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

University J Dent Scie 2017; No. 3, Vol. 1

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 – drprateek86@gmail.com

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University J Dent Scie 2017; No. 3, Vol. 1