|Year : 2016 | Volume
| Issue : 2 | Page : 92-95
Large reccurent gingival growth in the maxilla: A case report
Shwetha Nambiar1, Kaveri Hallikeri1, Venkatesh Anehosur2, Pragati Rai1, Veda Hegde1
1 Department of Oral Pathology and Microbiology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
|Date of Web Publication||18-May-2016|
SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka - 580 009
Source of Support: None, Conflict of Interest: None
Gingival growths are one of the frequently encountered types of lesion in the oral cavity. It is the common site for neoplastic and nonneoplastic lesions. Peripheral ossifying fibroma (POF) is one of the inflammatory reactive hyperplasias of the gingiva. It represents a separate clinical entity with diverse histopathological features. Even after adequate surgical excision of the lesion, repeated recurrence is not uncommon. Studies show a recurrence rate of 16-20% in these lesions. The suggested etiology for POF is low-grade irritation due to plaque and calculus. Proper excision of such overgrowths and appropriate oral hygiene instructions will ensure that the lesion does not recur. This case report is of a large, solitary gingival swelling in the maxilla of a 36-year-old male patient that had recurred for the third time after the surgical excision.
Keywords: Peripheral ossifying fibroma (POF), recurrences, solitary swelling
|How to cite this article:|
Nambiar S, Hallikeri K, Anehosur V, Rai P, Hegde V. Large reccurent gingival growth in the maxilla: A case report. J Sci Soc 2016;43:92-5
| Introduction|| |
Gingival growths constitute a heterogeneous group of disorders characterized by progressive enlargement of the gingiva caused by an increase in submucosal connective tissue elements.  Different lesions with similar clinical presentations make it difficult to arrive at a correct diagnosis. One of the more infrequent types of gingival lesion is peripheral ossifying fibroma (POF), which has a high rate of recurrence (8-20%), hence, appropriate diagnosis is essential. 
Multiple recurrences are very rare, usually seen within 6 months to 1 year after the occurrence of the primary lesion. In the case discussed here, recurrence has been after a long duration, as the primary lesion first occurred 20 years earlier.
| Case report|| |
A 36-year-old male patient reported with a chief complaint of a large, asymptomatic swelling over the right upper gum with a duration of 10 years, which started as a small swelling and gradually increased to an enormous size involving the whole right quadrant of the maxilla in the buccal aspect and also involved the palatal aspect in some areas. The patient had a history of similar swelling, which first appeared 20 years earlier. The lesion was excised and sent for histopathological evaluation, and a diagnosis of POF was given. The lesion recurred twice later and was excised both times in a private hospital and we have no information of the same.
On extraoral examination, facial asymmetry was present on the lower half of the face on the right side. A solitary swelling measuring 5 × 6 cm 2 extending from the ala of the nose up to 4 cm anterior to the tragus of the ear was present [Figure 1].
|Figure 1: Extraoral photograph showing swelling with facial asymmetry in the right middle third of the face|
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Intraoral examination revealed a large, solitary, well-defined, lobulated swelling on the buccal aspect of the gingiva, involving the buccal vestibule, extending from teeth 11 to 17. Anteroposteriorly the lesion measured 6 × 6 cm 2 . The overlying mucosa was erythematous in the center and pale at the periphery. Displacement of the tooth with regard to 11 was noted. The growth extended on the palatal aspect between 13 and 14. Grade II mobility of the teeth 11-16 was noted. The patient had poor oral hygiene [Figure 2].
|Figure 2: Intraoral photograph showing large, firm, lobulated and well-defined swelling in the buccal aspect of the gingiva|
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The pantomogram showed the shadow of the growth with regard to 14, 15, and 16 covering the sinus region. No evidence of calcification or bone loss related to growth was seen. Generalized bone loss was present in both upper and lower arches [Figure 3]. A provisional diagnosis of recurrent POF was given.
Surgical excision of the lesion with contouring of maxilla and adequate curettage under general anesthesia was carried out as this was a recurrent lesion. The patient was given oral hygiene instructions and was placed on regular follow-up.
|Figure 3: Pantamogram showing the shadow of the growth with regard to 14, 15, and 16 covering the sinus region with no bone loss|
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The excised specimen was sent for histopathological evaluation. The gross specimen was a single soft tissue, measured 5 × 4 cm 2 , was firm in consistency, and was predominantly white in color [Figure 4]. The specimen was gritty while grossing. The tissue was processed and 4 μ-thick sections were made and stained with hematoxylin and eosin.
|Figure 4: Gross specimen showing lobulations, which is firm and whitish in color|
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Histopathological evaluation revealed stratified squamous parakeratinized epithelium with atrophic changes. Subepithelially, chronic inflammatory cell infiltrate and numerous capillaries were seen [Figure 5]. The deeper sections in high power showed trabeculae of bone [Figure 6]. Based on these findings, a final diagnosis of POF was given.
|Figure 5: Histopathological picture showing stratified squamous parakeratinized epithelium with atrophic changes|
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|Figure 6: Histopathologically deeper sections showing trabeculae of bone|
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| Discussion|| |
In 1872, Menzel first described ossifying fibroma, but only in 1927 was a term assigned to it, by Montogomery.  In 1982, Gardner coined the term "peripheral ossifying fibroma" (POF) for a lesion that is reactive in nature and is not the extraosseous counterpart of a central ossifying fibroma (COF). 
There are two types of ossifying fibromas: The central type and the peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes the expansion of the medullary cavity. The peripheral type (i.e., POF) occurs solely on the soft tissues covering the tooth-bearing areas of the jaws.
POF accounts for 3.1% of all oral tumors and 9.6% of gingival lesions. This condition affects both genders but has been reported to occur at a higher rate in females. Whites (71%) are more frequently affected than blacks (36%). POF may occur at various ages, but exhibits a peak incidence between the second and third decades of life.
Clinically, POF appears as a solitary nodular mass that is either pedunculated or sessile. The surface mucosal color ranges from red to pink, and the surface is frequently ulcerated. The mass usually arises from the interdental papilla. Lesions occur slightly more frequently in the maxillary arch (60%) and the incisor cuspid region (50%). POF lesions usually measure less than 1.5 cm in diameter, but lesions with 6-9-cm diameters have been reported. POF can cause tooth separation, delayed tooth eruption, or tooth migration.
Radiographically, no apparent underlying bone involvement is visible. Superficial erosion of bone may be seen. Radiopaque specks over a soft tissue shadow may be seen. Occasionally, these lesions are associated with bone destruction.
There is much uncertainty about the pathogenesis of this lesion. An origin in the periodontal ligament has been suggested. The reasons for considering the periodontal ligament as the origin of POF include the exclusive occurrence of POF in the gingiva (interdental papilla), the proximity of the gingiva to the periodontal ligament, and the presence of oxytalan fibers within the mineralized matrix of some lesions. The mature fibrous connective tissue proliferates excessively in response to gingival injury, gingival irritation, subgingival calculus, or a foreign body in the gingival sulcus. Local irritants such as dental plaque, calculus, microorganisms, masticatory forces, ill-fitting dentures, and poor-quality restorations have been implicated in the etiology of POF. Chronic irritation of the periosteal and periodontal membranes causes metaplasia of the connective tissue and initiates the formation of bone or dystrophic calcification. 
POF is definitively diagnosed through a histopathological examination. Histologically, it is a nonencapsulated mass of cellular connective tissue with randomly distributed calcifications and/or mature bone. The histopathological examination usually shows the following features:
Acute or chronic inflammatory cell infiltration can also be observed in these lesions. Bone may be woven or lamellar that is at times surrounded by osteoid, or may be trabecular.
- Benign fibrous connective tissue with varying fibroblast, myofibroblast and collagen content,
- Sparse to profuse endothelial proliferation, and
- Mineralized material that may represent mature, lamellar or woven osteoid, cementum-like material, or dystrophic calcifications.
Differential diagnoses considered on the basis of clinical and radiographic features are gingival lesions such as pyogenic granuloma, fibroma/irritation fibroma/focal fibrous hyperplasia, peripheral odontogenic fibroma, and POF. Pyogenic granuloma is an elevated lesion with a smooth, lobulated surface that can be present in the interdental papilla area. In case of fibromas, they are well-defined, slow-growing, elevated nodules having a smooth surface with firm consistency. Peripheral giant cell granulomas are reactive, hyperplastic lesions that occur in response to local irritating factors. A peripheral odontogenic fibroma is a slow-growing, solid, firmly attached gingival mass that can arise interdentally, sometimes displacing teeth. A POF is a solitary nodular mass that arises interdentally. Radiographically, no significant abnormalities are seen in any of the lesions. Due to the similarities of all these lesions to the current case, they were considered in the differential diagnosis, but as the histopathological features were highly characteristic, a final diagnosis of POF was rendered. ,,
In a series reported by Cundiff, 16% of the cases recurred, while in a series of 50 cases reported by Eversole and Rovin, the recurrence was 20%. The treatment of choice is complete surgical excision with the removal of the irritating factors. It is important to remove lesions completely by including the subjacent periosteum and periodontal ligament, besides the possible causes, to reduce recurrence. POF recurs due to the following reasons:
- Incomplete removal of the lesion.
- Failure to eliminate local irritants.
- Difficulty in accessing the lesion during surgical manipulation as a result of the intricate location of the lesion (usually an interdental area). 
| Conclusion|| |
POF is a slowly progressing lesion, the growth of which is generally limited. Histopathological evaluation and confirmation is required to differentiate it from other gingival growths. Early surgical treatment including removal of identifiable etiological factors with postoperative follow-up is mandatory. ,
We would like to thank Dr. Srinath Thakur, Principal, SDM College of Dental Sciences and Hospital, Dharwad for his constant support.
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]