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Peripheral cemento-ossifying fibroma of maxilla

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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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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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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

1.EversoleLR.Craniofacialfibrousdysplasiaandossifyingfibroma.OralMaxillofacSurgClinNorthAm.
19979:632.

2.KeluskarV,ByakodiR,ShahN.Peripheralossifyingfibroma.JIndianAcadOralMedRadiol.
200820:546.

3.MartinsJuniorJC,KeimFS,KreibichMS.PeripheralOssifyingFibromaoftheMaxilla:CaseReport.Int
ArchOtorhinolaryngol.200812:2959.

4.KenneyJN,KaugarsGE,AbbeyLM.Comparisonbetweentheperipheralossifyingfibromaand
peripheralodontogenicfibroma.JOralMaxillofacSurg.198947:37882.[PubMed:2926546]

5.WaltersJD,WillJK,HatfieldRD,CacchilloDA,RaabeDA.Excisionandrepairoftheperipheral
ossifyingfibroma:areportof3cases.JPeriodontol.200172:93944.[PubMed:11495143]

6.DelbemA,CunhaR,SilvaJ,SoubhiaA.Peripheralcementoossifyingfibromainchild.afollowupof4
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7.NevilleBW,DammDD,AllenCM,BouquotJE.2nded.Philadelphia:W.B.SaundersCo2004.Text
bookoforalandmaxillofacialPathologypp.4512.

8.FarquharT,MaclellanJ,DymentH,AndersonRD.Peripheralossifyingfibroma:acasereport.JCan
DentAssoc.200874:80912.[PubMed:19000465]

9.KumarSK,RamS,JorgensenMG,ShulerCF,SedghizadehPP.Multicentricperipheralossifying
fibroma.JOralSci.200648:23943.[PubMed:17220623]

10.EversoleLR,LeiderAS,NelsonK.Ossifyingfibroma:aclinicopathologicstudyofsixtyfourcases.
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11.GranizoRM,CuellarAS,FalahatF.Cementoossifyingfibromaoftheuppergingiva.OtolaryngolHead
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12.EndoY,UzawaK,MochidaY,NakatsuruM,ShiibaM,YokoeH,etal.Differentialdistributionof
glycosaminoglycansinhumancementifyingfibromaandfibroosseouslesions.OralDis.20039:736.
[PubMed:12657032]

13.KendrickF,WaggonerWF.Managingaperipheralossifyingfibroma.JDentChild.199663:1358.

14.YadavR,GulatiA.Peripheralossifyingfibroma:acasereport.JOralSci.200951:1514.
[PubMed:19325214]

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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