Peripheral giant cell fibroma: A rare type of gingival overgrowth.

This case report describes a rare benign tumor in a 21-year-old female was referred to the department of Periodontics, regarding areas of gingival enlargement affecting both the maxilla and mandible on the right side. She was not having any systemic and family history. Surgical excision of the lesions was carried out under local anesthetic. Histopathological examination confirmed the diagnosis of giant cell fibroma. The condition responded to surgical excision and appears to have limited growth potential. It may affect a wide spectrum of ages, but it is most commonly found in young people and can be alarming due to rapid enlargement and ulceration; so careful diagnosis is important to avoid unnecessary aggressive treatment.

INTRODUCTION

Acquired enlargements or tumors’ of periodontal soft tissue result from inflammatory or neoplastic processes. Acute inflammatory enlargements of soft tissues are characterized by rapid growth, pain, and occasionally spontaneous regression. They may be diffuse or localized, fluctuant or hard on palpation and associated with regional lymphadenopathy and tenderness.[1]

In contrast, benign and malignant neoplasm of soft tissue is characterized by progressive growth without remarkable symptoms. They may be diffuse or localized, but seldom show regional lymphadenopathy until late in their clinical course.[2] The growth of benign neoplasm is measured in terms of months or years and they are often found incidentally on routine examination. Here we present a rare case report of peripheral giant cell fibroma, diagnosed incidentally on routine histo-pathological examination of an excised gingival enlargement.

CASE REPORT

Clinical features

A 21-year-old female was referred to the Department of Periodontics, with chief complaints of gingival enlargement of both maxilla and mandible on right side and an inability to chew on that side [Figure 1]. Before one year, she noticed a gingival over growth [Figure 1]. She did not respond to non-surgical periodontal management or the use of chlorhexidine mouthwash.

Figure 1

Preoperative clinical picture of Peripheral giant cell fibroma

An extra-oral examination revealed facial asymmetry and swelling extending anteriorly from angle of the mouth to the angle of the mandible posteriorly and superiorly from the lower eyelid to the base of the mandible inferiorly. The sub mandibular and sub mental lymphnodes were enlarged and palpable.

An intra-oral examination showed occlusal surfaces of all the posterior teeth on right side covered with plaque and calculus. A periodontal examination showed the bluish red gingival extending from maxillary canine to second molar and mandibular first premolar to second molar [Figure 2], with soft and oedematous consistency. A diffuse type of gingival enlargement which we classified as Grade III Enlargement was apparent in affected area. It covered three quarters or more of the crown (Bőkenkamp et al. , 1994). Generalized bleeding on probing with suppuration was present in relation to the area of gingival enlargement along with insufficient width of attached gingival.

Figure 2

Involvement of right side of maxillary and mandibular posterior teeth with gingival enlargement

On hard tissue examination, we found traumatic occlusion with pathological migration of the teeth. Mobility in relation to upper right premolars and molars and lower right molars was also noted.

Radiographic examination revealed horizontal bone loss from distal aspect of mandibular first premolar to second molar and maxillary premolars on the right side and vertical bone loss in relation to maxillary molars in the same region [Figure 3].

Figure 3

OPG of the patient

Treatment of lesion

After clinical and radiographic diagnosis, a complete treatment was planned to get the best possible results. Treatment started with non surgical periodontal therapy including scaling, root planing and polishing with oral hygiene instructions given to the patient, which was completed in three consecutive appointments. Occlusal correction was done to relieve the traumatic occlusion. Inflammation persisted on the right side even after non surgical periodontal therapy. So, a ledge and wedge technique was planned to excise the enlarged tissue, expose the surgical site to approach to furcation involvement and areas of bony defects and contour gingival morphology. After excising the tissue the surgical site was closed with interrupted loop sutures for better approximation. At the 7th day after surgery, patient presented good healing. Follow-up appointments were performed at 14th, 28th day, 3rd month, and 6th month [Figure 4]. An incisional biopsy was done and specimen sent for histopathological examination.

Figure 4

Postoperative clinical picture after 6 months

Histopathological examination

On histopathology examination, it showed normal to hyperplastic stratified squamous epithelium with elongated reteridges [Figure 5]. The underlying connective tissue showed thick, long collagen fibers arranged in bundles with thick plump fibroblasts intermixed with histiocytes and plasma cells with a scattering of fibrocytes. It also showed mononuclear and multinucleated giant cells [Figure 6]. Clusters of odontogenic epithelial rest cells were seen in few areas [Figure 7]. A diagnosis of peripheral giant cell fibroma, a benign tumor, containing multinucleated fibroblasts was made.

Figure 5

Hyperplastic stratified squamous epithelium with elongated reteridges (original magnification ×10)

Figure 6

Arrows show multinucleated giant cells in thick, long collagen fibers arranged in bundles (original magnification ×40)

Figure 7

Arrows show clusters of odontogenic epithelial rest cells (original magnification ×40)

DISCUSSION

Increase in size is a common feature of gingival disease. Accepted current terminology for this condition is gingival enlargement and gingival overgrowth. In a survey of 257 oral tumors, approximately 8% had occurred on the gingiva.[3] In another study of 868 growths of the gingiva and palate, 57% were neoplastic and the remainder inflammatory, the following incidence of tumors was noted: carcinoma, 11%; fibroma, 9.3%; giant cell tumor, 8.4%; papilloma, 7.3%; leukoplakia, 4.9%; mixed tumor, 2.5%; angioma, 1.5%; osteofibroma, 1.3%; sarcoma, 0.5%; and melanoma, 0.5%.[3]

Fibroma of the gingiva arises from the gingival connective tissue or from the periodontal ligament. They are slow-growing, spherical tumors that tend to be firm and nodular, but may be soft and vascular. Fibromas are usually pedunculated. Hard fibromas of the gingiva are rare; most of the lesions diagnosed cinically as “fibromas” are inflammatory enlargements.

The differential diagnoses of the benign lesions of periodontal tissue are pyogenic granulomas, hemangiomas, peripheral giant cell granulomas, and peripheral ossifying fibromas (Steven D. Vincent).

Giant cell lesions of the oral cavity demonstrate variable clinical behavior and histopathologic features. Peripheral giant cell fibromas occur only on the gingiva or alveolar mucosa and are more common in women than in men.[4] It can occur at any age, but are most common in children and young adults.[5] The lesions are vascular and red or purple in color.[6] A number of reports indicate that minor trauma often precedes the development of the lesions.

In the present case, clusters of odontogenic epithelial rest cells were also noted. There was no evidence of mineralization, e.g. bone, osteoid, acellular cementum, or dystrophic calcification. So we ruled out the possibility of peripheral ossifying fibroma. However, they usually respond to conservative surgical curettage or excision. Recurrences have been reported, but were readily controlled by local measures.[7] Careful diagnosis of this benign tumor is important to avoid unnecessary aggressive therapy. A conservative surgical treatment provide an excellent prognosis.[8-10]