Hence, a final diagnosis of Peripheral Cemento-Ossifying fibromawas given associating the clinical, radiographic along with thehistopathological findings.Discussion:Diagnosing and classifying the benign fibroosseouslesions of the jaws has been a challenging for the clinician.
The 1992 WHOclassification sets a name (cemento-ossifying fibroma) for two histologic forms (cementifying fibroma and ossifying fibroma) that may be otherwise difficult todistinguish.5This fibroma is an non-odontogeniclesion. A varied number of synonyms have been given for PCOF such as epulis, peripheral cementifying fibroma, ossifying fibroepithelialpolyp, peripheral fibroma with osteogenesis,peripheral fibroma withcementogenesis, peripheral fibroma with calcification, calcifying or ossifying fibroma and calcifying fibroblastic granuloma.6When osseous,dystrophic calcifications or calcified globules resembling acellular cementum arefound in the connective tissue the ossifying fibroma has been referred as thecement-ossifying fibroma. As mentioned above, the variants cementifying fibromaand the ossifying fibroma may be difficult to differentiate from other lesionsclinically however in a study by Endo et al, an immunohistochemical analysisfor the cementifying fibroma showed a immunoreactivity for keratin sulphate whileossifying fibroma and fibrous dysplasia showed immunostaining for chondroitinsulphate.
The pathogenesis of peripheralossifying fibroma is ambiguous but a sourcefrom periodontal ligament cells has been proposed in literature. The motivesfor consideringPeriodontal ligament originfor this lesion includes its selective occurrence in the gingiva (interdentalpapilla), the vicinity of gingiva to the periodontal ligament along with thepresence of oxytalan fibres within the calcifiedmatrix of few lesions. There could be some influence of the hormonal levels dueto its predilection in the females. It is also said to have a decline inincidence after third decade but few case reports by Antony et al7 and Pereira et al8 have reported cases inthe fourth decade in male patients.
Similarly Kumar et al and Mishra et al9 reported the occurrence ofPCOF in a 49 year old and a 50 year old female patient respectively. PCOFhas a predilection for maxillary anterior region of about 60%. In currentreport the growth was present in the maxillary incisors area, in a femalepatient aged 18 years. It measured around 13mmx13mm.
There were no radiographicchanges seen. Histopathology of the specimen confirmed the diagnosis. Features found in this lesion are fibrous connective tissue, endothelial proliferation alongwith mature or woven osteoid, cementum-alike or dystrophic calcificationsrepresented by the mineralized portion. Acute or chronic inflammatory cellinfiltration may be found in such cases. Majority of the common features werefound in the current report. It was identified by Gardner et al that peripheralossifying fibroma shows a cellularconnective tissue so distinctive that a histologic judgement could be made withpoise, irrespective of the grade of calcification.4An hypothesis that firstPOF presents as ulcerated growth with minimal calcification, letting misdiagnosis as a pyogenicgranuloma was given by one of the authors.
Hence, till the histopathologicalconfirmation is driven, POF as the diagnosis should be suspected. Treatmentof PCOF comprises of eradication of causal elements followed by scaling andtotal surgical removal along with involved periodontal ligament and periosteum.Possibility of recurrence would be minimal with this. Treatment done for thislesion in the present report was scaling and root planing, excision and an openflap debridement was done after it recurred in four weeks. Considering therecurrence rate of PCOF with a range of 8.9 to 20% a consistent follow up is obligatory. The probable cause for initial recurrence observed withinone month of excision in the present case may be due to persistence of fragmentsof the lesion in the vicinity or persistence of local irritants.
10Our patient has beenunder follow up and has not shown any signs of recurrence since the excisionfor the second time. Conclusion:PCOFis a slow growing lesion. Many cases may go unnoticed due to absence ofsymptoms experienced by the patient for long times before seeking the treatment.PCOF may be commonly misdiagnosed from the other gingival lesions.
Therefore, histopathologicalanalysis is crucial for exact diagnosis and appropriate management. Here is areport of PCOF in an 18 year old female, whichrecurred due to persistence of fragments of thelesion in the vicinity. Complete excision with thorough curettage oftissues is critical to prevent recurrence. Postoperative recall is essentialbecause of the progressive nature and recurrence rate of the lesion.