Peripheral ossifying fibroma, some rare findings.

The peripheral ossifying fibroma (POF) is a benign reactive gingival overgrowth; it occurs mainly in the anterior portion of maxilla in young adults, predominantly among females. The present report describes a case of POF in a male patient, which relapsed ten years later and of the lesion showed superficial bone erosion on surgical excision.

INTRODUCTION

There are many types of localized reactive lesions reported on the gingiva, including focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma (PGCG), and peripheral ossifying fibroma (POF).[123]

These lesions may arise as a result of irritants such as trauma, microorganisms, plaque, calculus, restorations, and dental appliance.[23] The cells of the periodontal ligament are considered to be an important factor in the histogenesis of POF.[345] Clinically, POFs are sessile or pedunculated, usually ulcerated and erythematous or exhibit a color similar to the surrounding gingival.[67]

The POF may occur at any age but exhibits a peak incidence between the second and third decades, the average age being around 28 years.[4] Solitary gingival enlargements in children are relatively common findings and are usually the result of a reactive response to local irritants. The lesions have a more female predilection (Female:Male - 4.3:1) with reported recurrence rate as high as 20%,[26] and a nearly equal maxilla to mandible ratio has been recorded[6] Most lesions are less than 2 cm in size, although larger ones occasionally occur, and in the vast majority of cases, there is no apparent underlying bone involvement visible on the roentgenogram. However, on rare occasions, POF appears to show superficial erosion of bone.[8]

The purpose of this article is to present a case of POF with few uncommon findings. The patient was a male patient with a history of recurrence of the lesion after ten years and showed traumatic bite and parafunctional habits like tongue thrusting habit along with local irritating factors like plaque and calculus. On surgical excision of the lesion by raising a full thickness flap, superficial erosion of bone was also seen.

CASE REPORT

A 27-year-old male patient reported to the department of periodontology and oral implantology, with the chief complaint of a growth of gum tissue in between the upper front teeth [Figure 1]. The lesion had been present for approximately one year. There was no contributory past medical history. Past dental history revealed that patient had a similar growth, which was excised ten years back. He also gave the history of wearing a removable partial denture for a brief period two years back, but he stopped wearing the same as the partial denture broke.

Figure 1

Clinical appearance of lesion

Intra-oral examination revealed a sessile growth (1 cm × 0.7 cm × 0.5 cm) in between the upper central incisors on marginal and attached gingival. The lesion was firm and erythematous having a smooth, non-ulcerated surface. On occlusal examination, the patient had a traumatic deep bite where the lower central incisors interfered with the lesion during biting [Figure 2]. However, the lesion was asymptomatic, with no sign of pain. Upon swallowing, the patient exhibited a habit of tongue thrusting with midline diastema.

Figure 2

Traumatic deep bite interfering with the lesion during occlusion

Radiographic examination

An intra-oral periapical radiograph was obtained. The radiographic examination revealed the superficial erosion of the bone [Figure 3], which was later reconfirmed during surgical excision.

Figure 3

Intra-oral periapical radiograph showing superficial erosion of bone

Differential diagnosis: Irritation fibroma, pyogenic granuloma, and peripheral giant cell granuloma (PGCG) were considered.

Treatment

Full mouth scaling was done to remove local irritants [Figure 4]. Occlusal correction was also done at this stage [Figure 5]. Excision and microscopic examination were planned, and patient's consent for the same was taken.

Figure 4

Pre-operative scaling

Figure 5

Occlusal correction

A full thickness flap was elevated facial to tooth 11, 21 using crevicular incision [Figure 6]. The lesion was excised completely using a 15 no. B.P blade [Figure 7]. The flap was repositioned over the exposed teeth of 11, 21 and stabilized with 3-0 silk sutures under local anesthesia [Figure 8]. During reflection of flap, the superficial erosion of bone was seen [Figure 9]. The excised tissue measured 1 cm × 0.7 cm × 0.5 cm [Figure 10]. The tissue was submitted to the oral pathology division for histopathological examination.

Figure 6

Full thickness flap elevation facial to tooth 11, 21 using crevicular incision

Figure 7

Excision of lesion

Figure 8

Suturing with 3-0 silk suture

Figure 9

Superficial erosion of bone upon reflection of full thickness flap

Figure 10

Excised tissue

Histopathology report read as follow

“H and E-stained soft tissue section shown fibrous connective tissue, which is composed of varying degree of cellularity, which includes plumb hyperchromatic, fibroblasts, calcification (Bone like), dense bundles of collagen fiber, chronic inflammatory cells comprising mostly of lymphocytes, and blood vessels [Figure 11].

Figure 11

Photomicrograph showing features of peripheral ossifying fibroma

Overlying epithelium is parakeratinized stratified squamous epithelium, which shows long and narrow rete ridge."

Diagnosis

The histopathological findings confirmed the lesion as POF.

Follow-up

The patient presented for follow-up examination 7 days, 15 days, and 45 days postoperatively [Figure 12]. The surgical site appeared to be healing well. There was no evidence of recurrence of the lesion, and the patient had no complaints pertaining to the lesion.

Figure 12

Satisfactory healing seen after 45 days

DISCUSSION

Intra-oral ossifying fibromas have been described in the literature since the late 1940s. Many names have been given to similar lesions, such as epulis,[1] peripheral fibroma with calcification,[2] peripheral ossifying fibroma,[23] calcifying fibroblastic granuloma,[9] peripheral cementifying fibroma, and peripheral fibroma with cementogenesis.[10] The sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions.[10]

It has been suggested that the POF represents a separate clinical entity rather than a transitional form of pyogenic granuloma, PGCG, or irritation fibroma.[1] Eversole and Rovin[2] stated that with the similar sex and site predilection of pyogenic granuloma, PGCG and POF, as well as similar clinical and histologic features, these lesions may simply be varied histologic responses to irritation. Gardner[3] stated that POF cellular connective tissue is so characteristic that a histologic diagnosis can be made with confidence, regardless of the presence or absence of calcification. Buchner and Hansen[4] hypothesized that early POF presents as ulcerated nodules with little calcification, allowing easy misdiagnosis as a pyogenic granuloma. The patient was also wearing a removable partial denture, which probably resulted in dental plaque or calculus accumulation, which could have contributed with etiopathology of the POF. Later, the patient also reported of facture of the removable partial denture significantly a deep traumatic bite, which also could be an irritation factor. On clinical examination, the patient also had tongue thrusting habit, which could contribute to the pathological migration of the teeth along with the local irritants resulting in diastema. On radiographic examination, interdental and superficial erosion of bone was seen. And, upon reflecting the full thickness flap during excision, superficial erosion of the bone was also seen.

Frequently, POF arises as an exophytic, ulcerated mass attached to the gingiva that shares similar clinical features with other extra osseous 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.[24] 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 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 of POF.

In the case reported here, the histopathological feature of the POF is characterized by the presence of plumb hyperchromatic fibroblasts, calcification, cells comprising mostly of lymphocytes, and blood vessels.

Most of the lesions are usually <1.5 cm, including in the present case.[5] 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 alteration.[67]

We are of the opinion that the present case wherein the lesion reappeared after ten years, it could have been due to local irritation and traumatic bite, which was triggered when patient was wearing removable partial denture for few months.

The patient was a driver by profession and most of the time on tour for long hours and unable to maintain optimum oral health. This could further increase local irritants like plaque and calculus. After the excision, the patient was also motivated to maintain good oral health care, and his traumatic bite was corrected.

CONCLUSION

The interesting part of this case there, it was a young male patient with recurrent growth after spans ten years and no clinical symptoms. The radiograph revealed superficial erosion of bone, which was reconfirmed during surgical procedure. The histological section confirms our diagnosis of POF by the presence of plumb hyperchromatic, fibroblasts, calcification (Bone like), dense bundles of collagen fiber, chronic inflammatory cells comprising mostly of lymphocytes, and blood vessels. POF resemblance PGCG, pyogenic granuloma, and irritation fibroma; hence, thorough knowledge of the difficult diagnosis and specific lesion is important to draw a conclusion.