Peripheral Ossifying Fibroma

Peripheral ossifying fibroma is defined as a non- neoplastic enlargement of gingiva that is classified as a reactive hyperplastic inflammatory lesion 1. The synonyms of POF are peripheral cementifying fibroma, calcifying or ossifying fibroid epulis, and peripheral fibroma with calcification. These lesions may arise as a result of irritants such as trauma, micro- organisms, plaque, calculus, faulty restorations, and dental appliances 2,3. It is typically seen on the interdental papilla and is believed to comprise about 9% of all gingival growths4. The pathogenesis of this lesion is uncertain and is thought to arise from the periosteal or the periodontal membrane5. It has been reported that it represents a maturation of a pre- existing pyogenic granuloma or a peripheral giant cell granuloma 4. Peripheral ossifying fibroma mainly affects women in the second decade of life ( 50% of all patients between 5- 25 years of age ). The lesions are most often found in the gingiva, located anterior to the molars and in the maxilla 6,7,8,9,10. Clinically the POF are sessile or it may be pedunculated and are usually less than 2 cm but occasionally can reach the size of 6 cm.

CASE REPORT

A female patient age about 26 years reported with the chief complaint of painless growth on the gingiva in the upper left front region of mouth since 6 months . It had gradually progressed & attained the present size. The growth was associated with occasional bleeding. The patient did not give any history of trauma. Intraoral examination revealed a solitary, sessile growth present i.r.t 21 and 24 , extending mesiodistally from the distal aspect of 21 up to mesial aspect of 24 region. Superioinferiorly, extending superiorly from marginal gingiva of 21,22,22 & 24 and inferiorly from 2 mm above the incisor line. Anteroposteriorly, extending from inner aspect of upper lip to the labial surface of 21 to 24 . The color of the growth is same as that of the adjacent gingiva. The growth was oval in shape and approximately 2.5*1.5 cm in size in greatest dimensions. The growth was firm & non tender on palpation. It was nonfluctuant, nonreducible & noncompressible.

Fig.1 Preoperative photograph

Clinically, differential diagnoses for the growth were peripheral giant cell granuloma, pyogenic granuloma, peripheral odontogenic fibroma, peripheral ossifying fibroma, traumatic or irritational fibroma.

Radiological investigations done include maxillary occlusal view and intraoral periapical radiograph

Fig. 2 Occlusal view

The growth was excised conservatively followed by extraction of 11,21,22,23,24 .

Fig. 3 Intraoperative photograph showing excision of growth

Fig. 4 Intraoperative photograph after excision of growth

The excised tissue was sent for histopathological examination and the area was sutured with 3-0 vicryl suture.

Fig. 5 Excised tissue specimen

Histopathologic examination showed parakeratinized stratified squamous epithelium with proliferation at few places. The underlying connective tissue shows loosely arranged wavy collagen fibres, dense chronic inflammatory cell infiltrate also exhibits thin endothelial blood vessels & deep in the connective tissue were seen numerous ossifications in the form of bony trabaculae.

Fig. 6 Histopathological slide

Fig. 7 Postoperative photograph after 24 hours

Fig. 8 Postoperative photograph after one week

Fig. 9 Postoperative photograph after one month

DISCUSSION-

Menzel first described the lesion ossifying fibroma in 1872, but its terminology was given by Montgomery in 192711. Ossifying fibroma occurs mostly in craniofacial bones and is generally categorized in to two types : central & peripheral. The central type of ossifying fibroma arises from the endosteum or the periodontal ligament 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. The reasons for considering a PDL origin for POF include : exclusive occurrence of POF in the gingiva ( interdental papilla ); the proximity of the gingival lesion to the periodontal ligament; the presence of oxytalan fibers within the mineralized matrix of some lesions; age distribution, which is inversely related to the number of lost permanent teeth; and the fibrocellular response in POF, which is similar to the other reactive gingival lesions of PDL origin12,13,14. The POF may occur at any age range, but exhibits a peak incidence between the second & third decades. The average age is around 28 years, with females being affected more than males. Most of lesions are usually more than 1.5 cm. Radiologically and depending on the size of the ossification foci, radiopaque stains can be seen on the periapical or panoramic X-ray15,16. Clinical differential diagnosis for gingival growths includes peripheral giant cell granuloma, pyogenic granuloma, peripheral odontogenic fibroma, peripheral ossifying fibroma, traumatic or irritational fibroma. The definitive diagnosis of POF is made by histologic evaluation12, 17. Histologically, the key feature of this lesion is exceedingly cellular mass of connective tissue comprising large numbers of plump, proliferating fibroblasts intermingled throughout with delicate fibrillar stroma17. Treatment consists of conservative surgical excision & scaling of adjacent teeth. The rate of recurrence is high, therefore, regular follow- up is required4,3,18.

REFERENCES