Journal of Indian Society of Periodontology

CASE REPORT
Year
: 2014  |  Volume : 18  |  Issue : 4  |  Page : 527--530

Peripheral ossifying fibroma: Series of five cases


Lata Kale1, Neha Khambete1, Sonia Sodhi1, Sushma Sonawane2,  
1 Department of Oral Medicine, Diagnosis and Radiology, C.S.M.S.S. Dental College and Hospital, Kanchanwadi, Aurangabad, Maharashtra, India
2 Department of Orthodontics, D.Y. Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India

Correspondence Address:
Neha Khambete
Department of Oral Medicine, Diagnosis and Radiology, C.S.M.S.S. Dental College and Hospital, Kanchanwadi, Aurangabad 431 001, Maharashtra
India

Abstract

Peripheral ossifying fibroma (POF) is a reactive lesion of the gingival tissues that predominantly affects women and is usually located in the maxilla anterior to the molars. It originates from the cells of the periodontal ligament. The definitive diagnosis is established by histological examination, which reveals the presence of cellular connective tissue with focal calcifications. Surgical excision is the treatment of choice, though the recurrence has been reported. We present a clinical, radiological and histological review of five cases of POF diagnosed and treated at our institute.



How to cite this article:
Kale L, Khambete N, Sodhi S, Sonawane S. Peripheral ossifying fibroma: Series of five cases.J Indian Soc Periodontol 2014;18:527-530


How to cite this URL:
Kale L, Khambete N, Sodhi S, Sonawane S. Peripheral ossifying fibroma: Series of five cases. J Indian Soc Periodontol [serial online] 2014 [cited 2021 Jun 23 ];18:527-530
Available from: https://www.jisponline.com/text.asp?2014/18/4/527/138762


Full Text

 INTRODUCTION



The term "epulis" includes a series of reactive gingival lesions often produced by irritating agents. The diagnosis is usually established on the basis of the clinical findings, with few clinical differences noted among the different disorders included under this term; these disorders include peripheral ossifying fibroma (POF), peripheral fibroma, peripheral giant cell granuloma (PGCG) and pyogenic granuloma. [1] The sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions. [2] Other terms used in reference to POF are peripheral cementifying fibroma, peripheral fibroma with cementogenesis and peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis and calcified fibroblastic granuloma. [2],[3]

POF is a lesion that mainly affects women in the second decade of life. [2],[4],[5] The lesions are most often found in the gingiva, located anterior to the molars and in the maxilla. [1] Clinically, POF usually manifests as a well-defined and slow-growing gingival mass measuring under 2 cm in size and located in the interdental papilla region. [4] The base may be sessile or pedunculated, the color is identical to that of the gingiva or slightly reddish and the surface may appear ulcerated. The definitive diagnosis is based on the histological examination, with the identification of cellular connective tissue and the focal presence of bone or other calcifications. [3],[4],[5],[6]

However, it has not been established whether POF is a tumor or represents a proliferation of a reactive nature. Surgery is the treatment of choice, though the recurrence rate can reach 20%. POF shows a clinically benign behavior. This paper presents a series of five cases of POFs reported and treated at our institute.

 Case Reports



Case 1

The first case is about a 40-year-old female patient who reported to Department of Oral Medicine and Radiology with the chief complaint of inability to eat due to a large growth in maxillary anterior region of the jaw since 1 year. The lesion had started as small growth, which had gradually increased to the present size. Patient gave no history of pain and bleeding from the overgrowth. The medical and dental history was non-contributory. On clinical examination, a solitary, pedunculated, pale pink exophytic growth with some erythematous areas, measuring about 4 cm × 3 cm was seen extending from distal aspect of maxillary right lateral incisor up to the distal aspect of maxillary left central incisor. The growth was firm in consistency and non-tender on palpation. Patient had very poor oral hygiene. On radiographic examination, intraoral periapical (IOPA) showed the presence of soft-tissue shadow, interspersed with radiopaque areas in maxillary left central and lateral incisors suggestive of calcification. Severe generalized horizontal bone loss was also seen. A provisional diagnosis of POF was given. The lesion was surgically excised after scaling and root planning and sent for histopathological examination which confirmed the diagnosis [Figure 1]a-c].{Figure 1}

Case 2

This was a second case of a 71-year-old male patient who reported to Department of Oral Medicine and Radiology with the chief complaint of growth in maxillary canine region of the jaw since 2 years. The lesion had started as small growth which had gradually increased to the present size. Patient gave no history of pain and bleeding from the overgrowth. The medical and dental history was non-contributory. On clinical examination, a solitary, sessile, pale pink exophytic growth measuring about 3 cm × 3 cm was seen extending from distal aspect of maxillary left canine up to mesial aspect of maxillary left first premolar. The growth had lobulated surface. There was displacement of maxillary left canine and first premolar due to growth. The growth was firm in consistency and non-tender on palpation. Patient had very poor oral hygiene. On radiographic examination, IOPA showed the presence of soft-tissue shadow, interspersed with radiopaque areas suggestive of calcification between the maxillary left incisor and canine region, corresponding to the area of exophytic growth. A provisional diagnosis of peripheral ossifying fibro was given. The lesion was surgically excised and sent for histopathological examination which confirmed the diagnosis [Figure 2]a-c].{Figure 2}

Case 3

A 27-year-old female patient reported to Department of Oral Medicine and Radiology with the complaint of slowly growing, painless, gingival growth in maxillary right incisor region since 6 months. The medical and dental history was non-contributory. On clinical examination, a solitary, sessile, reddish pink exophytic growth measuring about 1 cm × 2 cm was seen extending from distal aspect of maxillary right central incisor up to mesial aspect of maxillary right lateral incisor. The growth was also extending on the palatal aspect. The growth had lobulated surface. There was displacement of maxillary right central and lateral incisors due to growth. The growth was firm in consistency and non-tender on palpation. On radiographic examination no abnormality was detected except for displacement of maxillary central and lateral incisors. A provisional diagnosis of fibrous epulis was given. The lesion was surgically excised and sent for histopathological examination which revealed fibrillar stroma along with multiple trabeculae of immature bone and globules of darkly stained calcified material. Thus, a final diagnosis of POF was given [Figure 3]a-c].{Figure 3}

Case 4

A 50-year-old female patient reported to Department of Oral Medicine and Radiology with the complaint of slowly growing, painless, gingival growth in mandibular left canine region since 10 months. The medical and dental history was non-contributory. On clinical examination, a solitary, sessile, pale pink exophytic growth measuring about 1 cm × 2 cm was seen extending from distal surface of mandibular left lateral incisor up to mesial surface of mandibular left first premolar. The growth had a smooth surface. The growth was hard in consistency and non-tender on palpation. On radiographic examination, IOPA showed no abnormality. Mandibular occlusal radiograph showed solitary, radiopacity in the mandibular left canine region. A provisional diagnosis of POF was given which was confirmed by histopathologic examination [Figure 4]a-c].{Figure 4}

Case 5

A 35-year-old female reported to Department of Oral Medicine and Radiology with the chief complaint of growth in maxillary incisor region of the jaw since 3 years. The lesion had started as small growth which had gradually increased to the present size. Patient gave no history of pain and bleeding from the overgrowth. The medical and dental history was non-contributory. On clinical examination, a solitary, sessile, pale pink exophytic growth measuring about 2 cm × 2 cm was seen extending from midline up to mesial aspect of maxillary right lateral incisor. The growth extended palatally up to incisive papilla. The growth had lobulated surface. There was displacement of maxillary right central incisor due to growth. The growth was firm in consistency and non-tender on palpation. Patient had very poor oral hygiene. A provisional diagnosis of POF was given. Surgical excision of the lesion was carried out, which was confirmed by histopathological examination [Figure 4]d and e].

 DISCUSSION



Intraoral ossifying fibromas have been described in the literature since the late 1940s. It has been suggested that the POF represents a separate clinical entity rather than a transitional form of pyogenic granuloma, PGCG or irritation fibroma, [7] Eversole and Rovin [8] stated 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. [9]

Although the etiopathogenesis of PCOF is uncertain some investigators consider it a neoplastic process, whereas other argue it is a reactive process; however, in either case, 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, ill-fitting and poor quality dentures. [2]

POF is a focal, reactive, non-neoplastic tumor-like growth of soft-tissue often arising from the interdental papilla. POF may present as a pedunculated nodule, or it may have a broad attachment base. 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, size can vary and some lesions may be as large as 9 cm in diameter. Cases of tooth migration and bone destruction have been reported, but these are not common. [9],[10],[11],[12]

By most reports, the majority of the lesions occur in the second decade, with declining incidence in later years. [13] There are 2 reported cases of POF present at birth, presenting clinically as congenital epuli. [14],[15] In a retrospective study of 431 cases in the Chinese population by Zhang et al., [1] the mean age of incidence of POF was found to be 44 years, which is contradictory to previously published literature. POF appears to be more common among white people than black and slightly less common among those of Hispanic origin. [12]

The differential diagnosis of this condition includes traumatic fibroma, PGCG and pyogenic granuloma. Pyogenic granuloma is most common oral lesion known to involve the gingiva. Clinically, oral pyogenic granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic. Radiologically and depending on the size of the ossification foci, radiopaque stains can be seen on the periapical or panoramic radiographs. [4] The POF lesion is generally small and does not require imaging beyond radiographs. [3] Such radopacities were present in Case 1, 2 and 4. In Case 3 no obvious lesion was seen except for migration of affected teeth.

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 respectively. [7],[16] 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. The mineralized component of POF varies, occurring in approximately 23-75% of cases according to published reports. Mineralization can vary between cementum-like material, bone (woven and lamellar) and dystrophic calcification.

The treatment of choice for POF is local resection with peripheral and deep margins including both the periodontal ligament and the affected periosteal component. In addition, elimination of local etiological factors such as bacterial plaque and calculus is required. [2] The teeth associated with POF are generally not mobile, though there have been reports of dental migration secondary to bone loss. Extraction of the neighboring teeth is usually not considered necessary. [4] The recurrence rate of POF has been considered high for reactive lesions. The rate of recurrence has been reported to vary from 8.9% to 20% respectively. It probably occurs due to incomplete initial removal, repeated injury or persistence of local irritants. The average time interval for the first recurrence is 12 months. [17]

 Acknowledgment



We would like to thank Dr. Anand Swami, Dr. Neha Desai, Dr. Gaurav Agrawal, Dr. Jyoti Khedgikar for their help in preparation of the manuscript.

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