Falahat F. Cemento-ossifying fibroma of the upper gingivae. Otolaryngol Head Neck Surg 2000;122:775.  Back to cited text no. 10
    
11.
Arunachalam M, Saravanan T, Shakila KR, Anisa N. Peripheral ossifying fibroma: A case report and brief review. SRM J Res Dent Sci 2017;8:41.  Back to cited text no. 11
  [Full text]  
12.
Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43.  Back to cited text no. 12
    
13.
John R, Prabhu NT, Munshi AK. Peripheral ossifying fibroma report of a case. J Indian Soc Pedod Prev Dent 1996;14:107-8.  Back to cited text no. 13
    
14.
Kenney JN, Kaugars GE, Abbey LM. Comparison between the peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-82.  Back to cited text no. 14
    
15.
Sah K, Kale AD, Hallikerimath S, Chandra S. Peripheral cementoossifying fibroma: Report of a recurrence case. Contemp Clin Dent 2012;3 Suppl 1:S23-5.  Back to cited text no. 15
    


    Figures

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



 

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