|Year : 2009 | Volume
| Issue : 1 | Page : 49-51
Peripheral ossifying fibroma
UM Das, U Azher
Department of Pedodontics and Preventive Dentistry, V.S. Dental College and Hospital, K.R. Road, V.V. Puram, Bangalore - 560 004, Karnataka, India
U M Das
Department of Pedodontics and Preventive Dentistry, K.R. Road, V.V. Puram,Bangalore - 560 004, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The peripheral ossifying fibroma (POF) is a reactive gingival overgrowth occurring frequently in the anterior maxilla in teenagers and young adults. The pediatric patient with a POF has special management considerations compared to the adult, as it requires early recognition and treatment by the dentist. It requires proper treatment protocol with close postoperative follow-up. The present report describes a case of POF in a girl, which was surgically excised from the palatal mucosa in the maxillary incisor area. Some features of the differential diagnosis and therapy when it occurs are discussed.
Keywords: Calcifying of ossifying fibroid epulis, peripheral cementifying fibroma, peripheral fibroma with calcification, peripheral odontogenic fibroma, peripheral ossifying fibroma
|How to cite this article:|
Das U M, Azher U. Peripheral ossifying fibroma. J Indian Soc Pedod Prev Dent 2009;27:49-51
| Introduction|| |
Solitary gingival enlargements in children are relatively common finding and are usually the result of a reactive response to local irritation.  One such reactive lesion is the peripheral ossifying fibroma (POF), a gingival nodule composed of a cellular fibroblastic connective tissue stroma associated with the formation of randomly dispersed foci of mineralized product consisting of bone, cementum-like tissue, or dystrophic calcification.  A combination of the aforementioned products is often found.
It is widely considered that this lesion originates from the cells of the periodontal ligament ,,, and is often associated with trauma or local irritants, such as subgingival plaque and calculus, dental appliances, and poor-quality dental restorations. ,, Clinically, POFs are sessile or pedunculated, usually ulcerated and erythematous or exhibit a color similar to the surrounding gingiva. , Most lesions are <2 cm in size, although larger ones occasionally occur. Furthermore, the lesions have female predilection and recurrence rate is considered high for a benign reactive proliferation. ,,,
The POF may occur at any age range, but exhibits a peak incidence between the second and third decades. The average age is around 28 years, with females being affected more than males.  Kfir et al . 1980, Stablien and Silverglade 1985
In the vast majority of cases, there is no apparent underlying bone involvement visible on the roentgenogram. However, on rare occasions, there does appear to be superficial erosion of bone.
The lesions should be surgically excised and submitted for microscopic examination for confirmation of diagnosis. The extraction of adjacent teeth is seldom necessary or justified. However, the lesions do occur with some frequency and, in fact, repeated recurrences are not uncommon. In the series of Cundiff, 16% of the cases recurred, while in a series of 50 cases reported by Eversole and Rovin, the recurrence rate was 20%.
| Case Report|| |
A 12-year-old girl visited the Department of Pedodontics and Preventive Dentistry, V.S. Dental College, with the chief complaint of a soft tissue mass in the anterior maxilla. The lesion had been present for approximately four months. Intraoral examination revealed a well-circumscribed, sessile, erythematous, firm swelling measuring 1 cm in diameter, located on the palatal mucosa of the right maxillary central and lateral incisor [Figure 1].
The lesion was asymptomatic, nonulcerated, and overlying mucosa appeared normal. No radiological signs of involvement of alveolar ridge were observed. The intraoral examination also revealed a traumatic crossbite in the same region.
Clinically, the differential diagnosis included pyogenic granuloma, fibrous hyperplasia, POF, and peripheral giant cell granuloma.
Under local anesthesia, the lesion was completely excised [Figure 2]. The excisional biopsy was submitted for histological analysis. The histopathological examination [Figure 3] of the lesion revealed the prominent area of highly cellular fibrous connective tissue showing collagen fibers and proliferating plump fibroblasts, and focal areas of trabecular bone lined by osteoblasts. The covering stratified squamous epithelium was parakeratinized with focal areas of acanthosis. The diagnosis was POF according to both clinical and histopathological patterns. The patient is undergoing orthodontic treatment for the correction of the crossbite. A five-month postsurgical follow-up showed no evidence of recurrence.
| Discussion|| |
Reactive lesions, e.g., the POF, reported in this case, are relatively common clinical finding in children. The main etiological factors of POF ,,, are trauma and chronic irritation, particularly from subgingival plaque and calculus. Moreover, the occurrence of this lesion associated with an orthodontic appliance was detected in 3.8% of cases described by Buchner and Hansen  and 7% of pediatric cases described by Cuisia and Brannon.  Inflammatory hyperplasia originating in the superficial periodontal ligament is considered to be a factor in the histogenesis of the POF. , These findings include the exclusive occurrence on the gingiva, the proximity of gingiva to PDL, and the inverse correlation of age distribution of lesions with the number of the lost teeth and their corresponding PDL. Furthermore, high female predilection, rare occurrence in the first decade, and decline in incidence after age 30 suggest that hormonal influence may be a lesional growth factor. ,
In this case report, the patient had traumatic crossbite, which probably contributed with etiopathogeny of the POF causing dental plaque or calculus accumulation.
Frequently, POF arises as an exophytic, ulcerated mass attached to the gingiva that shares similar clinical features with other extraosseous lesions. Some of these lesions may be misdiagnosed as pyogenic granuloma, fibrous hyperplasia of peripheral giant cell granuloma, but other peripheral odontogenic tumors should also be considered. ,, In general, the pyogenic granuloma presents as a soft, friable nodule that bleeds with minimal manipulation, but tooth displacement and resorption of alveolar bone are not observed. Although peripheral giant cell granuloma has clinical features similar to those of POF, the latter lacks the purple or blue discoloration commonly associated with peripheral giant cell granuloma and radiographically shows small flecks of calcification. Thus, the diagnosis of the POF based only on clinical aspects can be difficult and histopathological examination of the surgical specimen obtained by excisional biopsy is mandatory for an accurate diagnosis. In the case reported, the histopathological feature of the POF is characterized by the presence of connective tissue with high cellularity and calcifications. ,,,
Although most of lesions are usually <1.5 cm, as shown in the present case, the occurrence of the POFs in children can exhibit an exuberant growth rate and reach significant size in a relatively short period of time.  If surgical intervention in an early stage is not done, POF can become large, causing extensive destruction of adjacent bone and significant functional or esthetic alterations. ,
Moreover, the recurrence rate of the POF has been considered high for reactive lesions ,, and it probably occurs due to incomplete initial removal, repeated injury, or persistence of the local irritants. ,,,
According to the series of 134 pediatric POFs analyzed by Cuisia and Brannon,  the average time interval for the first recurrence is 12 months. As in the case reported, early surgical treatment of the POF in children including removal of identifiable etiological factors is required to obtain satisfactory gingival repair and to minimize the possibility of recurrence.
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[Figure 1], [Figure 2], [Figure 3]
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