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12/6/2016 Peripheralcementoossifyingfibromaofmaxilla
JIndianSocPeriodontol.2010JulSep14(3):186189. PMCID:PMC3100863
doi:10.4103/0972124X.75915
Peripheralcementoossifyingfibromaofmaxilla
AnirbanChatterjee,NehaAjmera,andAmitSingh
DepartmentofPeriodontics,InstituteofDentalSciences,Bareilly,UttarPradesh,India
Addressforcorrespondence:Dr.NehaAjmera,DepartmentofPeriodontics,InstituteofDentalSciences,OppositeSureshSharmaNagar,
Bareilly,UttarPradesh243006,India.Email:nehaajm@gmail.com
Received2010Jan5Accepted2010Jun22.
CopyrightJournalofIndianSocietyofPeriodontology
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Abstract
Peripheralcementoossifyingfibromaisareactivegingivalovergrowthoccurringfrequentlyinanterior
maxilla.Itisaslowgrowingbenigntumorwhichmayleadtopathologicmigrationandotherperiodontal
problems,soitshouldbeexcisedassoonaspossible.Therecurrencerateofperipheralcementoossifying
fibromaisreportedtobe8%to20%,soaclosepostoperativefollowupisrequired.Herein,wearereporting
asimilarcaseofperipheralcementoossifyingfibromainthemaxillaryanteriorregion.
Keywords:Fibroma,gingivalovergrowth,peripheralcementoossifyingfibroma
INTRODUCTION
Ossifyingfibromaisabenignneoplasmarisingincraniofacialbones,composedofproliferatingfibroblasts
withosseousproductsthatincludeboneandovoidcalcificationstheselesionsarewelldemarcatedfromthe
adjacentbone.[1]
Therearetwotypesofossifyingfibromas:thecentraltypeandtheperipheraltype.Thecentraltypearises
fromtheendosteumortheperiodontalligamentadjacenttotherootapexandcausesexpansionofmedullary
cavity.Theperipheraltypeoccurssolelyonthesofttissuescoveringthetoothbearingareasofthejaws.[2]
In1872,Menzelfirstdescribedossifyingfibromabutonlyin1927,Montgomeryassignedaterminologyto
it.[3]
Itoccursexclusivelyonthegingivaandaccountsfor3.1%[4]ofalloraltumorsandfor9.6%ofgingival
lesions.[5]Thepathogenesisofthistumorisuncertain.Duetotheirclinicalandhistopathologicalsimilarities,
someperipheralcementoossifyingfibromasarebelievedtodevelopinitiallyasapyogenicgranulomathat
undergoesfibrousmaturationandsubsequentcalcification.Itisfrequentlyassociatedwithirritantagentssuch
ascalculus,bacterialplaque,orthodonticappliances,illadaptedcrownsandirregularrestorations.The
mineralizedproductprobablyoriginatesfromperiostealcellsorfromtheperiodontalligament.[6]
Ossifyingfibroidepulisperipheralfibromawithcalcificationperipheralcementoossifyingfibromaand
calcifyingfibromaarethetermswhichrefertoperipheralossifyingfibroma.[3]
Peripheralcementoossifyingfibromaappearsasanodularmass,eitherpedunculatedorsessile.Itmost
commonlyappearstooriginatefrominterdentalpapilla.Thecolorrangesfromredtopink,andthesurfaceis
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12/6/2016 Peripheralcementoossifyingfibromaofmaxilla
frequentlybutnotalwaysulcerated.Itismorecommonlyseeninthefirstandseconddecadesoflifeandhas
afemalepreponderance.Thereisaslightpredilectionforthemaxillaryarch(60%)andtheincisorcuspid
region(50%).[7]Apotentialoftoothmigrationduetothepresenceofperipheralcementoossifyingfibroma
hasbeenreported.[6]Thetreatmentofchoiceissurgicalexcisionwithremovalofirritationfactors.
CASEREPORT
A45yearoldwomanwiththechiefcomplaintofpainlessswellinginupperrightfrontregionreportedtothe
DepartmentofPeriodontics,InstituteofDentalSciences,Bareilly.Shereportedthatthelesionwaspresent
forthelast7months.Itwasofpeasizewhenitstarted,andgraduallyitincreasedtoattainthepresentsize.
Onextraoralexamination,swellingwaspresentontherightside,extendingfromphiltrumtoangleofmouth
[Figure1].
Intraoralexaminationrevealedagingivalovergrowthinrelationtointerdentalpapillabetween11and12of
approximately11.5cminsize,pedunculated,withcolorsameasthatofadjacentgingiva.Surfacewas
smoothwithfewareasofulceration.
TeethassociatedweregradeIImobileandpathologicallymigrated[Figure2].
Radiographicexaminationrevealedmoderateamountofbonelossinrelationto11and12inbothintraoral
periapicalandocclusalradiographs[Figures3and4].Routinehemogramwasfoundtobenormal.A
provisionaldiagnosisofperipheralcementoossifyingfibromawasmade.Thedifferentialdiagnosisincluded
irritationalfibroma,pyogenicgranulomaandperipheralgiantcellgranuloma.
Thepatienthadnosystemicproblem,andsurgerywasplannedonthebasisoftheclinicalandradiographic
examinations7daysafterthoroughoralprophylaxis.Afterextraoralandintraoralantisepsis,localanesthesia
wasgiven.Excisionofthelesionwasdone,followedbycurettageoftheareaandscalingoftheinvolved
teeth.Periodontaldressingwasplaced[Figures57].Thepatientwasrecalledafter1weekforremovalof
dressingandcheckup.
ThetissueexcisedwassenttotheDepartmentofOralPathologyforhistopathologicalexamination.
Histopathologicalreportrevealedparakeratinizedepithelium,densefibrousconnectivetissuestromawhich
comprisedofplumptostellatefibroblasts,alongwithspindleshapedfibroblasts.Connectivetissuealso
showedlargehematoxyphilicareasofcalcification/osteoidwithfewareasshowingentrappedosteocytesand
peripheralliningofosteoblastlikecells.Focalareasofinflammationwereseeninconnectivetissue,mainly
comprisingoflymphocytesandfewplasmacells[Figure8].
Thepatientwasrecalledeverythirdmonthformaintenancetherapyandtocheckforpossiblerecurrence[
Figure9].
DISCUSSION
Peripheralcementoossifyingfibromaisafocal,reactive,nonneoplastictumorlikegrowthofsofttissue,
oftenarisingfromtheinterdentalpapilla.[8]Alotofconfusionhasprevailedinthenomenclatureof
peripheralossifyingfibroma,withvarioussynonymsbeingused,suchasperipheralcementifyingfibroma,
ossifyingfibroepithelialpolyp,peripheralfibromawithosteogenesis,peripheralfibromawith
cementogenesis,peripheralfibromawithcalcification,calcifyingorossifyingfibrousepulisandcalcifying
fibroblasticgranuloma.[9]Ossifyingfibromaselaboratebone,cementumandspheroidalcalcifications,which
hasgivenrisetovarioustermsforthesebenignfibroosseousneoplasms.Whenbonepredominates,
ossifyingistheappellation,whilethetermcementifyinghasbeenassignedwhencurvilineartrabeculaeor
spheroidalcalcificationsareencountered.[10]Whenboneandcementumliketissuesareobserved,the
lesionshavebeenreferredtoascementoossifyingfibroma.
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12/6/2016 Peripheralcementoossifyingfibromaofmaxilla
Cementifyingfibromasmaybeclinicallyandradiographicallyimpossibletoseparatefromossifying
fibromas.[11]AnattempthasbeenmadebyEndoetal.todistinguishcementifyingfibromasfromossifying
fibromasandfibrousdysplasiasbyusingimmunohistochemicalanalysisforkeratansulfateandchondroitin
4sulfate,inwhichthecementifyingfibromasshowedsignificantimmunoreactivityforkeratansulfate,and
ossifyingfibromasandfibrousdysplasiasshowedintensiveimmunostainingforchondroitin4sulfate.[12]
Thoughtheetiopathogenesisofperipheralossifyingfibromaisuncertain,anoriginfromcellsofthe
periodontalligamenthasbeensuggested.Thereasonsforconsideringperiodontalligamentoriginfor
peripheralossifyingfibromaincludeexclusiveoccurrenceofperipheralossifyingfibromainthegingiva
(interdentalpapilla),theproximityofgingivatotheperiodontalligament,andthepresenceofoxytalanfibers
withinthemineralizedmatrixofsomelesions.[9]Excessiveproliferationofmaturefibrousconnectivetissue
isaresponsetogingivalinjury,gingivalirritation,subgingivalcalculusoraforeignbodyinthegingival
sulcus.Chronicirritationoftheperiostealandperiodontalmembranescausesmetaplasiaoftheconnective
tissueandresultantinitiationofformationofboneordystrophiccalcification.Ithasbeensuggestedthatthe
lesionmaybecausedbyfibrosisofthegranulationtissue.[13]
Lesionsinvolvingthegingivalsofttissuesarerarecomparedtothelesionsappearingwithinbone.[11]
Mesquita(1998)foundhighernumbersofargyrophilicnucleolarorganizerregions(AgNORs)and
proliferatingcellnuclearantigen(PCNA)positivecellsinossifyingfibromathaninperipheralossifying
fibroma,indicatinghigherproliferativeactivityinossifyingfibroma.Xraydiffractionanalysisindicatedthat
themineralphaseofbothcentralandperipheraltissuesconsistsofapatitecrystalsandthatthecrystallinityof
theseapatitesislowerthanthatofboneapatite.Also,itwassuggestedthatthecrystallinityoftheapatites
mightimproveprogressivelywiththedevelopmentofthelesion,possiblytothesamedegreeasthatofbone
apatite.[14]
Thereportedgingivalovergrowthhasbeenclearlydiagnosedasperipheralcementoossifyingfibromaafter
histopathologicexamination.Clinicalpictureoflessvasculargrowthrulesoutthepossibilityofpyogenic
granuloma.
Histopathologyshowednopresenceofgiantcellsinconnectivetissuestroma,thusrulingoutthepossibility
ofperipheralgiantcellgranuloma.
Furthermore,peripheralcementoossifyingfibromatendstooccurinthesecondandthirddecadesoflife,
withpeakprevalencebetweentheagesof10and19years.Almosttwothirdsofallcasesoccurinfemales,
withapredilectionfortheanteriormaxilla,i.e.,incisorcanineregion.Inthepresentcase,thefindings
correlatewiththegeneralcharacteristicsexceptforage.Thesizeoftheperipheralossifyingfibromaranges
from0.4to4.0cm.Inthepresentcase,thedimensionsofthelesionwerewellwithintheabovementioned
range.Further,thediagnosiswasconfirmedbyhistopathologicevaluation.
Lesionwassuccessfullytreated,andfollowupwasdoneat8monthstocheckforanyrecurrence.
Peripheralcementoossifyingfibromaisaslowlyprogressinglesion,withlimitedgrowth.Close
postoperativefollowupisrequiredbecauseofthegrowthpotentialofincompletelyremovedlesions,aswell
as8%to20%recurrencerate.[8]Itisimportanttoremovelesionscompletelybyincludingsubjacent
periosteumandperiodontalligament,besidesthepossiblecauses,toreducerecurrence.
Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared.
REFERENCES
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12/6/2016 Peripheralcementoossifyingfibromaofmaxilla
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3.MartinsJuniorJC,KeimFS,KreibichMS.PeripheralOssifyingFibromaoftheMaxilla:CaseReport.Int
ArchOtorhinolaryngol.200812:2959.
4.KenneyJN,KaugarsGE,AbbeyLM.Comparisonbetweentheperipheralossifyingfibromaand
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ossifyingfibroma:areportof3cases.JPeriodontol.200172:93944.[PubMed:11495143]
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7.NevilleBW,DammDD,AllenCM,BouquotJE.2nded.Philadelphia:W.B.SaundersCo2004.Text
bookoforalandmaxillofacialPathologypp.4512.
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12.EndoY,UzawaK,MochidaY,NakatsuruM,ShiibaM,YokoeH,etal.Differentialdistributionof
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13.KendrickF,WaggonerWF.Managingaperipheralossifyingfibroma.JDentChild.199663:1358.
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FiguresandTables
Figure1
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Photographshowingextraoralswellingonrightfrontregion,extendingfromphiltrumtoangleofmouth
Figure2
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Photographshowinggingivalovergrowthextendingfromrightcentralregiontolateralincisorregion
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Figure3
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IntraoralPeriApicalshowingmoderatebonelossin11,12region
Figure4
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Maxillaryocclusalviewshowingbonelossin11,12region
Figure5
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Photographshowingexcisionofgrowth
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Figure6
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Photographshowingexcisedtissue
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Figure7
Photographshowingsurgicalareaafterexcision
Figure8
Photographshowinghistopathologicalpictureoflesion
Figure9
Photographshowingpostoperativeviewat3months
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