ABSTRACT : A peripheral ossifying fibroma (POF) is a reactive soft tissue growth
whose pathogenesis is uncertain and seen mainly in the anterior portion of maxilla in
young adults. After elimination of local etiological factors, local surgical excision of POF
is the preferred treatment. Present case is considerable as it reports an occasional entity of
POF seen in posterior maxilla in an adult lady in her fourth decade of life and the first time
use of a bi layer collagen matrix to cover the soft tissue defect in addition to conventional
treatment. Present article highlights the several distinct advantages of use of bovine
collagen in treating POF and briefly review the current literature on this condition.
1 2 3 4Prateek Agarwal, Sunil Sharma Neha Bhargava, Mridula Trehan 1Assistant Professor Department of Oral and Maxillofacial SurgeryMahatma Gandhi Dental College and Hospital, Jaipur 2Dean, Principal, Head of Department Department of Oral and Maxillofacial SurgeryMahatma Gandhi Dental College and Hospital, Jaipur 3Assistant Professor, Department of Pediatric and Preventive Dentistry Rajasthan Dental College and Hospital, Jaipur4Director, P.G Studies Head, Department of Orthodontics and Dentofacial Orthopaedics, Mahatma Gandhi Dental College and Hospital, Jaipur
INTRODUCTION : Peripheral ossifying fibroma (POF) is a
benign fibro osseous lesion comprising about 9% of all
gingival growths. [1] Surgical excision followed by
aggressive curettage of the underlying periosteum to reduce
recurrence rate is the treatment of choice for POF. [2]
However conventional treatment leaves a large soft tissue
defect which may cause extensive pain, increased risk of
infection and delayed healing. The present article is probably
the first to be reported in literature to use biodegradable bi
layer collagen matrix (EUCARE Pharmaceuticals Pvt. Ltd
Chennai, India) as a temporary dressing material with
favorable prognosis in patients with POF.
CASE REPORT : A 43-year-old female patient reported to
Department of Oral and Maxillofacial surgery, with a
complaint of growth of gum tissue in upper back tooth region
for the past 6 months. There was no contributory past medical
and dental history. Intraoral examination revealed an
exophytic growth on the buccal gingiva of teeth 44 and 45
extending from mesial aspect of first premolar to distal aspect
of second premolar also extending occlusally between the two
premolars [Figure 1], measuring around 1.1x0.8x0.4cms in
size; irregular margins with smooth surface, firm in
consistency and slightly pedunculated. As reported by the
patient, the tissue growth was interfering with her bite and felt
uncomfortable. Occasionally bleeding occurred when she
brushed her teeth. Periodontal examination showed moderate
amount of supra-gingival calculus with respect to 44, 45 and
46 and gingival recession was also seen. Panoramic
radiograph were obtained and did not reveal any abnormality.
After detailed history, clinical and radiographic examination
a provisional diagnosis of peripheral ossifying fibroma was
made and the differential diagnosis included pyogenic
granuloma, peripheral fibroma, peripheral giant cell
granuloma, and fibro epithelial polyp.
TREATMENT : After approval of the protocol by the
institutional review board and obtained signed informed
consent by the patient and ensuring that the hemogram of the
patient was within normal limits, excisional biopsy of the
lesion was performed under local anesthesia followed by
aggressive curettage of underlying periosteum to reduce
chances of recurrence and specimen [Figures 2 and 3] sent for
histopathological study. Bilayer Collagen matrix removed
PERIPHERAL OSSIFYING FIBROMA : NEW TREATMENT APPROACH AND REVIEW OF THE LITERATURE
Key Words :
Peripheral ossifying
fibroma, gingival overgrowth,
bovine collagen.
Source of support : Nil
Conflict of interest: None
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 76
University J Dent Scie 2017; No. 3, Vol. 1
CaseReport
from sterile pouch and soaked in sterile saline solution, was
cut by scissors in slight excess of the wound size and sutured
to the edges of the wound by the use of vicryl suture [Figure
4]. A few quilting sutures were also given in addition to
making a few criss-cross incisions on the collagen matrix to
facilitate drainage. The adjacent teeth were scaled to remove
any local irritants. The histopathological examination of the
lesion revealed highly cellular fibrous connective tissue
comprising of plump hyperchromatic fibroblasts, focal areas
of bone and dense bundles of collagen fibres [Figure 5].
Overlying epithelium was parakeratinized stratified
squamous epithelium which shows broad rete ridges. The
diagnosis was confirmed as POF according to both clinical
and histopathological patterns. The initial follow up of the
case showed uneventful healing and certain degree of
disintegration in collagen sheet [Figure 6]. A 6 month
postsurgical follow up showed no evidence of recurrence,
however the patient's oral hygiene was found to be lacking
resulting in continued gingivitis in rest of the mouth [Figure
7].
DISCUSSION : There are 2 types of ossifying fibroma the
central type and the peripheral type. The peripheral type is
seen exclusively on the soft tissue covering the tooth bearing
areas of the jaws. [3] The term 'peripheral ossifying fibroma'
was coined by Eversol and Robin. [4] Etiology of POF is
uncertain; in order to reach some conclusion about the diverse
etiology of this condition, concise review of literature was
conducted [Table 1]. Most studies suggest its origin from the
periodontal ligament because of its exclusive occurrence on
the gingiva, the proximity of gingiva to periodontal ligament
and the presence of oxytalan fibres within the mineralized
matrix of some lesions. [5]
Frequently, POF arises as an exophytic, ulcerated mass
attached to the gingiva. Most of the lesions are usually <1.5
cm, including in the present case. If surgical intervention in an
early stage is not done, POF can become large, causing
extensive destruction of adjacent bone and significant
functional or esthetic loss. [6] POF shares similar clinical
features with many other extra osseous lesions, giving
misdiagnosis of pyogenic granuloma, peripheral giant cell
granuloma but other peripheral odontogenic tumors should
also be considered. [7] Thus, the diagnosis based only on
clinical aspects can be difficult, and histopathological
examination of the surgical specimen is mandatory for an
accurate diagnosis of POF.
The treatment of choice for POF is local resection with
peripheral and deep margins including both the periodontal
ligament and the affected periosteal component. [8] However
conventional treatment leaves a large soft tissue defect which
may cause extensive pain, increased risk of infection and
delayed healing. This exposed the need for further study and
the active involvement of the wound dressing that could serve
as temporary cover till times body is able to manufacture a
cover of its own. Present case is probably the first reported
case to use bi layer collagen matrix (EUCARE
Pharmaceuticals Pvt. Ltd, Chennai, India), which is purified
bovine derived reconstituted collagen, as a covering material
on the raw wound. Since collagen is an actual component of
the skin, it is used beneficially throughout the wound healing
process as well as for replacement of missing tissue. Few
studies in the literature reported that collagen graft promote
haemostasis, relieve pain, induce granulation and assist in
rapid epithelisation at the wound site, prevent infection,
contracture and scarring which was statistically significant.
[9, 10] Follow up examination of present case demonstrated
the surgical site to be healing well, patient was asymptomatic
and there was no evidence of recurrence of lesion. With
further advancement and laser evolving rapidly, this could be
the next treatment modality for such lesions however the only
disadvantage could be the cost effectiveness for the patient.
CONCLUSION : POF is a slowly progressing lesion, the
growth of which is generally limited. Many cases will
progress for long periods before patients seek treatment,
because of the lack of symptoms associated with the lesion. In
the current case collagen matrix acted as a temporary covering
material on the sensitive nerve endings of raw wounds which
reduced the postoperative pain, acted as an efficient
haemostatic agent and a mechanical barrier preventing wound
contamination. Matrix did not evoke any immunogenic
reactions and it was useful in preventing the tissue contracture
and scarring. Therefore it can be concluded that collagen
matrix can be used as an excellent biologic dressing material
following surgical resection of lesion thereby minimizing
patient discomfort and promote rapid healing.
References
1. Poonacha A, Shigli AL, Shirol D. Peripheral
ossifying fibroma: A Clinical report. Contemp
ClinDent 2010; 1:54-6.
2. Rossmann JA. Reactive Lesions of the Gingiva:
Diagnosis and Treatment Options. O J Pathology
2011; 5:23-32.
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 77
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3. Keluskar V, Byakodi R, Shah N. Peripheral ossifying fibroma. J Indian Acad Oral Med and Radiol 2008; 20:54-6.
4. Eversole LR, Robin S. Reactive lesions of gingival. J Oral Pathol 1972; 1:30-8.
5. Kumar KS, Ram S, Jargensen MG, Shuler CF, Parish P. Multicentric peripheral ossifying fibroma. J Oral Sci 2006;
48:239-43.
6. Cuisa ZE, Brannon RB. Peripheral ossifying fibroma: A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;
23:245-48.
7. Mesquita RA, Sousa SC, Araujo NS. Proliferative activity in peripheral ossifying fibroma and ossifying fibroma. J Oral
Pathol Med 1998; 27:64-7.
8. Trasad VA, Devarsa GM, Subba Reddy VV, Shashikiran ND. Peripheral ossifying fibroma in the maxillary arch. J
Indian Soc Pedod Prevent Dent 2011; 29:255-59.
9. Rastogi S, Modi M, Sathian B. The efficacy of collagen membrane as a biodegradable wound dressing material for
surgical defects of oral mucosa: A prospective study. J Oral Maxillofac Surg 2009; 67:1600-6.
10. Herford AS, Akin L, Cicciu M, Maiorana C, Boyne PJ. Use of a porcine collagen matrix as an alternative to autogenous
tissue for grafting oral soft tissue defects. J Oral Maxillofac Surg 2010; 68:1463-70.
Table 1: Comprehensive review of literature regarding the etiology and clinical presentation of peripheral ossifying fibroma
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University J Dent Scie 2017; No. 3, Vol. 1
Figures
Figure 1: Exophytic growth seen on buccal gingiva in upper
premolar tooth region
Figure 2: Post excision view
Figure 3: Excised specimen
Figure 4: Immediate stabilization of collagen matrix with
sutures
Figure 5: Histopathological section (10X): radioopaque foci
of bone seen
Figure 6: 7 days follow up
Figure 7: Post op after 6months showing no signs of
recurrence however poor oral hygiene
CORRESPONDING AUTHOR
Dr. Prateek Agarwal
Assistant Professor
Department of Oral and Maxillofacial Surgery
Mahatma Gandhi Dental College and Hospital
Sitapura (Jaipur) 302022, Fax: 0141-2770326
Contact Number: 09982542074
E-mail – [email protected]
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University J Dent Scie 2017; No. 3, Vol. 1