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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 106-110

Peripheral ossifying fibroma: A rare case series


1 Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan, India
2 Department of Prosthodontics, Jaipur Dental College, Jaipur, Rajasthan, India
3 Department of Oral Medicine and Radiology, Rajasthan Dental College, Jaipur, Rajasthan, India

Date of Web Publication19-May-2016

Correspondence Address:
Swati Phore
H. No: 59 (A) Hastsal, Near Vikaspuri, New Delhi - 110 059
India
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DOI: 10.4103/0976-433X.182667

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  Abstract 

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). These lesions may arise as a result of such irritants as trauma, microorganisms, plaque, calculus, restorations, and dental appliances. The purpose of this article is to present case series of POF, briefly review the current literature on this condition, and emphasize the importance of discussion of a reasonable differential diagnosis with the patient or a parent.

Keywords: Calcification, gingiva, ossifying fibroma, peripheral


How to cite this article:
Phore S, Panchal RS, Baghla P, Nabi N. Peripheral ossifying fibroma: A rare case series. SRM J Res Dent Sci 2016;7:106-10

How to cite this URL:
Phore S, Panchal RS, Baghla P, Nabi N. Peripheral ossifying fibroma: A rare case series. SRM J Res Dent Sci [serial online] 2016 [cited 2020 Oct 25];7:106-10. Available from: https://www.srmjrds.in/text.asp?2016/7/2/106/182667


  Introduction Top


Peripheral ossifying fibroma (POF) is a nonneoplastic enlargement of gingiva that is classified as a reactive hyperplastic inflammatory lesion, a common gingival growth, which is typically seen on the interdental papilla and is believed to comprise about 9% of all gingival growths.[1]

Ossifying fibroma occurs mostly in craniofacial bones and is generally categorized into two types: Central and peripheral. The central type of ossifying fibroma arises from the endosteum or the periodontal ligament (PDL) adjacent to the root apex and expands from the medullary cavity of the bone. On the other hand, the peripheral type shows a contiguous relationship with the PDL, occurring solely on the soft tissues overlying the alveolar process.[2],[3]

Intraoral ossifying fibromas have been described in the literature since the late 1940s. Many names have been given to similar lesions, such as epulis, peripheral fibroma with calcification, POF, calcifying fibroblastic granuloma, peripheral cementifying fibroma, peripheral fibroma with cementogenesis, and peripheral cemento-ossifying fibroma.[4],[5]

The sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions.[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.[7]

The female to male ratio reported in the literature varies from 1.22:1 and 1.7:1–4.3:1. By most reports, the majority of the lesions occur in the second decade, with a declining incidence in later years. There are 2 reported cases of POF present at birth, presenting clinically as congenital epulis. Approximately 60% of POFs occur in the maxilla, and they occur more often in the anterior than the posterior area, with 55–60% presenting in the incisor-cuspid region.[8]

With respect to race, there is a predominance in whites (70%) compared to blacks (36%).[9]


  Case Reports Top


Case 1

A 19-year-old female patient [Figure 1] visited the dental outpatient department (OPD) with the chief complaint of slow growing palatal swelling in left right front region of mouth for last 14 months. There were no relevant family and medical history. The patient did not give any history of trauma, injury, or food impaction. General physical examination was normal. On intraoral examination, a pinkish-red, well-defined growth was present palatally extending from the distal aspect of 11 until mesial aspect of 14, measuring about 3 cm × 3 cm in size [Figure 2]. It was slightly pedunculated with what appeared to be a broad-based attachment. Growth was firm to hard in consistency, tender on palpation, nonfluctuant, neither did it blanch with pressure with no pockets nor discharge of pus or blood. Adjacent gingival was normal and 12 and 13 were drifted distally, even before the lesion was present. After patient's informed consent, radiograph and blood investigations were advised. No abnormality was detected in both, with no finding pertaining to the maxillary exophytic lesion [Figure 3]. Electric pulp testing showed 11, 12, 13, and 14 were vital. The growth was excised [Figure 4] and [Figure 5]. Radiovisiography (RVG) was done on the excised specimen [Figure 6] which revealed multiple radiopaque foci suggestive of calcification; the specimen was then sent for histopathological examination which revealed fibro-cellular connective tissue stroma consisting of bundles of collagen fibers, fibrillar arrangement, with numerous proliferating fibroblasts and fibrocytes and eosinophilic area of calcification. At places, a few trabeculae of bone with osteocytes in lacunae were also seen. On the basis of clinical, histopathological, and radiographic examination, the diagnosis of POF was given. The patient presented for a follow-up examination 10 days postoperatively. The surgical site appeared to be healing well [Figure 7].
Figure 1: Frontal view

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Figure 2: Pinkish-red, well-defined growth, palatally extending from distal aspect of 11 until mesial aspect of 14

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Figure 3: No changes in intraoral periapical radiograph associated with the lesion

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Figure 4: Excision of the growth

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Figure 5: Excised tissue specimen

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Figure 6: Radiovisiograph of the excised specimen revealing multiple radiopaque foci suggestive of calcification

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Figure 7: Healing of the lesion

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Case 2

A 25-year-old female patient [Figure 8] visited dental OPD with the chief complaint of growth on the right lingual region for 3 months. Family and medical history were non contributory. On intraoral examination, pinkish-red, smooth, exophytic growth was present on the right lingual gingival extending from mesial aspect of 45 until distal aspect of 46 and from occlusal line until 2 mm above the sulcular depth, measuring about 3 cm × 3 cm in size [Figure 9]. Adjacent gingiva was normal in color. On palpation, it was firm to hard in consistency with no pockets, nontender, and no pus or blood discharge. After patient's informed consent, radiograph and blood investigations were advised. No abnormality was detected in both [Figure 10]. 44, 45, and 46 were vital when tested by electric pulp tester. The growth was excised. RVG was done on the excised specimen [Figure 11] which revealed multiple radiopaque foci suggestive of calcification; the specimen was then sent for histopathological examination which revealed fibro-cellular connective tissue stroma consisting of bundles of collagen fibers, fibrillar arrangement, with numerous plump proliferating fibroblasts and fibrocytes and eosinophilic area of calcification. At places, a few trabeculae of bone with osteocytes in lacunae were also seen. On the basis of clinical, histopathological, and radiographic examination, the diagnosis of POF was given. The patient presented for a follow-up examination 10 days postoperatively. The surgical site appeared to be healing well [Figure 12].
Figure 8: Frontal view

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Figure 9: Pinkish-red, smooth, exophytic growth on the right lingual gingival extending from mesial aspect of 45 until distal aspect of 46

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Figure 10: No changes in intraoral periapical radiograph associated with the lesion

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Figure 11: Radiovisiograph of the excised specimen revealing multiple radiopaque foci suggestive of calcification

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Figure 12: Follow-up after 10 days

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Both the patients were kept under regular follow-up for 3, 6, 10, and 14 months, and there were no signs of recurrence.


  Discussion Top


The POF is a focal, reactive, non neoplastic tumor-like growth of soft tissue often arising from the interdental papilla.[7]

It is a fairly common lesion, comprising nearly 3% of oral lesions biopsied in 1 study, approximately 1–2% in other studies.[10] In 1993, Das and Das obtained similar results, with 1.6% POFs among 2370 intraoral biopsies.[11]

POF may present as a pedunculated nodule, or it may have a broad attachment base.[12],[13] 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,[14] size can vary; reports range from 0.2–3.0 cm to 4–8 cm [15] 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.[16]

POFs are believed to arise from gingival fibers of the periodontal ligament as hyperplastic growth of tissue that is unique to the gingival mucosa. 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.[17]

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.[10]

The mineralized component of POF varies, occurring in 23% cases according to published reports.[18] Mineralization can vary between cementum-like material, bone (woven and lamellar), and dystrophic calcification.[14],[19] Calcification was observed in both the above cases RVG of the excised specimen.

Histologically, this malady is a noncapsulated mass of cellular fibrous connective tissue with randomly distributed calcifications and/or mature bone.[2]

The POF lesion is generally small and does not require imaging beyond radiographs.[20]

Roentgenographically, in a vast majority of cases, there is no apparent visible underlying bone involvement. On rare occasions, there appears to be superficial erosion of bone. In the present cases also, underlying bone involvement was not observed.[2],[21] In rare instances, superficial erosion of bone is noted.[22]

When presented clinically with a gingival lesion, it is important to establish a differential diagnosis. In this case, the clinical features led to a differential diagnosis of irritation fibroma, pyogenic granuloma. Although it is also important to maintain a high index of suspicion, discussion with family members should be tactful to prevent undue distress during the waiting period between differential diagnosis and definitive histopathological diagnosis.

Due to the high rate of recurrence (8–20%), close postoperative monitoring is required in all cases of POF.

POF recurs due to (1) the incomplete removal of the lesion, (2) the failure to eliminate local irritants, and (3) difficulty in accessing the lesion during surgical manipulation as a result of the intricate location of the lesion (usually an interdental area).[23]


  Conclusion Top


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. Close postoperative follow-up is required because of the growth potential of incompletely removed lesions and the 8–20% recurrence rate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names 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

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Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: Report of 376 cases. J Am Dent Assoc 1966;73:1312-20.  Back to cited text no. 4
    
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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. 7
    
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Das S, Das AK. A review of pediatric oral biopsies from a surgical pathology service in a dental school. Pediatr Dent 1993;15:208-11.  Back to cited text no. 11
    
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Cuisia ZE, Brannon RB. Peripheral ossifying fibroma – A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8.  Back to cited text no. 12
    
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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. 14
    
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Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol 1987;14:551-4.  Back to cited text no. 15
    
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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.  Back to cited text no. 16
    
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Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.  Back to cited text no. 17
    
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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.  Back to cited text no. 18
    
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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.  Back to cited text no. 19
    
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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.  Back to cited text no. 20
    
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Pendyala G, Joshi S, Marawar PP, Pawar B, Mani A. Peripheral ossifying fibroma-a case report. Pravara Med Rev 2012;4:27-30.  Back to cited text no. 21
    
22.
Glick G. Textbook of Burkets Oral Med Diag and Treatment. 10th ed. Ontario Hamilton: BC Decker; 2003. p. 142.  Back to cited text no. 22
    
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Sumona P, Shruti H, Vidya A. The varying clinical presentations of peripheral ossifying fibroma: A report of three cases. Rev Odonto Cienc 2012;27:251-5.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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