Management of massive peripheral ossifying fibroma using diode laser.

Peripheral ossifying fibroma (POF) represents a non-neoplastic, reactive lesion of gingiva. The precise etiopathogenesis of POF is unclear; however, it is suggested to originate from the connective tissue of periodontal ligament. This lesion predominantly occurs in the maxillary anterior region. The standard treatment protocol involves surgical excision followed by the biopsy of lesion. The reactive nature and unpredictable course attribute to a high recurrence rate of the lesion; hence, proper postoperative monitoring and follow-up of the lesion are necessary. The present case was surgically managed using diode laser and did not show any sign of recurrence during the follow-up period of 6 months. Minimum intraoperative bleeding and postoperative pain, ease of operation, and patient's acceptance enable laser-assisted growth excision as a better treatment modality to other conventional surgical procedures, thus offering diode laser as a viable and effective treatment alternative in the management of massive overgrowth.

INTRODUCTION

Peripheral ossifying fibroma (POF) is an inflammatory, reactive lesion of gingiva, which predominantly involves the maxillary anterior region.[12] It is non-neoplastic, originating from periodontal ligament (PDL) as a response of periodontal tissues to chronic injurious agents such as – dental calculus, plaque, orthodontic appliances, and ill-fitting restorations, etc.[3] It is commonly observed in the second and third decades of age, with females affected more than males. About 60% of these tumors occur in the maxilla, and more than 50% of the cases are found in the incisors and canine region.

Most of the POF lesions are approximately <2 cm. Radiographically, no bony involvement is apparent in the majority of cases. However, some cases may report with superficial erosion of the bone. The management of POF includes the elimination of local irritating factors with strict plaque control along with surgical excision of overgrowth.

Laser offers an advanced and promising treatment modality in the surgical management of such reactive lesions. Different wavelengths of lasers are used depending on soft-tissue and hard tissue management. Various types of lasers include carbon dioxide (CO2) laser, neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, erbium, chromium:yttrium-scandium-gallium-garnet (Er, Cr:YSGG), and diode laser. Lasers, such as the CO2, Nd:YAG, and diode, have been used in various surgical procedures such as – excision of intraoral soft-tissue lesions and mucogingival surgeries.[4] Hereby, the present case is an attempt to discuss the application of diode laser in effective and successful management of massive POF.

CASE REPORT

A 56-year-old female patient reported to the Department of Periodontology with the chief complaint of enlarged gums in the upper front teeth region since 6 months, resulting in difficulty on mastication and interference in occlusion. History of the present lesion revealed that initially the growth was small, which increased gradually over 6 months, attaining the present size. Growth was often associated with bleeding while brushing. Past dental history revealed exfoliation of severely mobile 11, 21, and 22. The patient had not visited any dentist after she had undergone the extraction of 18 and 38 due to gross caries 4 years back.

Periodontal examination revealed a solitary gingival overgrowth (GO) approximately 3.5 cm × 4 cm × 3 cm extending mesiodistally from the mesial aspect of maxillary right canine to mesial aspect of maxillary left canine (only maxillary right lateral incisor was present in this site) with buccopalatal extension covering the entire residual alveolar ridge (w.r.t 11, 21, and 22) and occlusal surface of maxillary right lateral incisor [Figure 1a and b]. The overgrowth was reddish in color, pedunculated, with ulcerated overlying mucosa, and well-defined margins. The GO did bleed on provocation. The indentation of lower teeth could be observed on an occlusal aspect of the growth. The oral hygiene status of the patient was poor with the presence of abundant local factors such calculus and plaque. Degree III mobility (Miller's index) was present with respect to the maxillary right lateral incisor. Generalized clinical attachment loss was present in rest of the dentition.

Figure 1

(a and b) Clinical presentation of gingival overgrowth. (a) Labial view showing mesiodistal extension; (b) Occlusal view showing buccopalatal extension with indentation over the incisal surface

On palpation, the GO was non-tender, non-pulsatile, non-fluctuant, firm in consistency, and non-compressible. Other oral clinical findings were root stump in relation to 36, proximal caries with respect to 16, 17, 26, 27, and 46. However, the patient was primarily concerned with the overgrowth present.

Radiological findings of orthopantomogram in the concerned area revealed faint radio-opacity in the region extending from tooth no. 13 to 23 with distal tipping of tooth no. 12. Soft-tissue shadow with interspersed radio-opacity simulating bone signifies the presence of ossification [Figure 2]. Periapical radiolucency reflecting infection was seen in relation to 36 and 46.

Figure 2

Orthopantomogram of patient

A provisional diagnosis of peripheral giant-cell granuloma and differential diagnosis of irritational fibroma and POF were considered on the basis of anatomic location and clinical presentation.

Two weeks after the completion of Phase I therapy, laser-assisted surgical excision of the growth was planned, and the treatment was explained comprehensively to the patient. After patients’ consent and required hematologic investigations, excisional biopsy using 940-nm diode laser (Biolase®) using a surgical fiber optic tip of 400 μm at power setting 1.2 watts in a pulsed P3 mode (50 ms On and 50 ms Off) was executed along with extraction of mobile maxillary right lateral incisor [Figure 3a and b]. Excised tissue sample fixed in 10% formalin was sent for histopathological examination. Protective eye gears were used by the operator, assistant, and the patient. High vacuum suction was used during the procedure.

Figure 3

(a) Immediate postoperative view; (b) Excised soft-tissue growth with extracted 12

Histopathological examination revealed the presence of parakeratinized stratified squamous epithelium at the surface. Underlying stroma was fibrocellular with scattered islands of variable sized osteoid tissue (both mature lamellar and immature women bone). Osseous tissue calcification showed peripheral osteoblastic rimming at places. Few endothelial cell proliferations and inflammatory cells were also noted within the tissue. Overall, the histopathological features were suggestive of POF [Figure 4a–d].

Figure 4

(a-d) Histopathological section of excised tissue reveals the presence of stratified squamous epithelium at the surface with underlying fibrocellular stroma at (a, ×20; b, ×40). Scattered islands of osseous tissue with osteoblastic rimming are also noticed (c, ×20; d, ×40), respectively

Based on the clinical presentation, radiological findings, and histopathological features, a confirmatory diagnosis of POF was made.

One week after the treatment, a superficial thin layer of denatured collagen was present, and in 1 month, the wound was completely healed. The postoperative healing was uneventful. The patient had stopped taking analgesics the next day after the surgery as the patient was comfortable and asymptomatic. No antibiotics were prescribed to the patient preoperatively/postoperatively. The patient was followed every month for 6 months [Figure 5a and b]. No evidence of recurrence was reported until the last follow-up.

Figure 5

(a and b) Postoperative follow-up of 1 month

DISCUSSION

The focal reactive lesions of gingiva are grouped as – pyogenic granuloma (PG); POF; fibrous hyperplasia; and peripheral giant-cell granuloma (PGCG). The prevalence of POF among reactive lesions is 20.78%.[3] The first case of ossifying fibroma was reported by Menzel in 1872, however, the terminology was given by Montgomery in 1927. Ossifying fibroma can be categorized into two categories – central and peripheral. The central type has its origin from endosteum and expands from medullary cavity of bone, whereas, the peripheral type is suggested to originate from PDL or from the soft-tissue overlying alveolar process (periosteum).

Usually, the size of POF is <2 cm; however, in the present case, it was a massive growth of 3.5 cm × 4 cm × 3 cm. Poon et al. have mentioned a case of giant POF measuring approximately 9 cm.[5] Many studies have been conducted to understand the etiopathogenesis of POF, however, the exact mechanism is still undefined. Few researchers have suggested that the low-grade chronic irritation caused by local factors results in inflammatory hyperplastic cellular response of PDL/periosteum, in the form of metaplastic changes in connective tissue.[36] Calcified metaplastic changes of the connective tissue may manifest in many histologic variants such as bone, cementum-like material, and dystrophic calcification. Some authors have interrelated the occurrence of POF and PGCG, and they mentioned that both the lesions are the progressive forms with the same spectrum of pathogenesis.[7]

Other group of researchers has suggested the influence of hormones as one of the factors in the etiopathogenesis of POF and considered it to be responsible for the higher prevalence in females.[2] Regezi et al. found a large number of XIIIa + cells and a subset of monocyte/macrophages, in POF and in other oral fibrovascular reactive lesions; they hypothesized the role of dendrocytes in these lesions.[8]

Differential diagnosis of POF from other reactive lesions such as – peripheral giant-cell granuloma, PG, traumatic fibroma, and peripheral odontogenic fibroma is of utmost importance for the accurate diagnosis and management of lesion [Table 1].[9] Clinically, POF can be differentiated from PGCG, as POF lacks the purple or blue discoloration commonly associated with PGCG. POF often shows foci of radio-opacities on the radiograph. PG presents soft, friable hemorrhagic nodule, which may or may not show calcification. Furthermore, tooth displacement and resorption of alveolar bone are rarely observed in PG. Traumatic fibroma usually occurs on buccal mucosa along the bite line. Peripheral odontogenic fibroma is an uncommon neoplasm that is believed to arise from odontogenic epithelial rests in PDL or attached gingiva itself.

Table 1

The important differences between peripheral ossifying fibroma, peripheral odontogenic fibroma, counterpart of ossifying fibroma, and central odontogenic fibroma

POF	POdF	COF	COdF
Classified under benign connective tissue lesion and may arise due to inflammation (reactive).	Classified under odontogenic tumours of ectomesenchyme with or without included epithelium (Neoplasm).	Classified under fibro-osseous lesions and represents an osteogenic tumour (Neoplasm).	Classified under odontogenic tumours of ectomesenchyme with or without included epithelium (Neoplasm).
Common lesion occurring only on gingiva.	Rare lesion of gingiva.	Common lesion in long bones, but rare in skull and jaw bones.	Very rare lesion occurring in jaw bones.
It does not represent a soft tissue (extraosseus) counterpart of COF.	It is a soft tissue (extraosseous) counterpart pf COdF.	Present centrally (intraosseous) - a distinct lesion from POF.	Present centrally (intraosseous) - related to POdF.
No further types of subclassifications.	Histologically same as WHO type of COdF in gingiva.	It is of two types:	It is of two types:
		i. Psammomatoid,	i. Simple type (with no mineralization),
		ii. Juvenile type	ii. WHO type (with bone/cementum).

POF, Peripheral ossifying fibroma; POdF, Peripheral odontogenic fibroma; COF, Counterpart of ossifying fibroma; COdF, Central odontogenic fibroma

Histopathological investigation is a definitive approach to reach a confirmatory diagnosis of reactive lesions. Histologically, POF can be differentiated from PGCG as the number of giant cells, overlying ulcerated epithelium is more frequent in PGCG, whereas, peripheral odontogenic fibroma contains odontogenic epithelium and dysplastic dentine; all these features are not seen in POF. POF is characterized by the presence of numerous fibroblasts, fibrocytes, fibrocellular stroma, mineralized foci simulating bone, cementum-like material, and dystrophic calcified structures.[167]

Elimination/correction of injurious agents, effective plaque control, good patient motivation, and precise surgical excision is the key for successful management of reactive gingival lesions. Various treatment modalities, such as conventional scalpel, electrosurgery, cryosurgery, etc., for the surgical excision of overgrowth, are being used for decades. Introduction of the laser is an innovative approach for the surgical management of overgrowth.

Semiconductor diode lasers (gallium arsenide and gallium-aluminum-arsenide) operate in a wavelength range of 810–980 nm. Diode laser has “hemoglobin” as one of their target chromophores; hence, they provide effective hemostasis at the surgical site. In the present case, the growth was massive, and excision with scalpel would have led to profuse bleeding; therefore, excision by the diode laser was preferred over the conventional technique. A good hemostasis could be achieved in the present case using diode laser. The clean field facilitated better vision, control, and access to operator; thereby, enabling complete excision and preventing the chances of recurrence. Similar observations have been documented by many researchers.[310] POF exhibits high recurrence rate (16%–20%),[3] which can be attributed to its reactive proliferation, incomplete excision, failure to eliminate local irritants, and difficulty in access during surgical excision due to its intricate location. Deep excisions have been preferred to avoid recurrences. There was no sign of recurrence of the lesion during the follow-up period of 6 months in our case. A case report by Chugh et al. supports similar observations.[11]

Antibiotics were not required in the present case which can be attributed to the bactericidal effect of laser phototherapy.[12] Furthermore, the patient was comfortable and has stopped taking analgesics after 24 h, this can be explained as laser application results in instant sterilization of surgical site, reduced bacteremia, decreased trauma, minimal postoperative swelling and pain, less wound contraction, and minimal scarring.[1314] Application of the laser reduces the psychological burden of scalpel surgery, thus reducing the anxiety and imparting a positive outlook in the patient toward dental treatment. Studies have shown the reduced need of local anesthesia, suturing, periodontal dressing, and postoperative medications with the use of lasers.

Definite steps should be practiced to safeguard the use of lasers. Wavelength-specific eye gears should be used by operator, assistant, and patient to prevent the retinal damage. High-speed evacuation device is to be used to eliminate the laser plumes produced during the procedure. Wherever, possible lasers should be used in pulse mode to provide thermal relaxation to the operating tissues. Limitations encompass necessary training and education for better understanding of various laser systems. They are associated with high investment cost, and also the clinician needs multiple lasers of different wavelength for various procedures. Lasers can cause inadvertent thermal damage to the surrounding tissues such as – pulpitis, necrosis, and microfractures.

CONCLUSION

The present case report highlights the advantages of diode laser-assisted overgrowth excision. The authors emphasize the ease of using diode laser with better predictable results, without any recurrence of growth. Nevertheless, more cases with longer follow-ups should be carried out to establish the outcome. Hence, lasers are valuable and promising treatment modality over the conventional techniques in reactive lesion excisions.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.