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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 130-132

Peripheral ossifying fibroma in premolar - A rare case report


CSI College of Dental Sciences and Research, Madurai, Tamil Nadu, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Rohini Govindasamy
Villa No C-16 A, Shriyaa Gardens, Masthanpatti, Opposite to Vickram Hospital, Madurai - 625 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_85_17

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  Abstract 

Solitary gingival growths, the most common finding in the oral mucosa, are usually due to reactive response to local irritation, and one such reactive lesion is peripheral ossifying fibroma (POF). This article is emphasized on a case report of POF in a 28-year-old female in the maxillary premolar region. Clinical presentation, radiographic details, histopathologic features, differential diagnosis, and treatment with regular follow-up are made.

Keywords: Gingival overgrowth, peripheral ossifying fibroma, premolar


How to cite this article:
Rajasekaran K, Subramanian S, Kandasamy J, Govindasamy R. Peripheral ossifying fibroma in premolar - A rare case report. J Int Oral Health 2017;9:130-2

How to cite this URL:
Rajasekaran K, Subramanian S, Kandasamy J, Govindasamy R. Peripheral ossifying fibroma in premolar - A rare case report. J Int Oral Health [serial online] 2017 [cited 2019 Aug 24];9:130-2. Available from: http://www.jioh.org/text.asp?2017/9/3/130/209059


  Introduction Top


In the oral cavity, gingiva is often the site of localized growths that are considered to be reactive rather than neoplastic in nature.[1] There exist many types of localized reactive lesions seen on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma (POF).[2]

Although many of these lesions clinically present with a diagnostic dilemma, they are identified as specific entity only on the basis of typical and consistent histomorphology. POF is one such common reactive hyperplastic inflammatory lesions of the gingiva. The gingival growth is usually seen on interdental papilla, and it constitutes 9% of all gingival growth.[2] It has been reported that POF represents a maturation of a preexisting pyogenic granuloma or a peripheral giant cell granuloma.[3]

POF presents clinically as red to pink, sessile or pedunculated growth with the size usually being <2 cm. Weeks or months may pass by before it is seen and diagnosed. There is a gender difference with 66% of the disease occurring in females.[4]

It appears only on the gingiva, more often on the mandible rather than maxilla and is frequently found in the area around incisors and canines and the adjacent teeth are usually not affected.[5]

Histologically, the POF consists of a fibrocellular component with focal deposits of bone, some cementum as well as irregular amounts of decalcification.[6]

The etiology of POF is unclear. Trauma or local irritants such as calculus, masticatory forces, ill-fitting dentures, and poor-quality restorations are all known to precipitate the development of POF.[7]

Elimination of local etiological factors followed by surgical excision is the preferred treatment modality.[8]


  Case Report Top


A 28-year-old female patient reported with the chief complaint of growth on the gingiva in her upper left second premolar region for the past 6 months and is painless.[2] The patient's past dental and medical histories were noncontributory. On intraoral examination, a growth of 2 cm × 2 cm was present in the attached gingiva buccally in relation to 24, 25 [Figure 1]. The growth extended palatally through the interdental papilla [Figure 2]. It was erythematous in appearance; firm in consistency with mild tenderness on palpation and bleeding on provocation was seen. Provisional diagnosis of pyogenic granuloma was made.
Figure 1: Intraoral view of the swelling on buccal aspect

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Figure 2: Intraoral view of the swelling on palatal aspect

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Intraoral periapical radiograph was obtained. Radiographic examination revealed normal bone architecture with no findings pertaining to the lesion. The differential diagnosis included peripheral giant cell granuloma and peripheral odontogenic fibroma. After routine blood examinations, excisional biopsy of the growth was done; mucoperiosteal flap was raised, thorough debridement and degranulation in relation to 24, 25 were done to prevent recurrence [Figure 3].
Figure 3: Excision biopsy and curettage done in relation to 24, 25 region

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Histopathological examination revealed evidence of nonkeratinized stratified squamous epithelium and underlying fibrocellular connective tissue with basophilic calcification and bone fibroma with ossification [Figure 4].
Figure 4: Histopathological view

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The follow-up of the case for 1 year showed normal healing of the area with no recurrence confirming the lesion as POF [Figure 5].
Figure 5: Postoperative review after 1 week

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  Discussion Top


Gingival overgrowths are one of the common lesions encountered in day-to-day practice. POF is one such gingival growth. There are two types of ossifying fibroma: central and peripheral. The central type arises from the endosteum and periodontal ligament (PDL) around the root apex and subsequently causes expansion of the medullary cavity while the peripheral type originates from the periodontal soft tissue around the interdental papilla.[1]

POF was coined by Eversole and Rovin.[6] It occurs exclusively on the gingiva; appears as a nodular mass, it may either be pedunculated or sessile. POF usually emanates from the interdental papilla, is often mistaken for pyogenic granuloma.[1] There exists a considerable confusion over the nomenclature and diagnosis of the lesion, and there are several terms to describe due to its varied histopathologic features.[4] Compared to the lesions considered under the differential diagnosis of POF, they are firmer and less friable with a typical longer course.[10]

Majority of reports suggest that POF is commonly seen during the second decade of life and reduction in size as age progresses. In the present case, POF is seen during the second decade as reported in other cases.[4] Approximately, 60% of POFs occur in females with predilection for the mandible, and incisor-cuspid region constitutes about 50%.[2],[4] However, in our case, the lesion was seen in the posterior maxilla which is rare.

POF clinically and histopathologically resembles pyogenic granuloma, considering the development of POFs secondary to fibrosis of granulation tissue.[11] In the present case, the etiopathogenic mechanism underlying POFs is due to inflammatory hyperplasia of cells of periosteum and PDL. Chronic irritation of periosteal and periodontal membrane is causing metaplasia of connective tissue resulting in the bone or dystrophic calcification.[12],[13] Some cases of POFs are associated with known genetic mutations such as nevoid basal cell carcinoma syndrome, multiple endocrine hyperplasia Type II, and neurofibromatosis and Gardner Syndrome.[14] Hormones seem to play a role in the progress of the lesions accounting for the female predilection.[4]

The exclusive occurrence of POF in gingiva is due to the proximity of gingiva to the PDL and presence of oxytalan fibers within the mineralized matrix of the lesion.[15],[16] POFs occur in children with mixed or primary dentition and little specific occurrence in primary teeth.[17],[18]

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.[6] In the present case, no radiographic findings were found which indicated that this could be early stages of the lesion.

Pyogenic granuloma appears as soft, friable nodule, small size, and bleeding tendency may or may not show calcifications. Displacement of the tooth and resorption of the alveolar bone are also not observed. Peripheral giant cell granuloma shares same clinical features but POF lacks the purple or blue discoloration commonly associated with peripheral giant cell granuloma, and radiographically, it appears similar as flecks of calcification is seen.[2] Treatment includes surgical excision followed with oral prophylaxis. Follow-up is essential because of its high recurrence rates. Recurrence rates vary between 8% and 20%.[19],[2] Recurrence may be due to incomplete excision or persistence of local factors. Early recognition and definitive surgical intervention result in reduction in recurrence rates and risk of tooth loss and bone loss.[20]


  Conclusion Top


Clinical diagnosis of gingival lesions and distinguishing each lesion from other lesions in the same spectrum is a challenge uninhibited. Hence, a meticulous and thorough correlation between clinical and histopathological presentation marks the path in making an accurate diagnosis of POF.

Although anterior mandible is the common site, presence in the posterior maxilla makes this case a rare entity. Histopathologic confirmation is mandatory. Complete surgical excision down to the periosteum is the preferred treatment. As the recurrence rate is high, close postoperative, follow-up is required.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raj PR, Nausheen E, Rawther NN, James J. Peripheral ossifying fibroma of posterior maxilla. A rare case report. Int J Sci Stud 2015;3:217-20.  Back to cited text no. 1
    
2.
Bhasin M, Bhasin V, Bhasin A. Peripheral ossifying fibroma. Case Rep Dent 2013;2013:497234.  Back to cited text no. 2
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3.
Parihar AS, Narang S, Narang A, Singh R. Peripheral ossifying fibroma. A diagnostic dilemma. J Adv Med Dent Sci Res 2015;3:162-4.  Back to cited text no. 3
    
4.
Barot VJ, Chandran S, Vishnoi SL. Peripheral ossifying fibroma. A case report. J Indian Soc Periodontol 2013;17:819-22.  Back to cited text no. 4
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5.
John R, Prabhu NT, Munshi MK. Peripheral ossifying fibroma report of a case. J Indian Soc Pedod Prev Dent 1996;14:107-8.  Back to cited text no. 5
    
6.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 6
[PUBMED]    
7.
Mesquita RA, Orsini SC, Sousa M, de Araújo NS. Proliferative activity in peripheral ossifying fibroma and ossifying fibroma. J Oral Pathol Med 1998;27:64-7.  Back to cited text no. 7
    
8.
Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol 1987;14:551-4.  Back to cited text no. 8
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9.
Rajendran R, Sivapathasundharam B. Shafers's Textbook of Oral Pathology. 6th ed. Noida, India: Elsevier; 2009. p. 128.  Back to cited text no. 9
    
10.
Taur S, Hadakar S, Patil P, Mane P. Peripheral ossifying fibroma: Report of a case. J Prev Clin Dent Res 2014;1:107-10.  Back to cited text no. 10
    
11.
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. 11
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12.
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. 12
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13.
García de Marcos JA, García de Marcos MJ, Arroyo Rodríguez S, Chiarri Rodrigo J, Poblet E. Peripheral ossifying fibroma: A clinical and immunohistochemical study of four cases. J Oral Sci 2010;52:95-9.  Back to cited text no. 13
    
14.
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. 14
    
15.
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. 15
    
16.
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. 16
    
17.
Ozalp N, Sener E, Songur T. Peripheral giant cell granuloma and peripheral ossifying fibroma in children: Two case reports. Med Princ Pract 2010;19:159-62.  Back to cited text no. 17
    
18.
Sairam V, Padmaja K, Praveen Kumar B, Naresh G, Vikas Reddy G. Peripheral ossifying fibroma: A case report. Adv Dent Oral Health 2016;1:1-4.  Back to cited text no. 18
    
19.
Chhina S, Gakhar A, Mavi S, Kalra S. Peripheral ossifying fibroma: A case report. IJSS Case Rep Rev 2015;1:61-4.  Back to cited text no. 19
    
20.
Zhang W, Chen Y, An Z, Geng N, Bao D. Reactive gingival lesions: A retrospective study of 2439 casa. Quintessence Int 2007;38:103-10.  Back to cited text no. 20
    


    Figures

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



 

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