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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 220-224
Multicentric variant of peripheral ossifying fibroma


1 Consultant, Periodontist Donnybrook Dental Surgery, 116, Southwest hwy, Donnybrook, Western Australia 6239
2 Department of Periodontics, Dayananda Sagar College of Dental Sciences, Bangalore, India
3 Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bangalore, India
4 Department of Periodontics, Farooqia Dental College and Hospital, Mysore, Karnataka, India

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Date of Submission28-Mar-2013
Date of Decision19-May-2013
Date of Acceptance05-May-2013
Date of Web Publication4-Jul-2014
 

   Abstract 

Peripheral ossifying fibroma (POF) is a solitary over growth of the gingiva known to arise from the cells of the periodontal ligament. The lesions usually start as a painless overgrowth of the interdental papilla unless associated with trauma and gradually involve the other counter parts of the gingiva. The lesion is more considered to be an inflammatory or reactive process rather than to be neoplastic. Here, the authors present a unique case of multiple POF in a young male adult aged 24 years where surgical excision was carried out quadrant wise. The biopsy specimen from multiple sites revealed similar histopathologic features consistent with POF, but also with the multicentric presentation of POF, which is a unique phenomenon. Multicentric variant of POF is indeed a rare case being only the second case so far which has been documented. Management of such case needs a multidisciplinary approach to prevent the recurrence along with regular long time follow-up.

Keywords: Case report excision, multicentric peripheral ossifying fibroma, peripheral ossifying fibroma

How to cite this article:
Choudary SA, Naik AR, Naik MS, Anvitha D. Multicentric variant of peripheral ossifying fibroma. Indian J Dent Res 2014;25:220-4

How to cite this URL:
Choudary SA, Naik AR, Naik MS, Anvitha D. Multicentric variant of peripheral ossifying fibroma. Indian J Dent Res [serial online] 2014 [cited 2020 Jul 5];25:220-4. Available from: http://www.ijdr.in/text.asp?2014/25/2/220/135928
With the recent advancements in technology, our understanding of the pathophysiology of reactive and fibro osseous lesions has improved to a large extent. One of the earlier discoveries was the fact that many of these conditions arose from progenitor cells in the periodontal ligament (PDL). These lesions present with a diverse spectrum of clinical conditions ranging from dysplastic to neoplastic and from focal to multifocal. The various localized gingival lesions include inflammatory lesions such as gingivitis, fibrous hyperplasia, epulis fissuratum, peripheral giant cell granuloma, pyogenic granuloma and gingival tumors (i.e., peripheral fibroma and peripheral ossifying fibroma [POF]). [1]

POF, term coined by Eversol and Robin is relatively a common gingival overgrowth usually arising from the interdental papilla and is considered to be reactive rather than neoplastic in nature. [2] This lesion is predominantly noted to affect teenagers and young adults, but can occur in any age group and it usually appears as a slow growing, solitary, nodular mass and can be either sessile or pedunculated. The surface is usually smooth or ulcerated and pink to red in color. If complicated by trauma and local irritants the surface appears red and ulcerated. [3]

In children, POF is known to cause displacement of teeth and delay in tooth eruption. [4] Elimination of local etiologic factors such as plaque, calculus, trauma from occlusion, followed by surgical excision of the lesion is the preferred treatment. The recurrence rate of the lesion is reported to be 8-20%. [2],[5],[6],[7] However, excision of the PDL and periosteum at the base of the lesion will reduce the rate of recurrence.

Though POF is a solitary gingival overgrowth, in this report we present a rare case of multicentric POF in a 24-year-old male, affecting maxillary and mandibular gingiva with the onset during 10-15 years age; the condition was seen to be associated with multiple impacted teeth in the canine premolar region; there were no associated neoplasms seen in this case. The condition was later corrected by surgical excision and the lesions did not show any recurrence.


   Case report Top


Case description

A 24-year-old male presented to the Department of Periodontics, St Joseph Dental College, West Godavari, India, complaining of generalized gingival overgrowth in the upper and lower arch. Patient had a very normal deciduous dentition and as he entered the mixed dentition period gingival overgrowths involving both maxillary and mandibular dentition had begun to develop. Patient is not married and no other immediate family member had any similar problem.

Past dental history signified that he underwent extraction of carious teeth 2 years ago, during which the lesion (near the carious teeth) was excised along with the involved tooth. The healing was satisfactory and the site showed no recurrence.

Patient is systemically healthy and was never hospitalized for any reason in the past. Patient was seen to be maintaining considerably good oral hygiene; however, subgingival deposits were seen with respect to the molar teeth. He never smoked nor consumed alcohol. Evaluation of patient's facial profile revealed dolichocephalic skull with prognathism of the maxilla, anterior deep bite and incompetent lips [Figure 1].
Figure 1: Facial profile of the patient

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The lesion, which started as a slowly progressive growth had now reached to a level where it was interfering with occlusion [Figure 2]. Size of the lesions ranged from 0.5 to 3 cm in diameter. The enlargement was higher in the molar region and in relation to the palatal gingiva. The enlargement on the anterior palate appeared as a nodular mass with ulcerated surface and was mildly erythematous [Figure 3]. Pain and bleeding were noted on palpation. In the region near the impacted canine teeth, the lesion was sessile, firm and painless.
Figure 2: Pre-treatment photograph-showing enlargement on the mandibular arch

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Figure 3: Pre-treatment photograph-palatal view

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Routine blood investigations including complete blood count were advised and were found to be within the normal limits. The lipid profile and levels of thyroid in the blood were at normal range; tests for hepatitis A, B and C were negative. Panoramic radiographs showed normal findings, with a moderate amount of horizontal bone loss in relation to upper anteriors, and impacted teeth in the cuspid regions in both arches [Figure 4]; however, the maxillary occlusal radiograph revealed a soft-tissue shadow of the lesion in the maxillary incisor region [Figure 5].
Figure 4: Pre-treatment orthopantomograph

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Figure 5: Pre-treatment occlusal view

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   Case management and results Top


After elimination of the local etiological factors such as plaque and calculus and correction of the traumatic bite, surgical excision of the lesion was planned and each isolated lesion was individually excised. The lesions were excised using internal bevel incision and crevicular incision. Care was taken to see that the base of the lesion including the periosteum and PDL was totally excised. During excision it was evident that the underlying connective tissue was dense and firmly attached to the alveolar bone. Following thorough debridement, moderate cupping defects were seen in the adjacent alveolar bone with peripheral buttressing. These defects were corrected by osteoplasty procedures [Figure 6] and [Figure 7].
Figure 6: Excisional surgery on the mandibular region. Lesion excised, the grossly decayed tooth was extracted and the area was sutured

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Figure 7: Excisional surgery on the mandibular region

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The excised tissue was sent for histopathologic examination. The biopsy specimens from different sites of involvement in the mandible and maxilla demonstrated moderately cellular fibrous connective tissue, multiple fibroblasts undergoing mitotic activity and scattered collagen fibers. Small islands of acellular osteoid like material with no evidence of necrosis or malignancy were seen [Figure 8]. All specimens revealed soft-tissue nodules with the proliferation of fibrous and myofibromatous connective tissue (which were arranged in the form of interweaving fascicles) beneath the oral stratified squamous surface epithelium. In the sections derived from palatal maxilla, the surface mucosa showed ulceration and exhibited fibrinopurulent membrane. The diagnosis of multicentric POF was confirmed based on the histopathologic findings, which clearly correlated with the clinical presentation. Following excision, patient maintained regular follow-up visits at 3 month interval and a 12 month re-evaluation showed no recurrence of the lesion.
Figure 8: H and E decalcified specimen, ×40. Biopsy sample shows areas of bone tissue with benign proliferation of fibrous connective tissue, which is consistent with the diagnosis of peripheral ossifying fibroma

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   Discussion Top


POF as a solitary lesion is very common to be seen involving the gingival tissues. Irrespective of whether being inflammatory or neoplastic, PDL cells were thought to be the cells of origin. [2],[6],[8] These lesions appear as a slow growing, solitary, nodular mass and can be either sessile or pedunculated. The surface is usually smooth and exhibit color similar to the surrounding gingiva, but if complicated by trauma and local irritants, the surface will appear red and ulcerated.

This lesion shares similar clinical features with other extraosseous lesions such as pyogenic granuloma, peripheral giant cell granuloma, osteosarcoma and chondrosarcoma. [9],[10],[11] In general, pyogenic granuloma is soft, friable, nodular in nature that bleeds with minimal manipulation, but tooth displacement and resorption of alveolar bone are not observed. Peripheral giant cell granuloma also appears similar, but the surface shows purple or blue discoloration and calcifications are not evident in radiographs. Osteosarcoma and chondrosarcoma are usually less frequently seen on the gingiva compared to POF. Malignant lesions show more pronounced bony changes and asymmetric widening of the PDL. [11]

Almost two-third of all cases were reported to occur in females and a total of 80% of the lesions occur anterior to the molar area and over 50% of the lesions occur in the incisor and canine regions. [3],[6] The case presented here is a male patient, but the incidence of the lesion during the mixed dentition period cannot rule out the role of hormones in the etiology of POF.

Based on the size of the lesion and rate of mineralization and presence of calcific masses, radiographic changes can be seen in the form of foci of radioopaque masses and slight bony resorption. Mild cupping defects of adjacent alveolar bone can also be seen. [3] Where as in this case, though there were multifocal lesions, there were no significant radiographic changes except for the radiolucent shadow over the maxillary anterior region with the displacement of the central incisors.

Maxillary involvement is more commonly noted than the mandible. The lesion usually measures to a size of <2 cm in diameter, but lesions of 6 cm [6],[12] or as large as 9 cm [13] have also been reported. While the etiology of POF is unclear, inflammatory hyperplasia originating in the superficial PDL is considered to be one of the factors. Other factors, which may have a role in the occurrence of POF, include trauma or the presence of local irritants such as microorganisms, calculus and plaque, poor quality restorations and masticatory forces. Similarly, in this case, the severity of the lesion was more in the palatal gingiva due to the trauma from lower anteriors, which showed an ulcerated surface epithelium (which was painful and bleeding on palpation). Flaring and displacement of upper anteriors was noted with moderate horizontal bone loss.

Confirmatory diagnosis is based on the histopathologic evaluation of the biopsy specimens. The following features are usually observed:

  • Intact or ulcerated stratified squamous epithelium
  • Benign fibrous connective tissue with varying number of fibroblasts
  • Sparse to profuse endothelial proliferation
  • Mineralized material consisting of mature lamellar or woven osteoid
  • Acute and chronic inflammatory cells.


All features were seen in this case. As stated by Cuisia and Brannon [4] the POF in children are associated with a delay in tooth eruption and further impaction of unerupted teeth. A similar condition was seen in this case with few bicuspid teeth being impacted.

In the literature, any such case of multicentric POF is known to be rare. To the best of our knowledge, this is only the second case reported until date. The very first such case was reported by Satish et al. (2006), [14] which was thought to be neoplastic and the condition was then attributed to genetic mutations that pre-disposes to gingival soft-tissue overgrowths. To confirm the genetic abnormalities karyotyping is necessary, which will help in knowing whether it is constitutional and can be passed to offspring. In the earlier case reported, there was a continuous recurrence of the lesion, whereas this case did not show any recurrence during a 12 month follow-up period. Further, the edentulous regions did not show any recurrence signifying the origin of lesion as PDL cells. Multicentric lesions of such type have been observed in conditions such as nevoid basal cell carcinoma syndrome, multiple neuromas, multiple neurofibromatosis and Gardner's syndrome. [3]

Treatment modalities for any such lesions include surgical excision of the lesion followed by periodic re-evaluation for any recurrence. The lesions were surgically excised and the PDL cells and the periosteum at the base of the defect were curetted thoroughly and the bone deformities (cupping defects) were treated by osteoplasty. The trauma to the palatal gingiva was corrected by a bite plane appliance. A proper surgical excision and minimizing the offending etiological factors and a periodic re-evaluation seemed to have prevented the recurrence of the lesion. However, considering the recurrence rate of such lesions to be around 8-20%, patient should be kept on regular follow-up during the course of time.


   Conclusion Top


Multicentric variant of POF is indeed a rare case being only the second case so far which has been documented. Management of such a case needs a multidisciplinary approach to prevent the recurrence and with regular long time follow-up.


   Acknowledgments Top


The authors wish to thank Dr. Pratima Maligi for rendering assistance in histology specimen preparation and taking photographs. The authors also greatly acknowledge the help of Dr. Chinnappa AB with the editing of the article.

 
   References Top

1.Manor Y, Merdinger O, Katz J, Taicher S. Unusual peripheral odontogenic tumors in the differential diagnosis of gingival swellings. J Clin Periodontol 1999;26:806-9.  Back to cited text no. 1
    
2.Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 2
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3.Neville BW, Damm DD, Allen CM, Bouguot JE. Soft tissue tumors. In: Text book of Oral and Maxillofacial Pathology. 2 nd ed., Ch. 12. Philadelphia: Saunders; 2002. p. 451-2.  Back to cited text no. 3
    
4.Cuisia ZE, Brannon RB. Peripheral ossifying fibroma - A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8.  Back to cited text no. 4
    
5.Bhaskar 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. 5
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6.Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1987;63:452-61.  Back to cited text no. 6
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7.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. 7
    
8.Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.  Back to cited text no. 8
    
9.Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg 1993;51:828-35.  Back to cited text no. 9
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10.Whitaker SB, Vigneswaran N, Budnick SD, Waldron CA. Giant cell lesions of the jaws: Evaluation of nucleolar organizer regions in lesions of varying behavior. J Oral Pathol Med 1993;22:402-5.  Back to cited text no. 10
    
11.Rajendran R. Benign and malignant tumors of oral cavity. In: Shafer WG, Hine MK, Levy BM, editors. Shafer's Text book of Oral Pathology. 5 th ed. Philadelphia, PA: W.B. Saunders Co.; 2006. p. 113-308.  Back to cited text no. 11
    
12.Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol 1987;14:551-4.  Back to cited text no. 12
    
13.Poon CK, Kwan PC, Chao SY. Giant peripheral ossifying fibroma of the maxilla: Report of a case. J Oral Maxillofac Surg 1995;53:695-8.  Back to cited text no. 13
    
14.Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;48:239-43.  Back to cited text no. 14
    

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Correspondence Address:
Archana R Naik
Department of Periodontics, Dayananda Sagar College of Dental Sciences, Bangalore, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.135928

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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