|Year : 2016 | Volume
| Issue : 1 | Page : 51-54
Peripheral Ossifying Fibroma
Sonal Srivastava1, Manaswita Tripathy1, BR Chethan1, Joel Dsilva2
1 Department of Oral Medicine and Radiology, KVG Dental College, Sullia, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, KVG Dental College, Sullia, Karnataka, India
|Date of Web Publication||27-Jun-2016|
C1/25, Sector-F, Jankipuram, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Peripheral ossifying fibroma is classified under reactive lesions of oral cavity. They are relatively uncommon gingival growth and constitute about 10% of all reactive lesions. Chronic irritation and trauma are considered to be etiological agent. Usually occur in young adults with a female predominance and are solitary in nature. We report a case of peripheral ossifying fibroma in a 22-year old female.
Keywords: Interdental, nonneoplastic, ossifying fibroma
|How to cite this article:|
Srivastava S, Tripathy M, Chethan B R, Dsilva J. Peripheral Ossifying Fibroma
. Indian J Oral Health Res 2016;2:51-4
| Introduction|| |
Reactive lesions are one of the most common findings of oral cavity. Among these, peripheral ossifying fibroma (POF) contributes to 10% and pyogenic granuloma constitutes 80% of cases.  Ossifying fibroma can have central and peripheral variety. Endosteum or periodontal ligament (PDL) adjacent to the root apex is considered to be origin for central variety, whereas peripheral originates mostly from soft tissue overlying the alveolar process. , POF is defined as any solitary growth on the gingiva thought to arise from the PDL; most commonly at the region of the interdental papilla. 
Other terms used for POF are peripheral odontogenic fibroma, ossifying fibroma epulis, ossifying fibroma with calcification,  calcifying fibroma, peripheral cemento-ossifying fibroma, ossifying fibroepithelial polyp, and calcifying fibroblastic granuloma. 
Hereby, we are reporting a case of POF in a female patient of age 22 years in maxillary anterior region of jaw. Since patient did not report any history of trauma and also considering the fact that local factors were minimal, these two could be easily excluded from being the etiological agent. Patient was in the 2 nd decade of her life and therefore hormonal changes could be the reason.
| Case report|| |
A 22-year-old female patient [Figure 1] reported to the Department of Oral Medicine and Radiology, with a chief complaint of swelling on the upper front region of mouth since last 6 months [Figure 2]. On eliciting the history of present illness, the swelling was insidious in onset. Initially, it was small peanut sized and progressively increased to present size. Occasionally, it was associated with pain. Patient did not give any history of trauma, injury, or food impaction and there was no significant medical history.
Intraoral examination revealed a well-defined, solitary, sessile swelling oval in shape, size approximately 2 cm × 2 cm seen in interdental area of 11 and 21. Swelling extended from attached gingiva till gingival margin superoinferiorly and from mesial surface of 11 to mesial surface of 21 mesiodistally. It had smooth surface and distinct edges. The overlying surrounding mucosa was apparently normal [Figure 2].
On palpation, the gingival growth was nontender, firm to hard in consistency, nonreducible, noncompressible and fixed to underlying structures. No bleeding on probing was seen. Pathological migration and midline diastema could be observed between 11 and 21. Based on history and clinical examination, a provisional diagnosis of pyogenic granuloma and differential diagnosis of inflammatory gingival hyperplasia and POF was considered.
Intraoral periapical radiograph was taken in relation to 11, 21, and few flecks of calcification were seen in interdental of 11, 21 [Figure 3]. Oral prophylaxis was performed and lesion was excised by raising the flap form 13 to 23 region under local anesthetic [Figure 4]. Thereafter, excised specimen [Figure 5] was subjected to histopathologic examination. Histological examination revealed predominant fibrocellular connective tissue stroma consisting of one or more bundles of collagen fibers. Furthermore, spindle- and stellate-shaped fibroblast with few areas of basophilic calcified masses, cellular inclusions, and reversal lines were seen which was suggestive of POF [Figure 6]. Patient was recalled after 2 week for follow-up [Figure 7].
|Figure 3: Intraoral periapical radiograph showing few flecks of calcification in interdental area of 11 and 21 and midline diastema|
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|Figure 6: Fibrocellular connective tissue consisting of dense collagen fibers interspersed with bony trabeculae and areas of dystrophic calcification|
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| Discussion|| |
First description of ossifying fibroma was given by Menzel in 1872 while the term was given by Montgomery in 1927. It was first described as relatively uncommon, solitary, nonneoplastic gingival growth by Eversol and Robin. ,
POF is found exclusively on the gingiva and does not arise in other oral mucosal location.  Can appear as pedunculated or sessile, nodular mass. Usually, seen in the 1 st and 2 nd decade of life with predilection for females. Most commonly, it is found in incisor-cuspid region of maxillary arch.  Usually, the mass is pink to red in color, slow growing, and asymptomatic. Consistency can vary from firm to hard based on the amount of calcification and ossification. 
Trauma and chronic irritation from subgingival plaque and calculus are considered to be the most common etiologic agent for POF. It is thought to be originating from PDL. Following reasons have been given for such consideration - exclusively seen on gingiva mostly interdental, lesion are in close proximity to PDL, within some lesions oxytalan fibers can be seen, age which is inversely proportional to a number of permanent teeth, and fibrocellular response which is similar to other gingival lesions of PDL origin. 
Howsoever, pathogenesis is still unclear. Certain hypothesis that has been given are - since these are clinically and histologically similar to pyogenic granuloma, some author thought it to be originating secondary to fibrosis of granulation tissue.  Similarly, these have a high predilection for female and the 2 nd decade of life hormones are thought to play an important role. Most widely accepted hypothesis states that the presence of local irritants such as plaque, calculus, overhanging restoration, and ill-fitting denture can lead inflammatory reaction which in turn leads to inflammatory hyperplasia of cells of periodontium and PDL. 
Clinically, it is similar to peripheral fibroma, but histopathologic examination always reveals immature bone and osteoid within the lesion. 
Radiographically, it appears as radio-opaque flecks or patches. Sometimes, separation of the adjacent teeth and occasionally resorption of the adjacent teeth may occur. 
Surgical excision is considered to be treatment of choice.  Improper removal can lead to recurrence. Recurrence rate of POF is high and varies from 7% to 45%.  Neville et al.  suggested that the lesion is removed from periosteum, and the adjacent teeth should be scaled to remove any remaining irritants. This helps in reducing the rate of recurrence. Furthermore, ill-fitting dental appliance and rough restoration if any should be removed. 
There are high chances that these cases can be misdiagnosed as pyogenic granuloma, peripheral giant cell granuloma, or odontogenic tumors, and therefore histopathological examination is essential for accurate diagnosis.  Literature shows that most of the cases of POF have a range of 1 st -2 nd decades, more common in females and maxillary anterior region. Same were the finding of the present case. Hormonal changes were thought to be main etiological agent for the present case; however, minimal plaque could be seen in the region. Therefore, along with surgical excision of lesion removal of risk factor was considered as the treatment of choice.
| Conclusion|| |
A slowly growing soft tissue mass with speckled calcifications in the anterior oral cavity of young adults or children should raise a suspicion of a reactive gingival lesion such as POF. Histopathological examination is essential for accurate diagnosis. Once diagnosed, POF should be treated by total excision to prevent recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]