|Type of manuscript: Case Report
Title: Peripheral Ossifying Fibroma: A Case Report.
Running title: Peripheral Ossifying Fibroma
Ravi Chandu Katta B.D.S1, Sreenivas Nagarakanti M.D.S, PhD2, Vijay Kumar Chava M.D.S3, B.V Ramesh Reddy M.D.S3 .
1 Postgraduate, Department of Periodontics, Narayana Dental College & Hospital
2 Reader, Department of Periodontics, Narayana Dental College & Hospital
3 Professor, Department of Periodontics, Narayana Dental College & Hospital
Dr. Sreenivas Nagarakanti, M.D.S, PhD
Department of Periodontics,
Narayana Dental College & Hospital,
INDIA, Pin: 524003
Total number of Pages: 8
Total number of Photographs: 3
Abstract word count: 56
Text word count: 909
Financial Support and Sponsorship: NIL
Conflict of Interest: There are no conflicts of interests
Acknowledgement: I would like to acknowledge Dr.Vandana, Professor and Head, Department of Oral and maxillofacial Pathology, Narayana Dental College & Hospital.
Peripheral Ossifying Fibroma: A case report.
The purpose of this article is to present a clinical case of a 23-year-old male patient with peripheral ossifying fibroma (POF) in the mandibular right central and lateral incisor region. Clinically, the lesion was asymptomatic, firm, pink and sessile. Surgical excision of the lesion was done followed by histopathologic confirmation with emphasis on the clinical aspect.
Keywords: Peripheral ossifying fibroma, gingival enlargement, case report.
Gingival enlargement is a common feature of gingival disease. Among them localized gingival overgrowth are encountered more frequently in the oral cavity and peripheral ossifying fibroma is one of them. 1,2 The bone fibrous lesions were broadly classified into three categories: fibrous dysplasia, reactive lesions (periapical cemento-ossifying dysplasia, focal cemento-ossifying dysplasia, fibrous ossifying dysplasia), and ossifying fibroma neoplasias.3 Reactive lesions (central and peripheral) mainly involve craniofacial bones.4
Central ossifying fibroma is an endosteal origin which expands into the medullar space of the bone, whereas peripheral ossifying fibroma (POF) originates from periodontal ligament cells which do not expand.5,6 The term POF was proposed by Eversol and Robin in 1972.7 POF represents 2–9 % of all gingival lesions and it is the third most common lesion of all localized reactive hyperplastic lesions after pyogenic granuloma and giant cell central granuloma.6
The etiology of POF is not clear but fairly acceptable theory states that it originates as an inflammatory hyperplasia from the cells of the periodontal ligament. This is why POF occurs exclusively in gingiva that is in close proximity to the periodontal ligament.8 Moreover, there has been evidence of calcified matrix-rich oxytalan fibers included in the POF.8,9 The inflammatory reaction in POF could be due to local irritants such as plaque and other mechanical irritating factors.9 There is evidence of bone formation and dystrophic calcification which could be due to connective tissue metaplasia of chronically inflamed periodontal ligament and periosteum.4
Clinically, the lesion appears as a nodular mass which may be pedunculated or sessile, pink to red in color with different grades of inflammation depending on the presence of local irritating factors and sometimes the surface might be ulcerated.
The basic microscopic pattern is one of a fibrous proliferation associated with the formation of a mineralized product. In and ulcerated lesion the epithelium covered by a fibrinopurulent membrane with a subjacent zone of granulation tissue. The deeper fibroblastic component often is cellular, especially in areas of mineralization. The type of mineralized component is variable and may consist of bone, cementum-like material, or dystrophic calcifications. Frequently, a combination of products is formed. Usually, the bone is woven and trabecular in type, although older lesions may demonstrate mature lamellar bone.10
The treatment of choice is local surgical excision with submission of the specimen for histopathologic examination. The mass should be excised down to periosteum because recurrence is more likely if the base of the lesion is allowed to remain. In addition, the adjacent teeth should be thoroughly scaled to eliminate any possible irritants.
A 23-year-old male patient was presented to the periodontal consultation at Narayana Dental College and Hospital with a complaint of mass in the gingival tissue in the lower front teeth region. (Figure1a) The mass appeared approximately 3 months before the consultation and had gradually increased in size until the time of the interview. The growth was painless, and the patient denied any other symptoms, while past medical, hereditary and drug history was unremarkable. Intraoral exploration showed a well-defined reddish pink sessile exophytic soft lesion located on the labial aspect of 41 and 42(FDI system of tooth notation), measuring 8 × 7 mm. The lesion was asymptomatic without indurations or ulceration. Mild spacing between 41 and 42 was observed.(Figure 1a) The overjet/overbite was observed under normal range.
The differential diagnosis included fibrous hyperplasia, pyogenic granuloma and peripheral giant cell granuloma and peripheral odontogenic fibroma.
Initial investigations include intraoral periapical radiograph (IOPAR) in relation to 41,42 and a complete haemogram.
IOPAR showed intact laminadura in relation to 41 and 42. No significant bony changes were observed. (Figure 2)
The proposed treatment was excisional biopsy with deep scaling and curettage. The patient was evaluated for fitness to undergo a surgical procedure. After taking written consent scaling and root planing was done before initiating surgery. Under local anesthesia, the lesion was completely excised down to the bone to clear the cells of origin and the adjacent teeth were again cleaned to avoid any source of irritation and the biopsy specimen was submitted for histological analysis.
Histopathological examination revealed a large central area of calcified mass composed of interconnected trabeculae of immature bone with osteoid and osteoblastic rimming. Few spicules of trabeculae are also seen lying close to it. The immediately surrounding and intervening connective tissue is very cellular with ovoid cells. A covering parakeratinized hyperplastic oral epithelium is noted with a fibrocellular lamina propria. A variable chronic inflammatory cell infiltrate is observed. Many spindle or oval plum cells and many small capillaries are noted. Few scattered irregular basophilic calcifications are seen. Histopathologic diagnosis was ossifying fibroma with superimposed inflammatory changes. (Figure 3-a,b)
Based on the clinical, radiographic and histological findings the lesion is diagnosed as POF.
6 months postoperative follow-up was done and no signs of recurrence were observed. (Figure 1b)
POF is a chronic lesion. As most of the POF lesions are asymptomatic, patients will seek treatment after a long period. If the lesion is not treated it might enlarge in size and interfere with mastication and in some cases there might me pathological migration of teeth. POF mimics other soft tissue growths in the oral cavity. Diagnosis should be confirmed by radiographic and histological examination. Proper excision of the lesion down to the bone should be done to clear the cells of origin further preventing recurrence. Close postoperative follow-up is required as the lesion has high recurrence rate.
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Figure 1a: Preoperative photograph of lesion in relation to 41,42 and spacing between 41 and 42 can be observed
Figure 1b: Six months postoperative clinical photograph with no signs of recurrence.
Figure 2: IOPAR in relation to 41,42
Figure 3a: Microscopic picture of biopsy slide showing large central area of calcified mass composed of interconnected trabeculae of immature bone with osteoid and osteoblastic rimming. (5×)
Figure 3b: Immature bone with osteoid and osteoblastic rimming. (40×)