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OJHAS Vol. 8, Issue 3: (2009
Jul-Sep) |
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Peripheral Ossifying Fibroma |
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Sudhakar S, Senior lecturer,
Praveen Kumar B, Senior lecturer
Prabhat MPV,
Associate professor
Department of Oral Medicine & Radiology,
St. Joseph Dental College & Hospital,
Eluru (Andhra Pradesh) – 534003
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Address For Correspondence |
Senior Lecturer,
Department of Oral Medicine & Radiology,
St. Joseph Dental College & Hospital,
Eluru (Andhra Pradesh) – 534003
E-mail:
drsudhakaroralmed@yahoo.co.in |
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Sudhakar S, Praveen Kumar B, Prabhat MPV. Peripheral Ossifying Fibroma. Online J Health Allied Scs.
2009;8(3):17 |
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Submitted: Sep 14, 2009; Accepted:
Sep 28, 2009 Published: Nov 15, 2009 |
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| Abstract: |
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Peripheral ossifying fibroma is a relatively uncommon
gingival growth that is considered to be reactive in
nature and postulated to appear secondary to irritation or trauma. They usually occur in young adults with a female
predominance and are solitary in nature. We report a
case of peripheral ossifying fibroma in a 55-year old female.
Key Words:
Peripheral ossifying fibroma; Gingiva; Multicentric; Periosteum; Recurrence
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Peripheral ossifying fibroma (POF) is a solitary, non-neoplastic gingival growth usually arises from
the interdental papillae. As the clinical spectrum of this entity has resemblance to other common gingival masses a thorough diagnostic sequence is necessary to rule out
other common benign gingival lesions.
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A 55-year old female patient reported with a complaint of painless swelling in the upper front gum
region since 2 months. Patient’s history revealed that she had noticed the swelling 2 months back and had gradually increased in size. There was no history of associated
symptoms such as pain, paraesthesia or numbness; however, the patient had a history of occasional bleeding on provocation. There was no history of trauma or similar growth
in the past. The medical, surgical and family histories were non-contributory. Extra-oral examination did not reveal any abnormalities. Intra-oral examination revealed a pink,
solitary, well defined oval shaped gingival growth ranging 2x1 cm in size in relation to 12, extending from the distal aspect of 11 to mesial aspect of 13. The growth had a
smooth surface and appeared to arise from the underlying soft tissue. It was pedunculated, mobile, non-tender, firm in consistency and bled to touch (FIG 1).
Based on the history and clinical findings the following differential diagnoses were considered: fibrosed pyogenic granuloma, peripheral ossifying fibroma, peripheral odontogenic
fibroma, solitary fibroma, fibrosed peripheral giant cell granuloma.
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Figure 1: Intra oral photograph showing the gingival growth |
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Patient was then subjected to routine hematological and radiographic investigations. The complete hemogram was within the normal limits. Intra oral periapical radiograph
(IOPAR) and orthopantomograph did not reveal any pathological changes except for generalized horizontal bone loss (FIG 2 & 3).
Excisional biopsy was performed and the lesion was removed along with its surrounding tissue. (FIG 4). Histopathological examination of the specimen showed
presence of ulcerated stratified squamous epithelium. The underlying connective tissue was highly cellular with plump fibroblasts intermingled in a delicate fibrillar
stroma associated with areas of woven trabecullar bone and osteoids.
Based on the clinical, radiographic and histopathological findings, a final diagnosis of peripheral ossifying fibroma was arrived. The patient is on regular follow-up for the
past 6 months with no signs of recurrence.
Figure 2: (Left) IOPAR showing right maxillary anteriors
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Figure 3:
Orthopantomograph showing generalized horizontal bone loss |
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Figure 4: Post
operative intra-oral photograph |
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Figure 5:
Photomicrograph 10X |
POF is a relatively uncommon, solitary, non-neoplastic gingival growth, coined by Eversole and Rovin.(1)
Over the years, various terminologies have been considered for its description and it includes: peripheral odontogenic fibroma, peripheral cemento-ossifying fibroma,
peripheral cementifying fibroma, ossifying fibro-epithelial polyp, peripheral fibroma with osteogenesis, peripheral fibroma with cementogenesis, peripheral fibroma with
calcification, fibrous epulis, calcifying or ossifying fibrous epulis, calcifying fibroblastic granuloma.(2,3) The term cement-ossifying fibroma is scientifically invalid,
as there is no histomorphic or biochemical difference between bone and cementum.(4) Whereas, peripheral odontogenic fibroma is a true neoplasm of odontogenic origin and it is
the counterpart of central odontogenic fibroma (World health organization type).(5,6) The peripheral ossifying fibroma however does not represent the soft tissue counterpart
of the central ossifying fibroma, as the latter arise from the endosteum and causes expansion of the medullary cavity.(5)
The pathogenesis of POF is uncertain. As they resemble clinically and histopathologically to pyogenic granuloma, some consider POF to develop secondary to fibrosis of granulation
tissue.(4) Moreover, due to its female gender and second decade predilection, the role of hormones has also been questioned.(7) The most widely acceptable histiogenesis for POF is the
inflammatory hyperplasia of the cells of the periosteum or periodontal ligament.(1,7-9) The inflammatory reaction is believed to occur secondary to trauma from local irritants such as
plaque, calculus, restorations or ill fitting dental appliances.(1,7-9) This is convincing, as they occur exclusively in gingiva and with the histomorphological evidence of oxytalan
fibers within the mineralized matrix.(4,10) Another interesting observation is the decline in number of cases as age advances.(6,11)
POF clinically appears as a solitary nodular mass, either pedunculated or sessile and arise from the interdental papilla.(8,10) The color ranges from pink to red and the
surface is frequently but not always ulcerated.(8) Most lesions are usually 1-2 cm in size, however, cases ranging more than 2cm have also been reported.(5) POF’s are usually
solitary, rarely, it can be multicentric.(10) Multicentric variants are reported at times in association with conditions such as nevoid basal cell carcinoma syndrome, multiple
endocrine neoplasia type II, neurofibromatosis and gardener’s syndrome.(10) The peak incidence of POF is between second and third decades and almost two thirds of all cases are
reported in females.(4,8,10,11) There is a slight predilection for the maxillary arch and are frequently observed in the incisor-cuspid region.(4,8) Usually, the teeth are
unaffected; rarely, it may cause migration, mobility and delay in eruption of permanent tooth.(8,10)
The radiographic features may range from no changes, as seen in the present case to destructive changes.(10,11) In certain cases, superficial erosion of underlying bone,
cupping defect and focal areas of radiopaque calcifications at the center of the lesion can be seen.(4,10,11) Considering the size of the lesion and details the plain
radiography provides, additional imaging studies are rarely required. If performed, CT (computed tomography) and MR (magnetic resonance) images can aid in evaluation of the
epicenter of the mass.(5) On CT, they appear as a well circumscribed mass with evidence of calcification and mild enhancement after contrast agent administration. At MR imaging,
an isointense signal to muscle on non-enhanced T1 weighted sequence and an iso-to-low signal on T2 weighted sequence can be seen.(5)
Microscopically, the epithelium can be intact or ulcerated. If ulcerated, superficial areas of fibrinopurulent membrane with a subjacent zone of granulation
tissue can be noticed.(4,8) Abundant fibroblastic proliferations, variable mineralized component, sparse endothelial proliferation and few inflammatory cells are other
predominant findings of POF.(4,10) The mineralized components may consist of bone, cementum like material or dystrophic calcifications.(4,8) Less frequently, ovoid droplets of
basophilic cementum-like material are formed. Usually the bone is woven, lamellar or trabecular in type and rarely contains unmineralized osteoids and multinucleated giant cells.(4,8)
The treatment of choice is local surgical excision. (8,12) POF has a high recurrence rate of about 8% to 16%; hence the mass should be excised deep into the periosteum with
complete removal of all irritants. In extensively destructive cases, repositioned flaps or connective tissue grafts may be necessary to repair the gingival defects.(8,12)
- Eversole LR, Rovin S. Reactive lesions of the gingival.
J Oral Pathol 1972;1:30-8.
- Zain RB, Fei YJ. Fibrous lesions of the gingiva: a histopathological analysis of 204 cases.
Oral Surg Oral Med Oral Pathol 1990;70:466-70.
- Waldron CA. Fibrosseous lesions of the jaws.
J Oral Maxillofac Surg 1993;51:828-35.
- Yadav R, Gulati A. Peripheral ossifying fibroma: a case report.
J Oral Sci 2009;51:151-4.
- 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.
- Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in south indian population: 2001-2006.
Med Oral Patol Oral Cir Bucal 2008 Jul 1;13(7): E414-8.
- Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.
- Neville BW, Damm DD, Allen CM, Bouquot JE. Soft tissue tumors. Oral and maxillofacial pathology. 3rd ed. Missouri: Elsevier. P 521-3.
- Delbem ACB, Cunha RF, Silva JZ. Soubhia AMP. Peripheral Cemento-Ossifying Fibroma in Child. A Follow-Up of 4 Years. Report of a Case.
Eur J Dent 2008;2:134-137.
- Kumar SKS, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma.
J Oral Sci 2006;48:239-43.
- Das UM, Azher U. Peripheral ossifying fibroma.
J Indian Soc Pedod Prevent Dent 2009; 27(1): 49-51.
- 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.
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