Laser excision of peripheral ossifying fibroma: Report of two cases.

Peripheral ossifying fibroma (POF) is a non-neoplastic enlargement seen more often in females, in the interdental papilla and the anterior part of the maxilla, accounts for about 9% of all gingival growths. Of unknown etiology, unpredictable clinical course and pronicity for recurrence, POF is a clinician's cause for concern. Surgical excision is the treatment of choice, but with a reported recurrence rate of 7-45%, the management is often frustrating. With increasing acceptance of lasers in the repertoire of clinician's armory, laser excision of such lesions has become a possible, feasible, and patient-preferred approach. The purpose of this article is to report successful management and 1 year follow-up of two cases of POF using neodymium-doped yttrium aluminum garnet (Nd: YAG) laser. The absence of operative bleeding, relative ease of the procedure and patient acceptance lends the laser excision as an alternate therapeutic modality for excision of gingival enlargements of suspicious and vexatious nature.

INTRODUCTION

Ossifying fibromas occurs mostly in craniofacial bones and has been described in literature since late 1940s.[1] They are generally categorized into 2 types, peripheral and central ossifying fibroma. The peripheral ossifying fibroma (POF) is a non-neoplastic enlargement of gingiva that is thought to be reactive in nature and not necessarily the peripheral counterpart of cement-ossifying fibroma.[2]

POF is typically a solitary, slow-growing nodular mass that is either pedunculated or sessile and has been cited in the literature under various names such as peripheral fibroma with osteogenesis, calcifying fibroblastic granuloma, peripheral cementifying fibroma etc.[34]

Surgical excision is the treatment of choice for POF.[5] Adjunctive local periodontal treatment in the form of scaling and root planing may ameliorate to only a negligible extent. One vexatious issue with surgical treatment of POF is the rate of recurrence which is reported to vary from 7% to 45%.[6] Traditionally lesions like POF have been treated with scalpel surgery, which has been further refined with the use of electrocuatery.[1] With the advent of soft-tissue lasers in the last two decades, attempts have been made to approach excision of such lesions with lasers. A review of literature has revealed two reports, which attempted use of lasers in the treatment of POF.[78] The present paper reports the successful management and 1 year follow-up of two cases of POF using neodymium-doped yttrium aluminum garnet (Nd: YAG) laser and advocates the use of lasers in the repertoire of a clinician.

CASE REPORTS

Case 1

A 32-year-old male reported to the author's practice in August 2011 with a complaint of growth in the gums. The growth started 6 months previously and slowly progressed to the present size. It was painless and the patient's complaint was discomfort because of cosmetic reasons. Extraoral examination did not reveal any abnormalities and there were no palpable regional lymph glands.

Intraoral examination showed a neglected mouth with poor oral hygiene as reflected by heavy accumulation of plaque. Except for plaque and calculus associated chronic gingivitis, patient had no overt periodontal disease, teeth mobility or loss of attachment in general.

On examination a pedunculated, enlarged interdental papilla in the region of maxillary right central and lateral incisor measuring around 1 cm × 1.5 cm was observed. The growth was pinkish red, soft with a smooth surface and was not ulcerated [Figure 1]. There was no spontaneous bleeding, but when gently handled with a blunt probe, bleeding was elicited indicating inflamed and engorged tissue. The teeth in the area of enlargement were vital, did not show any periodontal pockets except the deeper sulcus because of the enlargement.

Figure 1

Pre-operative

Intraoral periapical radiographs revealed no abnormality with normal periodontal ligament space, lamina dura and periapical tissues. An orthopantomogaph was taken to have a broader view of the jaws and did not reveal any bony lesions or pathology, which would have any relevance to the gingival enlargement directly or indirectly.

Patient was systemically healthy, there were no relevant medical problems, he was not on any medications and a hemogram and fasting blood sugar levels were within normal range.

Case 2

The second case involved a 35-year-old female who presented in the month of October 2011 with a similar overgrowth in relation to right maxillary canine and premolar region. Patient noticed it approximately 4 months before and reported that it was painless, but occasionally bleeding on tooth brushing and causing some esthetic problem with people around her noticing the red mass and commenting about it. Patients medical history was non-contributory and there was no extraoral changes. On examination a reddish, not too well defined mass of tissue approximately measuring 2 cm × 1.5 cm in the interproximal area was observed. The lesion extended onto the palatal aspect and revealed indentations made by the occluding mandibular teeth. The growth was pedunculated, not ulcerated and there was slight bleeding on gentle probing. There was no loss of attachment and no true pockets. Oral hygiene was fair with only slight plaque and calculus with resultant chronic generalized gingivitis. There was perceivable halitosis. There was no involvement of regional lymph glands.

A provisional diagnosis of pyogenic granuloma and differential diagnosis of irritational fibroma and POF were considered as possibilities in both cases.

Treatment

Teeth in the area of involvement were thoroughly root planed and debrided. Patients were put on a regimen of 0.2% chlorhexidine mouthwash and necessary oral hygiene instructions were given. The enlargement did not show perceptible improvement except for very slight reduction in inflammation and the option of surgical excision was considered at this stage. Patients were explained about the necessity for surgical excision under local anesthesia and were also given the choice of undergoing the excision either with traditional surgery or laser approach. After patient's consent for the laser procedure necessary pre-surgical screening were performed.

Excision technique

In both the cases, identical procedure for laser excision was followed using Nd: YAG laser (Fidelis plus III, Fotona; Ljubljana, Slovenia). Standard safety precautions for the patient, operator and the assistant were adhered to according to manufacturer's advice. After a pre-procedural rinse, 2 ml anesthetic solution (2% lignocaine hydrochloride) was infiltrated 1 cm from the margins of the lesion.

Nd: YAG laser irradiation was delivered through an optical fiber with 300 μm fiber at 4 W, 50 Hz, Long pulsed (LP) as recommended by the manufacturer in contact mode to control the depth of penetration. The lesion was excised 0.5-1 mm beyond its clinical extent and the underlying surface was thoroughly curetted and root planing was carried out on the adjacent teeth using the periodontal curettes. There was no bleeding and tissues were well coagulated during the entire procedure [Figure 2]. Patients were discharged with necessary post-operative instructions. Analgesics (Ibuprofen 200-400 mg) were prescribed to be taken as and when required and 0.2% chlorhexidine mouth rinse was advised twice daily for 4 weeks.

Figure 2

Immediately laser excision

The excised specimens after due processing were evaluated and a final diagnosis of POF was arrived at by the Pathologist. The light microscopic examination section showed cellular fibrous connective tissue. The fibrovascular tissue comprised of a large number of plump proliferating fibroblasts intermingling throughout in a delicate fibrillar stroma. The overlying squamous epithelium was intact. Within this cellular fibrous connective tissue, different forms of mineralized structures were observed, ranging from few immature cellular bone/woven bone type to droplets of calcified material resembling acellular cementum. Few endothelial cell proliferations and inflammatory cells were also noted within the tissue. All the histopathological features were suggestive of a diagnosis POF [Figures 3 and 4].

Figure 3

Photomicrograph showing cellular fibrous connective tissue with an overlying stratified squamous epithelium (H and E, ×4)

Figure 4

Photomicrograph showing mineralized structures in the form of immature woven bone and cementum like droplets (H and E, ×10)

One week after the treatment, a superficial layer of fibrin was present and 4 weeks after surgery the wound has completely healed [Figure 5]. Post-operative healing was uneventful. Patients were reviewed regularly for 1 year. No recurrence was observed during the 1 year follow-up [Figure 6].

Figure 5

One week follow-up

Figure 6

One year follow-up

DISCUSSION

A common growth accounting for about 9% of all gingival growths, POF is a non-neoplastic enlargement seen more often in females, in the interdental papilla and the anterior part of the maxilla.[9] The predilection of POF to occur in the anterior part of the maxilla is disputable with another source stating that mandible especially the pre-molar and molar areas being the common sites of involvement.[10]

The etiology is not known though various possibilities are suggested often without any corroboration and include, trauma, local irritants in the form of plaque and calculus, ill fitting dentures, and poor restorative dentistry. The higher prevalence in females and occurrence in early ages suggests a hormonal influence.[9]

It has been suggested that the origin of this growth is odontogenic or from periodontal ligament. However, microscopically identical neoplasms with cementum such as differentiation also have been reported in the orbital, frontal, ethemoid, sphenoid, and temporal bones consigning the issue of origin to question.[10] The periodontal ligament origin appears plausible for the reasons that the lesions occur exclusively in the gingiva, their proximity to the periodontal ligament; and the fibrocellular response, which is similar to the other reactive gingival lesions of periodontal ligament origin.[11]

There have been a plethora of reports with reference to POF and its management. Although not life threatening, the gingival growth should always be viewed with circumspection. Histopathological examination of the excised tissue is the sine quo non in this type of lesions as rarely an occasional innocuous and benign looking lesion may sometimes prove to be a dangerous malignant lesion. Gingival squamous cell carcinomas masquerading or mimicking soft gingival overgrowth are indeed reported and an astute practitioner should be wary of non-resolving soft-tissue lesions of considerable duration.[12]

One vexatious issue with surgical treatment of POF is the rate of recurrence which is reported to vary from 7% to 45%.[6] Yet another source has given the rate of recurrence at 8.9%,[13] 14%,[9] 16%,[2] and 20%.[4] Nazareth et al., excised a 3 cm × 2 cm lesion and after 3 months there was a suggestion of recurrence.[14] Sometimes the recurrence is swift and remorseless and nothing would be more disconcerting to the clinician than facing such a piquant situation. It mandates that all patients with such lesions should be forewarned about recurrences in spite of best surgical technique and judgment.

The extremes in recurrence statistics are attributable to surgical technique and the thoroughness of it. A cursory removal and casual curettage is more often likely to result in a recurrent lesion than the one thoroughly excised and the base of the lesion adequately scraped. It has been suggested that the lesion be removed down to the periosteum and adjacent teeth adequately divested of deposits hence that any irritant are eliminated.[10] Concomitant correction of any restorations and prosthetic appliance is mandatory. Often large lesions after thorough excision leave unsightly gingival margin defects in the esthetic zones of maxilla and this should be anticipated and an astute clinician will be forearmed with necessary defect coverage procedures like subepithelial connective tissue graft.[15]

Lasers are not new to dental surgery and have been in vogue for the last 3-4 decades for various intraoral procedures. Oral surgical procedures including removal of soft-tissue tumors, frenectomies, excision of gingival hyperplasias, vestibuloplasties, hemangioma removal, and periimplant soft-tissue surgery have been successfully carried out using the various wavelengths of lasers.[16] When incising pathologic tissues for biopsy laser provides many advantages over steel surgical instruments including, a dry and bloodless surgery, reduced bacteremia at the surgical site, reduced mechanical trauma with resultant lessened psychological trauma for the patient, minimal scarring, and wound contraction accelerating recovery and post-operative function. Nd: YAG laser has been successfully used for excision of pyogenic granuloma because of the lower risk of bleeding compared to other surgical techniques.[17]

Successful laser surgery in 70 patients without anesthesia and minimum bleeding compared to scalpel surgery was reported two decades ago and it was concluded that laser excision is well- tolerated by patients with no adverse effects and that CO2 and Nd: YAG laser irradiation is a successful treatment option.[18]

Alam et al., did laser excision in a young patient with cemento-ossifying fibroma of 3 cm × 2.5 cm and claimed that it was the first time such a lesion was treated with laser excision (diode).[8] Iyer et al., very recently reported a case of successful laser excision of POF with very little intraoperative bleeding, post-operative pain, and sutureless exercise, excellent healing at the end of 1 week and suggested that laser excision as one of the best option for management of POF. They however, recommended a study of the series of such laser excisions so that recurrence patterns if any can be evaluated.[7] To the best of our knowledge, the present report is the first of its type where laser has been used to excise two case of POF with a follow-up period of 1 year.

CONCLUSION

Of unknown etiology, unpredictable clinical course, and pronicity for recurrence, POF is a clinician's cause for concern. The report of two cases of excision with laser and the absence of recurrence over a period of 1 year makes the laser approach a promising treatment option.