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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 56-61
Mineralized components and their interpretation in the histogenesis of peripheral ossifying fibroma


Department of Oral Pathology, I.T.S Dental College & Research Centre, New Delhi-Meerut Road, India

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Date of Submission23-Nov-2009
Date of Decision28-Jul-2010
Date of Acceptance10-Nov-2010
Date of Web Publication25-Apr-2011
 

   Abstract 

Background: Peripheral ossifying fibroma (POF) is a lesion of gingival tissue that predominantly affects women and is usually located in maxilla, anterior to molars. The definitive diagnosis is established by histopathological examination, which reveals the presence of cellular connective tissue with focal calcifications.
Objective: This study hypothesizes the histogenesis of POF by analyzing the diverse spectrum of mineralized components with a polarizing microscope.
Materials and Methods: A retrospective study was undertaken which involved a detailed review of clinical, radiographic and histopathological features of 22 cases of POF, retrieved from departmental archives. These cases were subsequently stained with a histochemical stain (van Gieson) and observed under a polarizing microscope.
Results: The study revealed that the most common age of occurrence was in second and third decades with a strong female predilection (73%), Interdental papilla of the maxillary anterior region was the most commonly afflicted site. About 90% cases showed no radiographic features.Histopathological examination showed that 73% cases consisted of a fibrocellular connective tissue stroma surrounding the mineralized masses. 50% mineralized masses comprised of woven bone, 18% showed combination of lamellar bone and cellular cementum, 18% showed only cementum (cellular and acellular), and remaining 13.6% exhibited a mixture of woven and lamellar bone under polarizing microscope.
Conclusion: The study supports the theory that POF develops from cells of periodontal ligament (PDL)/periosteum as undifferentiated mesenchymal cells having an inherent proliferative potential to form bone or cementum, whose nature can be confirmed by polarizing microscope.

Keywords: Histogenesis, mineralized masses, polarizing microscopy

How to cite this article:
Shetty DC, Urs AB, Ahuja P, Sahu A, Manchanda A, Sirohi Y. Mineralized components and their interpretation in the histogenesis of peripheral ossifying fibroma. Indian J Dent Res 2011;22:56-61

How to cite this URL:
Shetty DC, Urs AB, Ahuja P, Sahu A, Manchanda A, Sirohi Y. Mineralized components and their interpretation in the histogenesis of peripheral ossifying fibroma. Indian J Dent Res [serial online] 2011 [cited 2014 Aug 20];22:56-61. Available from: http://www.ijdr.in/text.asp?2011/22/1/56/79976
Exophytic gingival lesions represent one of the most frequently encountered lesions in the oral cavity. Based on clinical appearance, different lesions are often indistinguishable from one another. These lesions are a result of trauma or chronic irritation, or they can arise from cells of the periodontium, periodontal ligament, or periosteum. Some of the most commonly encountered exophytic gingival lesions are irritation fibroma, peripheral ossifying fibroma, pyogenic granuloma, and peripheral giant cell granuloma. Each of the mentioned lesions has been associated with or related to trauma or low-grade irritation as an etiologic factor, and these are generally considered to be reactive and or non neoplastic. The treatment for each of these lesions is surgical excision. [1]

The peripheral ossifying fibroma mainly affects women in second decade of life. The lesions are most often found in gingiva, located anterior to molars and in the maxilla. Clinically it manifests as a slow growing gingival mass measuring approximately 2 cm in size and is located in interdental papilla region. The base may be sessile or pedunculated, the color is identical to that of gingiva or slightly reddish or the surface may appear ulcerated. It displays variable degrees of bone calcification and mineralization, and is believed to arise from the periodontium or periodontal ligament. [2] The mineralization is found within a non-encapsulated proliferation of fibroblasts. A chronic inflammatory infiltrate is commonly seen around the periphery of the lesion. Histologically, the peripheral ossifying fibroma consists of a fibrocellular component with focal deposits of bone, some cementum, as well as irregular amounts of dystrophic calcification. [3]

Prognosis is good, but some instances of recurrence have been reported regularly in various studies. Incidence of recurrence has been put at 16-20% by various studies. [4],[5],[6] Reasons for recurrence include a) incomplete removal of lesion, b) failure to eliminate local irritants and c) difficulty in access during surgical manipulation due to intricate location of POF being present usually at interdental areas. Deep excisions have been preferred as interjection to these recurrences.

Various reasons have been given for the diverse clinico-pathological behavior/spectrum of these lesions. The current study analyzes the histological spectrum seen in diiferent cases of POF and hypothesizes its possible histogenesis through interpretation of the mineralized components in POF with the use of polarizing microscopy.


   Materials and Methods Top


In the present study, 22 cases of previously diagnosed POF, retrieved from the departmental archives between March 2005 and December 2009, were subjected to clinical and histopathological analysis. All the 22 cases were analyzed by three different observers separately. The radiographs were assessed wherever necessary to assess any probable bone loss, if present. Clinically, the cases were examined for the following criteria: a) age, b) sex, c) site of the lesion and d) size of the lesion. Radiographically, the cases were evaluated for presence or absence of bone resorption. Twenty two tissue blocks of the selected cases were retrieved for sectioning using LEICA microtome, and 3-μm thick hematoxylin and eosin (H and E) sections were prepared. H and E stained sections were assessed for a) fibroblast population, b) nature of collagen and c) nature of the stroma around the mineralized tissue.

To evaluate the mineralized masses, 3-μm thick sections were taken as previously mentioned and stained with van Gieson[7] and subjected to polarizing microscopic analysis (Olympus System Microscope, Model BX41, Olympus Corporation, Tokyo, Japan). The varying polarizing patterns were further evaluated to quantitate the type of mineralized tissue present in the section. The criteria employed were based on the works of Giansanti [8] who pioneered the identification of these mineralized masses using polarizing microscopy.


   Results Top


The clinical features were enumerated and grouped [Table 1]. Majority of the cases showed a female predilection (73%), with the majority of the cases getting commonly affected in their second and third decades of life. The most common site affected was the interdental papilla of the incisor/cuspid region [Figure 1]. Most of the lesions measured 0.5-1.5 cm in size/dimensions. Clinically, the lesions were seen as red to pink nodular mass which were usually sessile and firm in consistency. The radiographic findings varied from none to slight saucerization of the cortical bone. Also, 90% of the cases showed no radiographic manifestations.
Figure 1: Clinical photograph showing typical presentation of POF involving the interdental papilla of 12 and 13

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Table 1: Clinical details of the specimen

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The various histopathological features are summarized and grouped in [Table 2]. Majority of the cases (73%) showed a fibrocellular connective tissue stroma [Figure 2] with plump fibroblasts around the mineralized areas [Figure 3]. The collagen seen was predominantly mature with few cases also showing areas of hyalinization.
Figure 2: Section showing mineralized tissue in fibrocellular connective tissue stroma (H and E, magnification ×10)

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Figure 3: Section showing high fibroblastic activity around mineralized masses (H and E, magnification ×40)

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Table 2: Histopathological details of the specimen

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On subjecting these 22 cases to polarizing microscopy, varying characteristic patterns were seen [Table 3]. Eleven out of the total (22) cases studied showed the presence of only woven bone [8] (50%) [Figure 4], 4 cases showed the presence of lamellar bone in combination with cellular cementum (18%) [Figure 5], whereas 4 cases showed the exclusive presence of cementum (cellular and acellular) (18%) [Figure 6] and [Figure 7] and 3 cases showed mixture of woven and lamellar bone (13.6%).
Figure 4: Section showing woven bone (random arrangement) under polarized light (van Gieson, magnification ×40)

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Figure 5: Section showing lamellar bone and cementum under polarized light (van Gieson, magnification ×40)

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Figure 6: Section showing cemental masses (cellular cementum with quilt appearance) under polarized light (van Gieson, magnification ×40)

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Figure 7: Section showing cemental masses (acellular cementum with typical brush border appearance) under polarized light (van Gieson, magnification ×40)

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Table 3: Polarizing pattern of mineralized tissues in study group

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   Discussion Top


Previously, POF was referred by many synonymous terms such as peripheral fibroma with calcifications, ossifying fibrous epulis and calcifying fibroblastic granuloma. It was Gardner in 1982, who advocated the term POF for a lesion that is reactive in nature and that it is not the extraosseous counterpart of central ossifying fibroma of maxilla and mandible. [9] This was also supported by a study conducted by Sousa et al.[10] who used proliferative markers such as AgNORs and PCNA which showed that there was increased proliferative activity in central ossifying fibroma when compared with POF.

The present study represents the plethora of clinico-pathological presentations as evident in POF. In the review of our 22 cases, POF was seen to affect younger individuals, with the majority of cases seen in second and third decades of life (16-28 years). This correlates well with the report of Bhasker et al.[11] Only one case in the present study was seen involving a 50-year-old female patient. The high female affliction (16:6; F > M) in the current study is in keeping with similar findings in the literature. [11] The consideration of POF being present in the close vicinity to the tooth/teeth bearing areas of the jaw needs to be emphasized. This association, as previously substantiated by Waldron et al., [12] has been observed in the present study too. Eversole, [13] in his study, has shown that the most common location of involvement for POF is the anterior maxilla with a strong localization to the interdental papilla of incisor/cuspid region. The present study also showed similar findings as 54% of the cases were seen to involve the interdental papilla of maxillary incisor/cuspid region. POF usually measures <1.5 cm in diameter but patients with lesions of 6 and 9 cm diameter have been reported. [14] The lesions in the present study usually were of 0.5-1.5 cm in diameter. Clinically, POF occurs as a solitary, pink to red, firm nodular lesion which may be sessile/pedunculated. [15]

Histopathologically, several variations were observed, with equal number of cases showing ulcerated epithelium and others showing hyperplastic epithelium. In the current study, three-fourth of the cases showed fibrocellular connective tissue stroma with fibroblast showing moderate-high activity. Occurrence of plump fibroblasts with vesicular nucleus was a common feature. The plump fibroblasts can be considered to be representative of the undifferentiated mesenchymal cells arising from PDL, whereas, if the fibroblasts are spindle shaped, they may represent a metaplastic change as seen in pyogenic granuloma. A very characteristic feature of POF is the presence of high cellularity around the mineralized tissue as stated by Eversole (1972), which helps in differentiating the connective tissue stroma from other peripheral lesions like pyogenic granuloma. This high cellularity around the mineralized tissue was predominant in the case study.

Buchner and Hansen reported that there are three types of mineralized tissue in POF: dystrophic calcification, bone (woven or lamellar) and cementum like material. The distinction between these mineralized masses is quite arbitrary in routine H and E sections. With the advent of polarizing microscopy, its efficacy in accurately identifying these mineralized masses was advocated by Waldron and Giansanti (1973) in their various studies conducted on fibro-osseous lesions. [16]

These principles were used to identify the exact nature of the mineralized masses in POF and the results are evident in [Table 3]; thus, a clear distinction between woven bone, lamellar bone, cellular and acellular cementum was possible. Acellular cementum demonstrates characteristic "brush border" appearance on polarizing because acellular cementum rarely shows intrinsic collagen bundles, and the extrinsic fibers arising from the PDL and getting incorporated into the cementum exhibit a visual loss since these fibers cannot be seen by rotation of the polaroids. A possible explanation for this phenomenon is that the fibers change their direction. If the new direction of these fibers were perpendicular to the surface of the slide, they would not be birefringent, since collagen is isotropic when viewed from this aspect. Cellular cementum mainly exhibited thin parallel fiber arrangement and/or quilt-like which consisted of short lengths of fine collagen bundles grouped in random fashion. [8] Cundiff [6] stated that mineralization is an inherent potential of periodontal ligament and/or periosteum, which would further lead us to dwell on the reasons of their pathogenesis. Two schools of thought have been professed to explain the histogenesis. [17] The first group of researchers believed that POF develops from cells of PDL/periosteum, which has been accepted by many, while the other group believed that these lesions were simply a more mature variant of pyogenic granuloma. Long standing pyogenic granuloma showing maturation and calcifications in their histopathology could mimic an overall picture of POF, which may be due to the metaplastic change depicted in the fibroblasts.

Polarizing microscopy clearly delineated between bone and cementum; and of the 22 cases studied, none showed the presence of dystrophic calcification. Such calcifications representing degenerative tissue are seen in other reactive gingival lesions such as pyogenic granuloma. When these dystrophic calcifications are seen under polarizing microscope, these calcifications are non-polarizable. Thus, these two factors further reiterate the origin of POF from the undifferentiated cells of periodontal ligament. The undifferentiated mesenchymal cells have an inherent proliferative potential; this can account for the high recurrence rate (13% according to Lee, 14.2% according to Kenney and 16% according to Cundiff) [4],[5],[6] seen in POF. The presence of these lesions in the interdental area may contribute to the incomplete removal due to the paucity of access. Thus, a deep excision, whenever possible, to the base of periosteum and affected PDL should be advocated to minimize the unexpectedly high recurrence rate for these benign fibroblastic lesions.


   Conclusion Top


Studies carried out with the help of polarizing microscope to decipher the presence of the kind of mineralized tissue have led to the finding of the definitive presence of cementum, bone and a combination of the two. Also, the presence of the tissue architecture and the type of cell further emphasizes that these growths are probably not metaplastic in origin but arise de novo. This would lead to an analysis which could suggest the origin of these lesions to be in deeper structures which are in close association with the tooth. Further studies are required to relate the clear association between the undifferentiated cells of PDL giving rise to POF, to emphatically hypothesize the present findings.

 
   References Top

1.Thawlet SE, Panje WR, Batsakis JG, Lindberg RD. Non odontogenic tumours: clinical evaluation and pathology. In: comprehensive management of head and neck tumours, 2 nd ed,. WB Saunders, Philadelphia. 1999; 1641-2.  Back to cited text no. 1
    
2.Marx RE, Stern D Oral and maxillofacial pathology: a rationale for diagnosis and treatment. Quintessence, Chicago; 2003.  Back to cited text no. 2
    
3.Zhang W, Chen Y, An Z, Geng N, Bao D. Reactive gingival lesions: a retrospective study of 2,439 cases. Quintessence Int 2007;38: 103-10.  Back to cited text no. 3
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4.Lee KW. The fibrous epulis and related lesions- Granuloma pyogenicum, pregnancy tumor, fibro-epithelial polyp and calcifying fibroblastic granuloma- A clinico-pathological study. Periodontics 1968;6:277-92.  Back to cited text no. 4
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5.Kenney JN, Kaugars GE, Abbey LM. Comparison between the peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral Maxillofac Surg 1989;47:378-82.  Back to cited text no. 5
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6.Cundiff EJ. Peripheral Ossifying Fibroma: A review of 365 cases. Thesis Indiana University, 1972.  Back to cited text no. 6
    
7.Bancroft JD, Gamble M. Theory and practice of histological techniques. 5 th ed. London: Churchill Livingstone; 2002.  Back to cited text no. 7
    
8.Giansanti JS. The pattern and width of the collagen bundles in bone and cementum. Oral Surg 1970;30:508-14.  Back to cited text no. 8
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9.Gardner DG. The peripheral odontogenic fibroma: an attempt at classification. Oral Surg Oral Med Oral Pathol 1982;54:40.  Back to cited text no. 9
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10.Sousa SC, Mesquita RA, Araujo NS. Proliferative Activity in peripheral ossifying fibroma and ossifying fibroma. J Oral Pathol Med 1998;27:64-7.  Back to cited text no. 10
    
11.Bhasker SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: report of 376 cases. J Am Dent Assoc 1966;73:1312-20.  Back to cited text no. 11
    
12.Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51:828-35.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Eversole LR, Rovin S. Reactive lesions of the gingival. J Oral Pathol 1972;1:30-8.  Back to cited text no. 13
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14.Poon CK, Kumar PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: report of a case. J Oral Maxiilofac Surg 1995;53:695-8.  Back to cited text no. 14
    
15.Kumar KS, Saravanan R, Jorgensen GM, Shuler FC, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-243.  Back to cited text no. 15
    
16.Waldron AC, Giansanti SJ. Benign fibro-osseous lesions of the jaws: A clinical-radiologic-histologic review of sixty-five cases. Oral Surg 1973;35:340-50.   Back to cited text no. 16
    
17.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3 rd ed. Noida: Elseiver; 2009.  Back to cited text no. 17
    

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Correspondence Address:
Devi Charan Shetty
Department of Oral Pathology, I.T.S Dental College & Research Centre, New Delhi-Meerut Road
India
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DOI: 10.4103/0970-9290.79976

PMID: 21525678

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    Figures

  [Table 2], [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 3]

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