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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 1  |  Page : 36-40

A novel approach for the treatment of peripheral ossifying fibroma: A case report with 1-Year follow-up


Department of Periodontics and Implantology, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Dr. Shaswata Karmakar
Smrity Bhavan, RBC Road, Chakdaha, Nadia - 741 222, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdl.jdl_7_18

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  Abstract 

Peripheral ossifying fibroma (POF) is a nonneoplastic enlargement of the gingiva precipitated by local irritation and minor trauma. POF represents 9.6% of all gingival tumors and 3.1% of the oral lesions which are biopsied. Dental calculus, plaque, microorganisms, dental appliances, and restorations are considered to be examples of etiological factors. A 38-year-old female patient presented with a chief complaint of swelling in her upper front teeth region for 6 months. Examination revealed a nontender oval, sessile growth with respect to tooth number 21, 22 region, measuring approximately 2 cm × 1.5 cm × 1.5 cm in size with a pinkish red overlying mucosa without any ulcerations. Palpation revealed a sessile base with firm consistency. Based on these clinical, radiological, and histopathological findings a final diagnosis of POF with respect to 21, 22 region was made. The treatment consisted of scaling and root planning followed by complete excision of the lesion using a combination technique of using both surgical scalpel and diode laser. The patient was followed up for 1 year and there were no signs of recurrence. This case of excision with the combination of scalpel and laser and the absence of recurrence over a period of 1 year makes this novel approach a promising treatment option.

Keywords: Diode laser, histopathology, peripheral ossifying fibroma, surgical excision


How to cite this article:
Karmakar S, Srinath R, Prakash S. A novel approach for the treatment of peripheral ossifying fibroma: A case report with 1-Year follow-up. J Dent Lasers 2018;12:36-40

How to cite this URL:
Karmakar S, Srinath R, Prakash S. A novel approach for the treatment of peripheral ossifying fibroma: A case report with 1-Year follow-up. J Dent Lasers [serial online] 2018 [cited 2021 Oct 25];12:36-40. Available from: https://www.jdentlasers.org/text.asp?2018/12/1/36/235381


  Introduction Top


Gingival enlargements are common condition in the oral cavity, one of them is Peripheral ossifying fibroma (POF), which is a nonneoplastic enlargement of the gingiva primarily caused by local irritation and minor trauma. Literature reveals that various terminologies have been used to name POF, namely peripheral fibroma, fibrous epulis, ossified fibrous epulis, peripheral cementifying fibroma, calcifying fibroblastic granuloma, or peripheral fibroma with calcification. Nonencapsulated mass of cellular and fibrous connective tissue with randomly distributed calcifications or sometimes even matured bone is the characteristic histological feature of POF.[1] Ossifying fibromas of the oral cavity can be divided into Central type which arises from the endosteum or periodontal ligament and peripheral type which arises from the soft-tissue. POF represents 9.6% of all gingival tumors and 3.1% of the oral lesions which are biopsied. It can occur at any age, but more commonly presents in second or third decade of life with a slight preponderance to occur more in females in a ratio of 1.22:1.[2] It is a focal reactive lesion of gingiva, which is nonneoplastic with tumor-like appearance often arising from the maxillary anterior region from the interdental papilla. The confusion with this lesion often arises with its clinical presentation which mostly resembles such as pyogenic granuloma (PG), it can be well differentiated from other fibrous proliferative lesions by the presence of various types of calcifications such as mature lamellar bone, immature bone, dystrophic calcification which are more common in initial lesions and even lamellar bone in case of older lesions.[3] The diagnosis of such a condition is purely by histopathological examination (HPE). The treatment is surgical excision of the lesion including the underlying periosteum to reduce recurrence after elimination of all local causes.[4]


  Case Report Top


A 38 year old female patient reported to the Department of Periodontics, College of Dental Sciences Davangere with a chief complaint of swelling in her upper front teeth region for 6 months where the lesion started as a small nodule and slowly increased over the period to the present size [Figure 1] and [Figure 2]. The swelling was interfering with speech, mastication, and was highly unesthetic. Her medical and dental history was not contributory. Examination revealed an oval, sessile growth with respect to tooth number 21, 22 regions, measuring approximately 2 cm × 1.5 cm × 1.5 cm in size with a pinkish red overlying mucosa without any ulceration. Palpation revealed a sessile base with firm consistency. The swelling was nontender with no local rise in temperature or any pulsations. The patient was partially edentulous with 26 remaining teeth which had advanced periodontal disease. All the hematological and urine investigations were within normal limits and HIV-1 and HIV-2 was negative. The maxillary occlusal radiograph showed spacing and crestal bone loss of 4 mm between 21 and 22 [Figure 3]. Panoramic radiograph such as orthopantomograph revealed the maxilla-mandibular complex with remaining 26 teeth and moderate to severely resorbed bone in both the jaws [Figure 4]. Based on these clinical and radiological findings, provisional diagnosis of PG with respect to 21, 22 regions was estimated.
Figure 1: Preoperative occlusal view

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Figure 2: Preoperative frontal view

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Figure 3: Occlusal radiograph

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Figure 4: Orthopantomograph

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Treatment

After 2 weeks of completion of phase 1 therapy, which consisted of oral hygiene instructions, motivation and scaling and root planing, the growth was excised conservatively using a combination technique of surgical scalpel and diode laser. Local anesthesia was given, and then surgical excision was carried out with the desired depth of 2–3 mm below the epithelial surface including the underlying periosteum, using No. 11 and No. 15 BP blade [Figure 5]. The outline of the lesion was made around 0.5–1 mm beyond its clinical extent in a slow and controlled fashion using diode laser [Figure 6] of wavelength 810 nm at 1.5 W with the 300-μm optical fiber [Figure 7]. The excised lesion was submitted for HPE. HPE revealed a hyperplastic stratified squamous lining epithelium with underlying connective tissue showing areas of proliferating plump fibroblasts, mixed inflammatory cell infiltrate along with immature calcific mass [Figure 8], [Figure 9], [Figure 10]. Based on these clinical and histopathological findings, the lesion was diagnosed as POF. The patient was followed up for one year, and there were no signs of recurrence [Figure 11] and [Figure 12].
Figure 5: Excision using surgical scalpel

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Figure 6: Soft-tissue diode laser

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Figure 7: Adjunctive use of laser

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Figure 8: Histopathology showing the size of the lesion

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Figure 9: Histopathology report

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Figure 10: Histopathology

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Figure 11: Immediate postoperative view

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Figure 12: One-year postoperative view

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  Discussion Top


Eversole and Rovin in 1972 described POF as a reactive lesion of gingiva and Gardner in 1982 coined the term POF.[5] The lesion is highly reactive in nature and is not the extraosseous counterpart of central ossifying fibroma (COF). The etiopathogenesis of POF is still not clear, and it is often difficult to identify the causative factor of its growth. Dental calculus, plaque, microorganisms, dental appliances, and restorations are considered as such irritants. POF clinically appears as a small, well-demarcated focal mass on the gingiva with a sessile or pedunculated base, originating from an interdental papilla. Histologically, the POF is a noncapsulated mass of a cellular fibroblastic connective tissue covered by stratified squamous epithelium. Randomly distributed calcification may be dispersed throughout the cellular connective tissue. The lesion derives its name from the histological evidence of calcifications and ossifications. POF may occur at any age but exhibits a peak incidence between second and third decades of life with average age at around 28 years. The size of the lesion is usually smaller than 1.5 cm, but it has been reported in literature to occur at even larger sizes measuring about 4 cm even. Females are more commonly affected than males thus suggesting an hormonal influence in the occurrence of this lesion. Although the pathogenesis is unclear, it has a known fact that there are pluripotent cells in the periodontal ligament and periosteum, which may undergo a metaplastic change into osteoblasts, fibroblasts, or cementoblasts due to the local irritants.[6]

The mineralized product seen in ossifying fibromas probably originates from periosteal cells or from the periodontal ligament. The periodontal ligament is considered to be the origin because of the exclusive occurrence of fibromas in the interdental papilla. All lesions do not demonstrate radiographic calcifications but a few may demonstrate radiopaque foci of calcifications scattered in the central area of the lesion. Usually, there is no underlying bone involvement associated; rarely superficial erosion of bone is may be present.[7] Various investigations have attempted to establish a relationship between PG and POF, stating that PG and POF may represent extremes of the spectrum of the same pathology.[8] Histologically, POF can exhibit either ulcerated or intact stratified squamous epithelium.

The calcified material can generally take one or more of the following four forms: (a) Mature lamellated trabecular bone; (b) immature, highly cellular bone; (c) circumscribed amorphous, almost acellular, eosinophilic or basophilic bodies, and [4] minute microscopic granular foci of calcification.[9] The nonulcerated lesions are typically identical to the ulcerated type except for the presence of surface epithelium. Cementum-like material is found in less than one-fifth of the lesions, and dystrophic calcifications are more prevalent in ulcerated lesions.[1]

POF is not considered as the counterpart of the COF which represents a central benign neoplasm arising from endosteum or periodontal ligament. POF shows a contiguous relationship with periodontal ligament occurring in the soft tissues covering the alveolar bone. PG which is a vascular type reactive lesion of gingiva usually does not show any calcifications. However, recently, there is an opinion that POF falls within the spectrum of PG which undergoes maturation. Initially, the lesion starts as PG which in long-standing duration undergoes a process of the organization leading to the decreased vascularity, increased fibrotic component, and foci of calcifications seen histologically. The other lesions which may resemble POF are fibrous hyperplasia, irritation fibroma, peripheral giant cell granuloma and squamous cell carcinoma.[10] Surgical excision is the treatment of choice for POF. Although the traditional method of scalpel excision is considered as the gold standard, lasers are not new to dental surgery and have been in vogue for the past 3–4 decades for various intraoral procedures. Excision of gingival hyperplasias, frenectomies, hemangioma removal, and peri-implant soft-tissue surgery have been successfully carried out using the various wavelengths of lasers and laser therapy.[11] 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, better accessibility to the intricate areas, reduced mechanical trauma with resultant lessened psychological trauma for the patient, minimal scarring, and wound contraction accelerating recovery and postoperative function and most importantly, less recurrence.[12]

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).[13] Iyer et al., very recently reported a case of successful laser excision of POF with very little intraoperative bleeding, postoperative 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.[14] To the best of our knowledge, the present report is the first of its type where combination of scalpel and laser has been used to excise a case of POF with a follow-up period of 1 year.


  Conclusion Top


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

Clinical significance

Excision with the novel technique of using a combination of scalpel and laser can be a promising treatment option for gingival overgrowths like POF.

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.

 
  References Top

1.
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. 1
    
2.
Canger EM, Celenk P, Kayipmaz S, Alkant A, Gunhan O. Familial ossifying fibromas: Report of two cases. J Oral Sci 2004;46:61-4.  Back to cited text no. 2
    
3.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Philadelphia: W.B. Saunders Co.; 1995. p. 374-6.  Back to cited text no. 3
    
4.
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 4
    
5.
Horwitz J, Akrish S, El Naaj I. Surgical management of recurrent peripheral ossifying fibroma. Clin Adv Periodontics 2014;15:1 21.  Back to cited text no. 5
    
6.
Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol 1987;14:551-4.  Back to cited text no. 6
    
7.
Kendrick F, Waggoner WF. Managing a peripheral ossifying fibroma. ASDC J Dent Child 1996;63:135-8.  Back to cited text no. 7
    
8.
Popat R, Popat P. Peripheral ossifying fibroma-case report. Int J Dent Sci Res 2014;2:63-5.  Back to cited text no. 8
    
9.
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. 9
    
10.
Chugh S, Arora N, Rao A, Kothawar SK. Laser excision of peripheral ossifying fibroma: Report of two cases. J Indian Soc Periodontol 2014;18:259-62.  Back to cited text no. 10
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11.
Deppe H, Horch HH. Laser applications in oral surgery and implant dentistry. Lasers Med Sci 2007;22:217-21.  Back to cited text no. 11
    
12.
Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I, et al. Nd: YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med 1994;14:178-83.  Back to cited text no. 12
    
13.
Alam T, Dawasaz AA, Thukral N, Jangam D. Surgical diode laser excision for peripheral cemento-ossifying fibroma: A case report and literature review. J Oral Laser Appl 2008;8:43-9.  Back to cited text no. 13
    
14.
Iyer V, Sarkar S, Kailasam S. Use of the Er, Cr: YSGG laser in the treatment of peripheral ossifying fibroma. Int J Laser Dent 2012;2:51-5.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]


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