|Year : 2011 | Volume
| Issue : 3 | Page : 255-259
Peripheral ossifying fibroma in the maxillary arch
VA Trasad1, GM Devarsa2, VV Subba Reddy2, ND Shashikiran3
1 Department of Pediatric Dentistry, S.D.M College of Dental Sciences & Hospital, Dharwad, India
2 Department of Pediatric Dentistry, College of Dental Sciences & Hospital, Davangere, Karnataka, India
3 Department of Pediatric Dentistry, People's College of Dental Sciences & Research Center, Bhopal, Madhya Pradesh, India
|Date of Web Publication||10-Oct-2011|
V A Trasad
Assistant Professor, Department of Pediatric Dentistry, S.D.M Dental Sciences & Hospital, Dharwad
| Abstract|| |
Many types of localized reactive lesions may occur on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma and peripheral ossifying fibroma. Peripheral ossifying fibroma is a gingival growth, usually arising from interdental papilla and represents up to 2% of all lesions that are biopsied. Other terms used to describe this lesion include peripheral cementifying fibroma, peripheral fibroma with cementogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis and calcified fibroblastic granuloma. This article reports a case of a 10 year old male child with an unusually large peripheral ossifying fibroma in the left maxillary alveolar ridge which showed recurrence after the surgical treatment.
Keywords: Fibro-osseous lesions, maxilla, ossifying fibroma, recurrence
|How to cite this article:|
Trasad V A, Devarsa G M, Subba Reddy V V, Shashikiran N D. Peripheral ossifying fibroma in the maxillary arch. J Indian Soc Pedod Prev Dent 2011;29:255-9
|How to cite this URL:|
Trasad V A, Devarsa G M, Subba Reddy V V, Shashikiran N D. Peripheral ossifying fibroma in the maxillary arch. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2013 May 22];29:255-9. Available from: http://www.jisppd.com/text.asp?2011/29/3/255/85837
| Introduction|| |
Many types of localized reactive lesions may occur on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma.  Peripheral ossifying fibroma is typically solitary, slow growing nodular mass that is either pedunculated or sessile;  surface mucosa is smooth or ulcerated and pink to red in color. Migration of teeth with inter-dental bone destruction has been reported in some cases.  Peripheral ossifying fibroma usually measures <1.5 cm in diameter but patients with a lesion of 6 cm and 9 cm diameter have also been reported. Etiology and pathogenesis of peripheral ossifying fibroma remain unknown. Some investigations consider it a neoplastic process, while others argue that it is a reactive process; in either case, the lesion is thought to arise from cells in periodontal ligament. Trauma or local irritants such as dental plaque, calculus, microorganisms, masticatory forces, ill fitting dentures, and poor-quality restorations have been implicated in etiology of peripheral ossifying fibroma. 
The definitive diagnosis of peripheral ossifying fibroma is based on histological examination with the identification of cellular connective tissue and the focal presence of bone or other calcifications. However, it has not been established whether peripheral ossifying fibroma is a tumor or represents proliferation of a reactive nature.  After elimination of local etiological factors, local surgical excision of peripheral ossifying fibroma is the preferred treatment. Excision should include the periodontal ligament and periosteum at the base of lesion in order to reduce the chance of recurrence. Here we present a case report of a 10-year-old male child with an unusually large peripheral ossifying fibroma in the left maxillary alveolar ridge which showed recurrence even after the surgical treatment.
| Case Report|| |
10-year-old boy reported to Department of Pedodontics of College of Dental Sciences with the complaint of swelling in the upper left back region since 3 months. Though there was no associated pain the patient had inability to eat hard food. The patient had history of extraction of primary second molar 3 months back in the same region. Initially the swelling was small but there was gradual increase in size of the lesion.
On extra-oral examination the patient was found to have an asymmetrical face [Figure 1] with diffuse swelling on the left side of the face, with angle of the mouth and ala of the nose stretched on the lateral side, and difficulty in approximating the lips.
On intra-oral examination, we could see a swelling in the left maxillary region [Figure 2] which was ovoid in shape measuring around 6 cm wide, 6 cm in length, and 3 cm in height, which extended from the left canine anteriorly to the left first permanent molar region posteriorly. The swelling extended 2 cm on the buccal side and 4 cm on the palatal side from the maxillary dental arch. The swelling had crossed midline of the palate on the right side by 1 cm. It covered distal and palatal aspects of left primary first molar. The obliteration of buccal vestibule and palatal vault was observed. Overlying mucosa was reddish in color with few areas of ulceration with no compressibility or depressibility, and cuspal indentations [Figure 3] of lower teeth were clearly seen on the occluding surface of swelling.
The patient had developed pain in tempero-mandibular joint as his occlusion was disturbed for over 2 months. His masticatory efficiency was reduced drastically as he was unable to occlude his teeth on the right and left sides; he could not chew on swelling because of ulcerations so the patient was mainly on liquid and semi-solid diet.
OPG, occlusal, and IOPA radiographs were obtained. OPG [Figure 4] showed mesial displacement of primary maxillary left first molar and canine, distal displacement of first permanent molar and apical displacement premolars. A uniform radio-opacity similar to bone was seen in the area of lesion. Left primary second molar and primary lateral incisors were missing.
After detailed history, clinical, and radiographic examination a differential diagnosis of focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma were made.
As the patient reported late with lot of discomfort it was decided to go for an excisional biopsy. After all the tests for pre-operative evaluation for general anesthesia were carried out, the surgical exposure revealed that the lesion was well demarcated from surrounding bone permitting relatively easy separation of a tumor from its bony bed. As excision of the lesion resulted in loss of supporting tissues to left first primary molar and permanent first molars were removed. The excised tissue was sent to the Department of Oral Pathology for histopathological diagnosis.
The patient presented for a follow-up examination after 15 days postoperatively [Figure 5]; the surgical site appeared to be healing well; but when the patient visited after 2 months with a reoccurring swelling
[Figure 6] of 1.5 cm × 1.5 cm. The patient was motivated to undergo surgical excision of the reoccurred lesion again but he did not turn up for further follow-up visits.
| Discussion|| |
Intraoral ossifying fibromas have been described in the literature since the late 1940s. It has been suggested that the peripheral ossifying fibroma represents separate clinical entity rather than a transitional form of pyogenic granuloma, peripheral giant cell granuloma, or irritational fibroma. 
Peripheral ossifying fibroma is a common gingival growth, usually arising from interdental papilla  and represents up to 2% of all lesions that are biopsied. Other terms used to describe this lesion include peripheral cementifying fibroma, peripheral fibroma with cementogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis, and calcified fibroblastic granuloma.  All the terminologies are appropriate for this tumor as they might contain a variety of calcified materials. When bone predominates in the lesion the term "ossifying" is the appellation, while the term "cementifying" has been assigned when curvilinear, trabecular, or spherical calcifications are encountered; when both cementum and bone-like tissues are observed the lesions are then referred as cemento-ossifying fibromas.
Ossifying fibroma occurs from craniofacial bones and is generally categorized into two types, central and peripheral ossifying fibromas. The central type arises from 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 periodontal ligament, occurring solely on the soft tissue. Peripheral ossifying fibroma is not the peripheral counterpart of central ossifying fibroma. Inflammatory hyperplasia originating in the superficial periodontal ligament is considered to be a factor in the histogenesis of peripheral ossifying fibroma. 
Clinically peripheral ossifying fibroma presents as exophytic, smooth surfaced pink or red nodular mass that is sessile or is less frequently seen on a pedicle. The interdental papilla is frequently involved. The lesion in our case had developed from soft tissue may be arising from the interdental papilla was a focal reactive tumor-like growth with a broad attachment base. The patient also had history of extraction of primary maxillary second molar in the same region 3 months back before presenting to our department.
Ossifying fibromas may occur at any age, but are more common in young adults. A variant of ossifying fibroma, juvenile (aggressive) ossifying fibroma, has been described in children and young adults who are younger than 15 years of age.  Females are more commonly affected than males and anterior maxilla is the most common location of involvement where lesion predominates in the second decade of life.  Hormonal influences may play a role, given the higher incidence of peripheral ossifying fibroma among females, increasing occurrence in the second decade, and declining incidence after the third decade.  In the present case anterior maxilla was involved and the patient was almost at the end of his first decade. But interestingly in our case the patient was male although it is seen more commonly in females.
Histologically, these lesions are fibro-osseous in nature. They are composed of cellular fibrous tissue with areas of fibrovascular tissue that often contain an inflammatory component with abundant plasma cells. Ossification is usually seen in the cellular zone, and shows considerable variations both quantitatively and qualitatively. From small rounded calcified deposits to large trabecular bone areas surrounded by osteoblasts may be observed.  The predominant cell of this lesion is a bland spindle cell. Mitotic figures are rare. Admixed in the fibrous background are irregularly shaped osseous islands. The histopathologic hematoxylin and eosin stained section [Figure 7] of lesion revealed a well-circumscribed, capsulated mass; the capsule was fibrous and thinned out at places. The subcapsular area comprised interconnected bony trabeculae encasing plump osteocytes with most of the trabeculae exhibiting osteoblastic rimming. Concentric lamellated and spherical ossicles were seen with a basophilic center and peripheral eosinophilic mass. The fibrous tissue is of varying cellularity with few chronic inflammatory cells.
The treatment of choice for peripheral ossifying fibroma is local resection with peripheral and deep margins including both the periodontal ligament and the affected periosteal component. , In addition elimination of the local etiological factors such as plaque and tartar is required. , The teeth associated with peripheral ossifying fibroma are generally not mobile, though there have been reports of migration secondary to bone loss. , In the present case mesial displacement of primary left maxillary canine and first molar and distal displacement of permanent maxillary first molar was seen. These teeth were removed due to lack of supporting tissues.
After the 15-day follow-up, the surgical site showed uneventful healing but after 2 months we noticed reoccurring lesion in the same region. Hence excision should include the periodontal ligament and periosteum at the base of lesion in order to reduce the chances of recurrence. Recurrence rates of 8% to 20% have been reported. ,, Recurrence is probably a result of incomplete resection of the lesion, failure in sectioning the periodontal ligament, or the development of new lesions. 
| Conclusions|| |
Peripheral ossifying fibroma is a benign fibro-osseous lesion with significant growth potential. This lesion is mainly characterized by slow growing soft tissue nodule mainly involving the anterior maxilla in second decade of life. Many patients do not approach a dentist as it is mainly asymptomatic during initial stages till the size increases considerably. In rural India due to lack of proper guidance, early diagnosis and prompt treatment of such lesions is not possible. Treatment consists of surgical excision of the lesion, and these lesions have considerable reoccurrence rates hence requiring close postoperative follow-up visits.
| References|| |
|1.||Farquhar T, Maclellan J, Dyment H, Anderson RD. Peripheral ossifying fibroma: A case report. J Can Dent Assoc 2008;74:809-12. |
|2.||Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43. |
|3.||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. |
|4.||Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: report of 376 cases. J Am Dent Assoc 1966;73:1312-20. |
|5.||Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1987;63:452-61. |
|6.||Cuisia ZE, Brannon RB. Peripheral ossifying fibroma-clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8. |
|7.||Moon WJ, Choi SY, Chung EC, Kwon KH, Chae SW. Peripheral ossifying fibroma in the oral cavity: CT and MR findings. Dentomaxillofac Radiol 2007;36:180-2. |
|8.||Cawson RA, Odell EW. Cawson's oral pathology and oral medicine, 7th ed, Edinburgh: Churchill Livingstone; 2002. p. 133. |
|9.||Marx RE, Stern D (2003). Oral and maxillofacial pathology: A rationale for diagnosis and treatment, 1st Ed, Chicago: Quintessence; 2003. p. 23-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]