|Year : 2012 | Volume
| Issue : 3 | Page : 199-201
Recurrent peripheral ossifying fibroma
Department of Dentistry, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||10-Jun-2013|
Department of Dentistry, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/0972-4958 .113254
A case of recurrent painless swelling of the gingiva which was clinically diagnosed as pyogenic granuloma in an 18-years-old female is reported to highlight the prevalence of recurrent peripheral ossifying fibroma, the need for a thorough curettage up to the deepest possible tissue at the time of excision and strict postoperative follow-up.
Keywords: Curettage, Gingival, Peripheral ossifying fibroma, Recurrent
|How to cite this article:|
Sanjeeta N. Recurrent peripheral ossifying fibroma. J Med Soc 2012;26:199-201
| Introduction|| |
Among the localised benign overgrowths of the gingiva occurring in the oral cavity, peripheral ossifying fibroma is peculiar because it is composed of highly cellular fibrous tissue proliferation that is associated with the formation of a mineralised product. The lesion should be excised down to the periosteum as recurrence is more likely if the base the lesion is allowed to remain. The teeth in the area of the lesion should also be thoroughly scaled to eliminate any possible irritants which may stimulate a recurrence. These issues necessitate regular post-operative follow up for early detection of recurrence.
| Case Report|| |
An 18-years-old female reported to the outpatient department of the Department of Dentistry on 10 th June, 2011 with a complaint of a painless swelling in relation to her upper posterior teeth which was present for the past 8 months. History revealed that the patient had a similar swelling in the same region about 3 years back which was surgically removed. The present swelling started about 8 months back as a small nodule that gradually increased to the present size. The patient's past history did not reveal any history of trauma, injury or food impaction. Extraoral examination did not reveal any facial asymmetry or any other abnormality. Intraorally, there was a pedunculated non-tender, well-demarcated, firm pinkish red swelling measuring about 2.1 cm in 15 and 16 region [Figure 1]. The oral hygiene of the patient was satisfactory. An intraoral periapical radiograph of 15 and 16 region showed resorption of superficial interdental bone. The lesion was provisionally diagnosed as pyogenic granuloma. The lesion was then excised under local anesthesia and the underlying surface was thoroughly curetted upto the deepest possible tissue and crestal osteoplasty was done.
|Figure 1: Clinical photograph of the swelling on the maxillary interdental gingiva of 15 and 16 region|
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Histopathological examination revealed a parakeratinized mildly hyperplastic stratified squamous epithelium with the underlying connective tissue exhibiting moderately cellular fibrous tissue in which are seen bundles of collagen fibres, fibroblasts, mixed inflammatory cell infiltration consisting predominantly of polymorphs along with areas of dystrophic calcification and ossification [Figure 2] and [Figure 3].
|Figure 2: Photomicrograph of the lesion showing formation of bone and basophilic globules depicting dystrophic calcification within a moderately cellular fibrous stroma|
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|Figure 3: Higher magnification of the same slide showing basophilic dystrophic calcification|
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Based on the history, clinical features and histopathological features, the lesion was diagnosed as peripheral ossifying fibroma.
| Discussion|| |
Localized overgrowths of the gingiva are a common occurrence in the oral cavity. The focal overgrowths that commonly occur in the gingiva comprises of fibroma, giant cell fibroma, pyogenic granuloma, peripheral giant cell granuloma, peripheral ossifying fibroma, and peripheral odontogenic fibroma.  These lesions of the gingival tissues have derived their names from the characteristic histologic features that the lesions exhibit and are mostly reactive rather than neoplastic in nature having arisen as a result of trauma or irritation.
Peripheral ossifying fibroma is a relatively common gingival growth that occurs exclusively on the gingiva that is considered to be reactive rather than neoplastic in nature.  The lesion is microscopically characterized by a high degree of cellularity usually exhibiting bone formation, although, occasionally cementum - like material or rarely dystrophic calcification may be found.  The fact that the peripheral ossifying fibroma (POF) occurs only on the gingiva and its possible derivation from the periodontal ligament suggests an odontogenic origin according to some investigators.  However, its exact derivation is still unknown.
The peripheral ossifying fibroma can occur at any age although, it occurs more commonly in children and young adults.  In a study of 365 cases by Cundiff,  50% of the lesions occurred between the ages of 5 and 25 years with the peak incidence at 13 years, while the mean age was 29 years and over 80% of the lesions occurred anterior to the molar area in both the jaws. There is a definite female predilection in occurrence with the ratio ranging from 2:1 to 3:2. The lesions are approximately equally divided between the maxilla and the mandible. In this case, the lesion occurred on the labial gingiva in a female in the second decade of life.
Clinically, the lesion appears as a well-demarcated nodular mass of tissue on the gingiva with either a pedunculated or a sessile base that usually emanates from the interdental papilla.  The surface may or may not be ulcerated. , The lesion may be smooth or lobulated or cauliflower like. The color may be the same color of normal gingiva or may be slightly red or red. The size usually varies from 0.2 to 3 cm with the largest reported diameter to be 9 cm. , In our case, the lesion was seen arising from the interdental region between 15 and 16, was pinkish red in color with a pedunculated base and measured 2.1 cm in greatest diameter.
Radiographically, in the vast majority of cases, there is no visible sign of bone involvement.  However, in the present case, crestal bone loss was seen in 15 and 16 region which could be a result of localized chronic periodontitis as it was not possible to maintain proper oral hygiene in that area because of the swelling.
Microscopically, POF is characterized by an exceedingly cellular mass of connective tissue comprising large numbers of plump proliferating fibroblasts intermingled throughout a very delicate fibrillar stroma.  The cellularity is more evident around mineralizing bone and is less evident where ossification are less. ,, Variable mineralized components may be seen in POF. , It may be bone, cementum-like material or dystrophic calcifications. , Bone may be woven or lamellar that is at times surrounded by osteoid or may be trabecular. Cementum-like material may be seen as spherical bodies resembling cementum or large acellular round to oval eosinophilic bodies that appear to coalesce forming islands of various sizes and shapes. Dystrophic calcification may be seen as small clusters of minute basophilic granules or tiny globules to large, solid, irregular masses. In this case, globules of basophilic areas representing dystrophic calcification along with areas of ossification are seen interspersed in the fibrous connective tissue.
The overlying surface epithelium in the vast majority of the cases is parakeratinized or orthokeratinized stratified squamous of variable thickness that may be either intact or more frequently ulcerated. In our case, the epithelium was parakeratinized stratified squamous without ulceration.
The treatment of choice for POF is local surgical excision. ,, The lesions do recur with some frequency and repeated recurrences are not uncommon. Sixteen percent of the cases recurred in the series studied by Cundiff  while the recurrence rate was 20% in the 50 cases investigated by Eversole and Rovin.  Excision of the mass should be done down to the periosteum because recurrence is more likely, if the base of the lesion is allowed to remain. The adjacent teeth should be thoroughly scaled to eliminate any possible irritants.
All the treated cases of POF should be strictly followed up. Our patient did not show any sign of recurrence in the 6 months follow-up. Recurrent cases should be treated aggressively followed by reconstruction of the defect if necessary. 
Lack of literature on recurrent peripheral ossifying fibroma in the Indian literature and need for careful excision of the fibroma mass down to the periosteum had prompted the author to report this case.
| References|| |
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[Figure 1], [Figure 2], [Figure 3]