Fibroma

Hence, a final diagnosis of Peripheral Cemento-Ossifying fibroma
was given associating the clinical, radiographic along with the
histopathological findings.

Discussion:

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Diagnosing and classifying the benign fibroosseous
lesions of the jaws has been a challenging for the clinician. The 1992 WHO
classification sets a name (cemento-ossifying fibroma) for two histologic forms (cementifying fibroma and ossifying fibroma) that may be otherwise difficult to
distinguish.5This fibroma is an non-odontogenic
lesion. A varied number of synonyms have been given for PCOF such as epulis,  peripheral cementifying fibroma, ossifying fibroepithelial
polyp, peripheral fibroma with osteogenesis,
peripheral fibroma with
cementogenesis, peripheral fibroma with calcification, calcifying or ossifying fibroma and calcifying fibroblastic granuloma.6When osseous,
dystrophic calcifications or calcified globules resembling acellular cementum are
found in the connective tissue the ossifying fibroma has been referred as the
cement-ossifying fibroma. As mentioned above, the variants cementifying fibroma
and the ossifying fibroma may be difficult to differentiate from other lesions
clinically however in a study by Endo et al, an immunohistochemical analysis
for the cementifying fibroma showed a immunoreactivity for keratin sulphate while
ossifying fibroma and fibrous dysplasia showed immunostaining for chondroitin
sulphate.

             The pathogenesis of peripheral
ossifying fibroma is ambiguous but a source
from periodontal ligament cells has been proposed in literature. The motives
for considering

Periodontal ligament origin
for this lesion includes its selective occurrence in the gingiva (interdental
papilla), the vicinity of gingiva to the periodontal ligament along with the
presence of oxytalan fibres within the calcified
matrix of few lesions. There could be some influence of the hormonal levels due
to its predilection in the females. It is also said to have a decline in
incidence after third decade but few case reports by Antony et al7 and Pereira et al8 have reported cases in
the fourth decade in male patients. Similarly Kumar et al and Mishra et al9 reported the occurrence of
PCOF in a 49 year old and a 50 year old female patient respectively. PCOF
has a predilection for maxillary anterior region of about 60%. In current
report the growth was present in the maxillary incisors area, in a female
patient aged 18 years. It measured around 13mmx13mm. There were no radiographic
changes seen. Histopathology of the specimen confirmed the diagnosis.

 Features found in this lesion are fibrous connective tissue, endothelial proliferation along
with mature or woven osteoid, cementum-alike or dystrophic calcifications
represented by the mineralized portion. Acute or chronic inflammatory cell
infiltration may be found in such cases. Majority of the common features were
found in the current report. It was identified by Gardner et al that peripheral
ossifying fibroma shows a cellular
connective tissue so distinctive that a histologic judgement could be made with
poise, irrespective of the grade of calcification.4An hypothesis that first
POF presents as ulcerated growth with minimal calcification, letting misdiagnosis as a pyogenic
granuloma was given by one of the authors. Hence, till the histopathological
confirmation is driven, POF as the diagnosis should be suspected.

  Treatment
of PCOF comprises of eradication of causal elements followed by scaling and
total surgical removal along with involved periodontal ligament and periosteum.
Possibility of recurrence would be minimal with this. Treatment done for this
lesion in the present report was scaling and root planing, excision and an open
flap debridement was done after it recurred in four weeks. Considering the
recurrence rate of PCOF with a range of 8.9 to 20% a consistent follow up is obligatory. The probable cause for initial recurrence observed within
one month of excision in the present case may be due to persistence of fragments
of the lesion in the vicinity or persistence of local irritants.10Our patient has been
under follow up and has not shown any signs of recurrence since the excision
for the second time. 

Conclusion:

PCOF
is a slow growing lesion. Many cases may go unnoticed due to absence of
symptoms experienced by the patient for long times before seeking the treatment.
PCOF may be commonly misdiagnosed from the other gingival lesions. Therefore, histopathological
analysis is crucial for exact diagnosis and appropriate management. Here is a
report of PCOF in an 18 year old female, which
recurred due to persistence of fragments of the
lesion in the vicinity. Complete excision with thorough curettage of
tissues is critical to prevent recurrence. Postoperative recall is essential
because of the progressive nature and recurrence rate of the lesion.

 

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