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Authors: Dr. Deepa Hegde.Y,Dr. Sudhindra Baliga,Dr.Umesh Chandra Prasad .

Peripheral ossifying fibroma (POF) was coined by Eversole and Rovin in 1972.It is a relatively uncommon gingival growth that is considered to be reactive in nature and postulated to appear secondary to irritation or trauma. They usually occur in young adults with a declining incidence in the later years, with a female predominance and are solitary in nature. Gingival growths are one of the most frequently encountered lesions in the oral cavity.Lesions such as irritational fibroma, pyogenic granuloma, peripheral ossifying fibroma and peripheral giant cell granuloma, are innocuous and rarely present with aggressive features.A clinical report of a 12-year-old girl with an asymptomatic  peripheral ossifying fibroma in the left  anterior maxilla is presented.

In 1982, Gardner suggested the term peripheral ossifying fibroma for a lesion that is reactive in nature and is not the extraosseous counterpart of a central ossifying fibroma (COF) of the maxilla and mandible (1). There are two types of ossifying fibromas: the central type and the peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes the expansion of the medullary cavity. The peripheral type occurs solely on the soft tissues covering the tooth-bearing areas of the jaws (2).  Peripheral ossifying fibroma is a focal, reactive, non-neoplastic tumor-like growth of the soft tissue that often arises from the interdental papilla. It may be pedunculated or sessile broad based, usually smooth surfaced and varies from pale pink to cherry red in color. It is believed to comprise about 9% of all gingival growths and to arise from the gingival corium, periosteum, and the periodontal membrane. It has also been reported that it represents a maturation of a pre-existing pyogenic granuloma or a peripheral giant cell granuloma(3).

Case report
A  12-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry ,K.D.Dental College and Hospital, with a slow-growing , painless gingival growth in the right anterior maxillary region that had been present for 2 months. An intraoral examination revealed a sessile growth  extending from the middle of the marginal gingival in relation to 21 to the interdental papilla between 22 and 23. The color  was  pale pink with few  erythematous areas. The growth measured approximately 2 cm × 1.5cm x 1.0cms in size(Figure 1).On palpation, the growth was not tender and was firm in consistency . The differential diagnosis of irritation fibroma,pyogenic granuloma ,peripheral giant cell granuloma(PGCG) and peripheral ossifying fibroma were made.
The lesion was surgically excised under local anaesthesia and a periodontal pack(Coe Pak) was placed (Figure 2).The excisional biopsy was submitted for histopathological analysis, which revealed a stratified squamous epithelium overlying a connective tissue stroma.The connective tissue was made up of a highly cellular mass comprising of large number of plump proliferating fibroblasts intermingled with fibrillar stroma throughout.The stroma also showed calcifications in the form of interconnecting trabaculae of bone and a few areas revealed osteoid like material.Few giant cells were also visualized seen.(Figure 3).   A histopathological diagnosis of Peripheral Ossifying Fibroma was made. The periodontal pack was removed after one week and the surgical site showed satisfactory healing(Figure 4). The patient was on regular follow-up for the next 6 months and there were no signs of recurrence.

 FIGURE 1: Clinical appearance of the pof in the upper left maxillary region FIGURE 2: After surgical excision of the lesion
FIGURE 3: Photomicrograph showing irregular trabaculae of bone within the cellular stroma(H&E stain) FIGURE 4:1 week post operative  image after removal of  coe-pak.

Intraoral ossifying fibromas have been described in the literature since the late 1940s. Many names have been given to similar lesions, such as epulis, (3) peripheral fibroma with calcification,(3) peripheral ossifying fibroma (4,5)calcifying fibroblastic granuloma(6) peripheral cementifying fibroma, peripheral fibroma with cementogenesis (7) and peripheral cemento-ossifying fibroma.(8) The sheer number of names used for fibroblastic gingival lesions indicates that there is much controversy surrounding the classification of these lesions.(7,9) It has been suggested that the POF represents a separate clinical entity rather than a transitional form of pyogenic granuloma, PGCG or irritation fibroma.(3)    
There is much uncertainty about the pathogenesis of this lesion. An origin in the periodontal ligament has been suggested. The reasons for considering the periodontal ligament as the origin of POF include the exclusive occurrence of POF in the gingiva (interdental papilla), the proximity of the gingiva to the periodontal ligament, and the presence of oxytalan fibers within the mineralized matrix of some lesions (10). The mature fibrous connective tissue proliferates excessively in response to gingival injury, gingival irritation, subgingival calculus or a foreign body in the gingival sulcus. Chronic irritation of the periosteal and periodontal membranes causes metaplasia of the connective tissue and initiates the formation of bone or dystrophic calcification.Thus local irritants such as dental plaque, calculus, microorganisms, masticatory forces, ill-fitting dentures and poor quality restorations have been implicated in the etiology of POF (11). In addition, factors such as a higher prevalence in females and a peak occurrence in the second decade of life suggest hormonal influences (12). The rare manifestation of multicentric occurrence points to a role of genetics in the pathogenesis of this disease (10).
POF recurs due to 1) the incomplete removal of the lesion, 2) the failure to eliminate local irritants and 3) difficulty in accessing the lesion during surgical manipulation as a result of the intricate location of the lesion (usually an interdental area) (13). The treatment of choice is local surgical excision. (14,15) POF has a high recurrence rate of about 8% to 16%; hence the mass should be excised deep into the periosteum with complete removal of all irritants. In extensively destructive cases, repositioned flaps or connective tissue grafts may be necessary to repair the gingival defects.(14,15)                In conclusion, many cases of POF will progress for long periods before patients seek treatment because of the lack of symptoms associated with the lesion. A slowly growing pink tissue nodule in the anterior maxilla of an adolescent more frequently female should raise suspicion of a POF. Discussion of the differential diagnosis should be done tactfully and prompt treatment should be provided to prevent unnecessary distress to the patient and family.and close postoperative follow-up is also mandatory because of high reported rate of recurrence in cases of incompletely removed lesions .