Background: The term “peripheral fibro-osseous lesion (PFOL)” is used relatively for common gingival lesions characterized histologically by hypercellular connective tissue showing either new bone-like formations or cementum-like substance and rarely dystrophic calcifications. These lesions are closely related to the other fibro-osseous lesions such as cemental periapical dysplasia, fibrous dysplasia, and other calcifying odontogenic cysts and tumors. The etiology is unknown, but certain authors suggest plaque, dental calculus, and ill-fitting dentures which might be the irritating agents causing irritation to the periodontal ligament which leads to such reactive growth. Aim: The main aim of the present study is to present the clinicopathological features of a series of cases from the institute of D. Y Patil Deemed to be University, School of Dentistry. Materials and Methods: A total of 38 cases were evaluated over a period of 20 years. The age, size, gender, location, signs and symptoms, irritating agents, and the type of mineralized tissue present in the lesions were evaluated. Modified Gallego's Stain was performed to identify the hard tissues. Results: The age range of patients (males = 23, females = 15) was 6–71 years (mean = 29.842 years). The lesions had more predisposition for males (males = 60.53%, females = 39.47%). The occurrence of the lesion was more in maxilla with 65% of cases occurring in anterior region. Conclusion: According to the present study, PFOL has a slight predominance in males, with the mean age being 29.842 years with the highest occurrence in the anterior maxillary arch.
Keywords: Periodontal ligament, peripheral cementifying fibroma, peripheral cemento-ossifying fibroma, peripheral fibro-osseous lesions, peripheral ossifying fibroma
|How to cite this URL:|
Jain A, Mehta R, Pereira T, Vidhale RG, Anjali A K, Shetty SJ. Peripheral fibro-osseous lesion: An institutional study of 38 cases. J Microsc Ultrastruct [Epub ahead of print] [cited 2023 Feb 8]. Available from: https://www.jmau.org/preprintarticle.asp?id=362494
| Introduction|| |
Multiple gingival overgrowths such as peripheral giant cell granuloma, pyogenic granuloma, and fibro-osseous lesions like peripheral ossifying fibroma (POF) occur in the oral cavity. These may occur as a result of local irritation caused due to trauma, microorganisms, plaque, calculus, ill-fitting dentures, and poor restorations., Fibro-osseous lesions are a group of lesions in which the cellular fibrous tissue is replaced by the deposition of bone containing a foci of mineralization which can vary in its amount and appearance. Among all the fibro-osseous lesions of the jaw, the most common are ossifying fibroma, fibrous dysplasia, and cemento-osseous dysplasia. In previous reviews, authors have given the synonyms of ossifying fibroma as cemento-ossifying fibroma (COF), cementifying fibroma, and juvenile ossifying fibroma. Further, these lesions can be divided into two types: central and peripheral.
Peripheral fibro-osseous lesions (PFOL) are solitary, nonneoplastic gingival growths. These lesions usually present as solitary, sessile, or pedunculated nodular masses., The pluripotent cells of the periodontal ligament (PDL) have the ability to transform or metaplastically alter into osteoblast, cementoblast, or fibroblast, which explains the presence of bone- and cementum-like structures in POF., The growth of the lesion is marked by ulceration which presents itself as red or pink whereas healing ulcers show an intact surface which was stated by Brad et al. PFOLs are predominantly lesions of teenagers and young adults. Most lesions are >2 cm though larger lesions up to 10 cm may occur. There is a marked female predominance and a slight predisposition for the maxillary arch. More than 50% of cases occur in the incisor-cuspid region. Mergoni et al. claim that PFOLs have a high rate of recurrence of about 8%–45%. The radiographic occurrence of the lesion is a well-demarcated, sharply defined border with an expansile profile. These lesions constitute a high degree of cellularity usually showing bone tissue formations although cementum-like material and dystrophic calcifications may also be found. The main identifying feature for these PFOLs is that when bone predominates in the histologic picture, the term “ossifying” is used whereas when cementum-like hard tissue is observed, the term “cementifying” is used. When both bone- and cementum-like hard tissues are present in the lesion, the term “cemento-ossifying” is used.
The main aim of the present study is to present the clinicopathological features of a series of cases of PFOL from an Indian Institute.
| Materials and Methods|| |
In the present study, 38 cases of PFOL were chosen on an average, over a period of 20 years (2002–2022), retrieved from archives of the Department of Oral and Maxillofacial Pathology and Microbiology, D.Y. Patil University School of Dentistry, Navi Mumbai. Medical and clinical history was retrieved for each case through referral letters, requisition forms, and biopsy reports. Different anatomical locations were considered such as: anterior and posterior maxilla, and anterior and posterior mandible.
Each section was stained in hematoxylin and eosin (H and E) stain and was examined under a light microscope. The mineralized tissues present in the lesions were divided into three groups:
- Osteoid tissue
- Cementum-like hard tissue
- Osteoid tissue and cementum-like hard tissue.
The tissues were also stained using the Modified Gallego's Stain to confirm the presence of the hard tissues present in these lesions.
Data were summarized using mean values for all the parameters.
This is a retrospective study for which an ethical clearance was obtained from the institute IREB/22/OP/3822. The approval date was 03/03/2022. An informed consent was taken from each patient regarding their clinical photos being added to research work following the Declaration of Helsinki.
| Results|| |
PFOLs (38 cases) constitute about 0.9% of all 4038 oral biopsies performed in this institute from January 2002 to June 2022. Average age range at the time of diagnosis is 6–71 years with a mean of 29.842 years. The highest occurrence of cases of POF was in the 1st decade, whereas for Peripheral COF (PCOF), it was 2nd decade. Only 6 cases were recorded in PCF out of which 4 occurred between the 1st and the 4th decades. 65.7% of the total cases (38 cases) occurred between the 1st and the 3rd decades. Of all 38 cases, 23 were male patients and 15 were female patients.
Out of all the 38 cases, 52.63% of cases were observed in the maxilla and 44.73% cases were observed in the mandible. 2.64% of the cases were seen in both jaws.
The lesions were solitary, pedunculated nodular masses and mostly occurred on the gingiva [Figure 1] with a higher predilection for the maxillary arch, except for 2 cases one of which occurred on the retromolar pad region and other on the body and ramus of mandible.
|Figure 1: Clinical picture of POF in a 14 year old male showing gingival overgrowth. POF: Peripheral ossifying fibroma|
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The size of the lesion for all 3 entities ranges from 0.25 cm2 to 100 cm2, the smallest being 0.5 cm × 0.5 cm and the largest being 10 cm × 10 cm.
Thirty-four out of the 38 cases complained of only swelling, 3 cases complained of pain and swelling whereas a single case showed the presence of bleeding along with pain and swelling.
Of all the 38 cases, 7.89% cases exhibited tobacco habit, 15.78% cases had poor oral hygiene, one case (2.63%) presented a history of trauma, and the remaining 73.68% cases did not present any form of irritating agent.
The treatment for all 38 lesions was surgical excision along with prophylaxis.
The excised lesions were processed, stained with H and E stain, and observed under light microscope. The H and E stained section of one of the lesions showed underlying connective tissue with ulcerated stratified squamous epithelium in some areas. The underlying fibrillar connective tissue stroma shows osteoid tissue formations and plump proliferating fibroblasts [Figure 2] and [Figure 3]a, [Figure 3]b.
|Figure 2: H and E stained section under ×100 showing fibrillar connective tissue stroma with new bone formation. H and E: Hematoxylin and eosin|
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|Figure 3: (a) H and E stained section under ×400 depicting new bone formation. (b) H and E stained section under ×400 showing plump fibroblasts in fibrillar connective tissue stroma. H and E: Hematoxylin and eosin|
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In the routine H and E staining procedure, it is difficult to differentiate the hard tissues present and poses a great difficulty in the correct diagnosis and treatment planning for these lesions. Modified Gallego's Stain helps in identifying the hard tissues by staining them with different colors and hence aids in the correct diagnosis. Modified Gallego's stain uses basic reagents hematoxylin, carbolfuchsin, and aniline blue. Under Gallego's stain, green trabecular areas were observed which depicted bone [Figure 4]b, whereas dark red depositions depicted cementum-like hard tissues [Figure 4]a, [Table 1] and [Table 2].
|Figure 4: (a) Modified Gallego's stain showing dark red depositions of cementum-like structure (b) Modified Gallego's stain showing green trabecular regions depicting bone|
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|Table 1: Clinical and histopathological features of cases affected by peripheral ossifying fibroma, peripheral cementifying fibroma and peripheral cemento-ossifying fibroma|
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| Discussion|| |
PFOLs are common reactive overgrowths on the gingiva that usually arise from the interdental papilla. These lesions occur predominantly in the second decade of life and affect females more than males. In contradiction, in a study done by Zhang et al., they observed that the peak incidence of occurrence was fifth to sixth decades. POF is the third most common localized gingival overgrowth and the term was coined by Eversole and Robin in 1972., The term COF was first given by Menzel in 1872 as a variant of ossifying fibroma. In 1971, COF was classified under cementum forming lesions which include fibrous dysplasia and ossifying fibroma., Some oral pathologists believe POF to be a type of inflammatory hyperplasia. These lesions show high occurrences in the anterior region of the mandible. The authors also observed that lesions of POF of the jaw usually affect the posterior mandible. Cuisia and Brannon along with other authors observed that POF occurs more frequently on the anterior maxilla whereas Kaur et al., Effiom et al., Mishra et al., García de Marcos et al., and Sivapathasundharam found that POF occurs equally in maxilla and mandible. In the present study, 52.63% of the total cases occurred in the maxilla while 44.73% of cases occurred in the mandible, which shows that PFOL has predominance for the maxilla.
PFOLs represent proliferation of reactive nature though clinically benign. These lesions constitute 3.1% of all oral tumors and 9.6% of gingival lesions. The criteria for the nomenclature of these lesions are based on nature of the growth, location of growth, and the histopathological components. Lesions that grow intraosseously are termed “central lesions” and the lesions that grow extraosseous or on soft tissues are termed “peripheral lesions.” The etiopathogenesis of these lesions is lesser known, however, they resemble clinically and histopathologically pyogenic granuloma and hence some authors believe that these lesions may arise as a result of maturation of chronic pyogenic granuloma., Another hypothesis says that since POF has a female predilection and occurs during puberty and pregnancy, hormonal factors can be responsible for the growth of POF. In support of the above statement, studies have shown, that females are more affected than males in PFOL with a ratio of 2:1 which contradicts the present study, wherein a slight variation was observed in the occurrence of PFOL showing male predominance (60.53% cases).
Clinically, these lesions appear as asymptomatic, slow-growing mass that may be pedunculated or sessile with the first sign being the displacement of teeth. According to Buchner and Hansen, the early lesion of POF is clinically seen as ulcerated nodules that show calcifications and can easily be misjudged as pyogenic granuloma., Neville et al. and Sivapathasundharam found that the cause of POF may be chronic, long-standing pyogenic granuloma. In the present study, 7.89% of cases had tobacco habits, 15.78% cases presented poor oral hygiene while 2.63% of cases gave a history of trauma. The remaining 73.68% of cases were devoid of any form of irritating agent.
In literature, the size of these lesions was suggested to be 0.5 cm ranging up to 9 cm which coincides with the present study, where the size of PFOL was seen ranging from 0.5 to 10 cm. According to literature, a rare multicentric case of POF has been reported. The size of these lesions can be <1.5 cm in diameter and can go up to 9 cm or more. The surface mucosa of these lesions may or may not be ulcerated.
In literature, there is a variability regarding the age range of the occurrence of PFOL.
Numerous studies,,, state that these lesions predominantly affect children and teenagers between the ages 10 and 19 years or they can affect young adults with the mean age being 29 years.
Authors have also suggested that these lesions occur during the third to fourth decade of life., In the present study, the mean age of occurrence of all PFOL was found to be 29.8 years.
Mergoni et al. along with Neville et al. found that cases of POF showed slight discomfort.
The patient usually comes with a complaint of swelling. The teeth remain unaffected.
Numerous other studies observed that POF and PCOF produced expansion and thinning of the buccal and lingual cortical plates, although perforation was rare. The teeth may show a slight root displacement but resorption is not common. Of 38 cases, 34 cases, in the present study, complained of only swelling, 3 cases complained of pain and swelling while a single case presented bleeding along with pain and swelling.
Histologically, the three lesions can be distinguished from each other on the basis of the hard tissue present, i.e. if bone-like structures are present, it is designated as “ossifying fibroma,” if cementum-like structures are present, it is designated as “cementifying fibroma” and when both are present, it is termed as “COF.” POF is a nonencapsulated lesion that is lined by stratified squamous epithelium and shows unevenly distributed calcifications in a highly cellular connective tissue stroma with fibroblasts, myofibroblasts, and collagen., The current study shows varying histopathological strata which correlate with a study given by Poonacha et al. depending on the ulcerated or intact surface epithelium:
Strata I: Superficially ulcerated epithelium with neutrophils and leukocytes predominating.
Strata II: The connective tissue composed of plump and immature fibroblasts with chronic inflammatory infiltrate.
Strata III: Fibro-cellular connective tissue stroma comprising osteoid like and new bone formation.
With respect to the calcified material, Bhaskar and Jacoway explained four forms: (a) mature bone; (b) immature bone; (c) dead bone; and (d) foci of calcification were evidently seen.
In cases with nonulcerated epithelium, the features are homogenous with ulcerated epithelium exhibiting differences such as presence of surface epithelium, less than one-fifth of the lesion having cementum-like material, and dystrophic calcifications being the most recognized.
The radiographic appearance of PFOL is a well-demarcated, either unilocular or multilocular lesion with varying degrees of radiolucency and radiopacity.
The treatment modality for these lesions is surgical removal. The excised tissue must be sent for histopathological examination for confirmation of diagnosis. There are cases that show recurrence, hence the surgeon must carefully resect the lesion along with the removal of the surrounding peripheral and deep margins along with the PDL and the affected bone., The recurrence rate as reported by authors was observed to be ranging from 8.9% to 20%, which can be due to persistent local irritants, repeated trauma, etc.
The differential diagnosis of PFOL could be pyogenic granuloma, peripheral giant cell granuloma, peripheral odontogenic fibroma, hemangioma, chondrosarcoma, and osteosarcoma.
| Conclusion|| |
Reactive fibro-osseous lesions are lesions characterized by the replacement of cellular stroma by bony structures. Among these lesions, ossifying fibromas are one of the most common lesions. PFOL are solitary, nonneoplastic, reactive gingival overgrowths that may appear as sessile or pedunculated nodular masses. According to the present retrospective study, these lesions occur more commonly in the second decade (mean age = 29.842 years) with males being more affected than females. They occur predominantly in the maxillary jaw with the anterior region being the most common. These lesions, although being benign in nature, have a high rate of recurrence and hence the surgeons must carefully evaluate and treat them accordingly.
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.
I am sincerely thankful to D.Y. Patil Dental College for providing me the opportunity to write a case study on the above topic. I am also thankful to Dr. Treville Pereira for guiding me in every stage of this research paper. Without his support, it would have been extremely difficult for me to prepare the paper so meaningful and interesting. I am also thankful to Dr. Subraj Shetty who has helped me during this course of research paper in several ways.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Oral Pathology, D.Y Patil Deemed To Be University, D.Y Patil School Of Dentistry, Sector 7, Nerul, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]