|Year : 2013 | Volume
| Issue : 6 | Page : 819-822
Peripheral ossifying fibroma: A case report
Varshal J Barot, Sarath Chandran, Shivlal L Vishnoi
Departments of Periodontics and Implantology, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat, India
|Date of Submission||08-Mar-2013|
|Date of Acceptance||01-Jul-2013|
|Date of Web Publication||7-Jan-2014|
Varshal J Barot
E 2/5, Professors Quarter's, New Civil Hospital Campus, Majura Gate, Surat 395 001, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Localized gingival growths are one of the most frequently encountered lesions in the oral cavity, which are considered to be reactive rather than neoplastic. Different lesions with similar clinical presentation make it difficult to arrive at a correct diagnosis. These lesions include pyogenic granuloma, irritation fibroma, peripheral giant cell granuloma, peripheral ossifying fibroma (POF). Among these lesions, an infrequently occurring gingival lesion is the POF. Considerable confusion has prevailed in the nomenclature of POF due to its variable histopathologic features. This is a case presentation of a 30-year-old female with gingival overgrowth in the mandibular left canine-premolar region. Clinically, the lesion was asymptomatic, firm, pale pinkish and sessile. Surgical excision of the lesion was done followed by histopathologic confirmation with emphasis on the clinical aspect. Given the rate of recurrence for POF being 8-20%, close post-operative follow-up is required.
Keywords: Cemento-ossifying fibroma, cementum-like calcification, gingival overgrowth, ossifying fibroma
|How to cite this article:|
Barot VJ, Chandran S, Vishnoi SL. Peripheral ossifying fibroma: A case report. J Indian Soc Periodontol 2013;17:819-22
| Introduction|| |
Localized gingival growths are one of the most frequently encountered lesions in the oral cavity and Peripheral ossifying fibroma (POF) is one of them. It accounts for 3.1% of all oral tumors and for 9.6% of gingival lesions. , POF is a focal, reactive, non-neoplastic tumor like growth of the soft tissue that often arises from the interdental papilla.  Though the etiopathogenesis is uncertain, an origin from cells of the periodontal ligament has been suggested.  It tends to occur in the 2 nd and 3 rd decades of life, with the peak prevalence between the ages of 10 and 19 years.
| Case Report|| |
A 30-year-old female patient reported with the complain of discomfort during chewing and speaking due to a growth in the left lower posterior region of the jaw, which started as a small papule approximately 8 months ago and gradually increased in size with time to attain present size. There was no associated history of bleeding or pain. Her medical history was non-significant and no h/o any medication at that time. She had a habit of chewing smokeless tobacco, since many years.
Intraoral examination revealed an approximately 2 cm × 2 cm sessile, non-tender, firm, pale pinkish growth present on the interdental gingiva in relation to the mandibular left canine-premolar region [Figure 1] and [Figure 2]. The lesion was extending from mesial of left lateral incisor to the mesial of left first premolar and up to the level of the occlusal surface, causing occlusal interference. Pathologic migration of mandibular left canine was present as mesial and buccal migration. Radiographically, there was angular bone loss in relation to mandibular left canine and premolar with displacement of mandibular left canine [Figure 3].
|Figure 1: Clinical presentation of the lesion with pathologic migration of 33, left side view|
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|Figure 3: Intraoral periapical radiograph of 33, 34 showing angular bone loss|
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The differential diagnosis included irritation fibroma, pyogenic granuloma and POF. Based on the clinical and radiographic findings, the provisional diagnosis of irritation fibroma was made.
The periodontal treatment plan included patient education and motivation for oral hygiene instructions and quitting the habit, scaling and root planing, reevaluation and surgical excision of the lesion under local anesthesia. Scaling and root planing was performed for elimination of local etiological factors. After 1 week of scaling and root planing, a reevaluation and surgical excision down to the periosteum were performed [Figure 4] and periodontal dressing was placed [Figure 5]. Patient was given post-operative instructions and was prescribed with analgesic (tablet ibuprofen-400 mg tds every 4-6 h as needed for pain) and antimicrobial rinse (0.2% chlorhexidine gluconate twice-a-day for 1 week). She was recalled, after 1 week for follow-up. The excised tissue [Figure 6] was placed in 10% neutral buffered formalin and sent for the histopathologic examination.
Biopsy specimen microscopically consisted of hyperplastic parakeratinized stratified squamous epithelium with thin, long and anastomosing rete ridges and fibrous connective tissue containing several irregularly shaped trabeculae of bone, droplets of basophilic cementum-like material and numerous plump fibroblasts [Figure 7]. Histopathologic diagnosis was POF.
|Figure 7: Histopathological slide (40×) showing basophilic cementum-like material and numerous plump fibroblasts|
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At 1 week post-operative visit, patient presented for periodontal dressing removal and follow-up examination. Recovery was uneventful with a satisfactory healing [Figure 8]. Patient is on regular follow-up at 6 months post-operative without any recurrence [Figure 9].
|Figure 8: Post-operative 1 week showing uneventful recovery, left side view|
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|Figure 9: Post-operative 6 months with no recurrence of the lesion and repositioning of 33, left side view|
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| Discussion|| |
The reasons for considering periodontal ligament origin for POF include exclusive occurrence of POF in the gingiva (interdental papilla), the proximity of gingiva to the periodontal ligament 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 calculus or a foreign body in the gingival sulcus. Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue and resultant initiation of formation of bone or dystrophic calcification.
Almost two-third of all cases occur in females,  with a predilection for the anterior maxilla. , Hormonal influences may play a role, given the higher incidence of POF among females, increasing occurrence in the 2 nd decade and declining incidence after the 3 rd decade.  The size of the POF ranges from 0.4 to 4.0 cm  and whites (71%) are more frequently affected than blacks (36%). 
Histologically, when bone and cementum-like tissues are observed, the lesions have been referred to as cemento ossifying fibroma.  The term "cemento ossifying" has been referred to as outdated and scientifically inaccurate.  Moreover, on H and E staining it is difficult to the distinguish histologically between cementum and bone. Mineralized products in the form of trabeculae of woven and/or lamellar bone, cementum like material and dystrophic calcification are noticed.
Radiographic features of POF may 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. 
A confirmatory diagnosis of POF is made by histopathologic evaluation of biopsy specimens. The following features are usually observed during the microscopic examination: (1) Intact or ulcerated stratified squamous surface epithelium; (2) benign fibrous connective tissue with varying numbers of fibroblasts; (3) sparse to profuse endothelial proliferation; (4) mineralized material consisting of mature, lamellar or woven osteoid, cementum-like material or dystrophic calcifications; and (5) acute or chronic inflammatory cells in lesions. , Moreover, histopathologically, lamellar or woven osteoid pattern predominates; hence, the term "POF" is considered more appropriate.
Different treatment modalities include surgical excision by scalpel, laser or radial/electrosurgery.  The carbon dioxide laser can effectively excise the lesion and has been shown to allow diagnostic microscopic evaluation with a minimal distortion of the biopsy sample.  The advantages of laser excision are minimal post-surgical pain and no need for suturing the biopsy site. This precise tissue destruction can also result in partial or incomplete removal of the base of the pathologic lesion, which can lead to recurrence.  Thus, surgical excision including the involved periodontal ligament and periosteum is the preferred treatment,  which was performed in this case.
| Conclusion|| |
POF is a benign, slowly progressive lesion, with limited growth. Clinically difficult to diagnose, so histopathologic confirmation is mandatory. Complete surgical excision down to the periosteum is the preferred treatment and as the recurrence rate is high (8-20%),  close post-operative follow-up is required. 
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