A Peripheral Ossifying Fibroma of the Mandible: Literature Review and Case Report

Moitra PN and Kamble R

Published on: 2025-06-28

Abstract

Peripheral ossifying fibroma (POF) is a reactive overgrowth that most commonly occurs on the gingiva. It is a benign oral soft tissue tumour. It is most commonly found on the anterior maxilla and has a female predilection. Most commonly found to occur in the second decade of life. This type of lesion originates from the cells of the periodontal ligament. It is often associated with trauma or local irritants, such as subgingival plaque and calculus, dental appliances and poor-quality dental restorations. This entity requires a proper treatment protocol and a regular follow-up. It can cause significant discomfort and irritation in oral health if left untreated. The recurrence rate of the lesion varies according to the authors. POF is usually small in size; its measure is < 2cm in diameter but rarely reaches important sizes. This case report describes a case of POF of the mandible measuring >2cm in diameter in an adult male patient which was treated using surgical excision resulting in an uneventful healing during the post-operative period.

Keywords

Peripheral ossifying fibroma; Peripheral giant cell granuloma; Pyogenic granuloma

Introduction

Peripheral ossifying fibroma (POF) is a benign lesion usually found at the interdental papilla, with a slight preference for the maxilla and the female gender; it occurs between the first and second decades of life. It is characterised as a nodular mass with a sessile or pedunculated base, presents slow growth and has a present pink-red colour [1].

Local trauma and irritation are the main developmental aetiologies of this pathology. The definitive diagnosis is based on histological examination, with identification of cellular connective tissue and presence of focal bone or other calcifications. The radiographic appearance of POF may range from an entirely radiolucent lesion to the presence of calcified foci dispersed in the central area of the lesion with a thin radiopaque halo [2].

In most cases, the lesions are approximately 2 cm in diameter. However, there are reports in the literature of POF with larger volumes, which may displace teeth; they receive the nomenclature of “gigantiform”. The histological pattern of this lesion is defined by the presence of fibroblasts, preserved or ulcerated stratified squamous epithelium and mineralised tissue, which may consist of cementum, bone or dystrophic calcifications. Such mineralised tissues may also be presented together [3].

Some synonyms are mentioned in the literature, such as 'calcifying fibroma, calcifying fibroblastic granuloma, peripheral cemento-ossifying fibroma, and ossifying fibrous epulis. Currently, the terminology most commonly used is POF or peripheral giant cell granuloma, which are indistinguishable from each other [2].

Lesions such as pyogenic granuloma, fibrous hyperplasia, giant cell fibroma, and peripheral giant cell lesions bear great similarity to POF due to the need for irritating agents for its emergence to occur; therefore, there is a need for a differential diagnosis. The treatment of choice consists of total enucleation of the lesion together with the periodontal ligament involved and the removal of possible causative agents [4]. There are reports of relapses, but their risk is reduced if excision is performed under the periosteum [5].

The present study aims to report a rare case of mandibular POF in a young patient and discuss the clinical, radiographic and histological findings addressed in the literature.

Case Report: A 19-year-old male college student from an urban area reported to the department of oral medicine and radiology with a chief complaint of swelling in the lower right back region of his jaw for one year. The patient was apparently alright a year back, then he suddenly noticed swelling in the right lower back region of his jaw, which was slowly enlarging and painful to the touch. Initially it was small in size but had grown gradually to attain the present dimension. He informed us that the swelling caused disturbances in normal speech and swallowing of food. So, he reported to the department for the needed treatment. The past medical and dental histories, as well as the family and surgical histories, were non-contributory. The patient was from a low socioeconomic class, explaining the delay in the consultation. Intraoral examination revealed the presence of a firm, mobile, non-tender, soft tissue growth of size 1.2 × 2.3 × 1.5 cm (app) seen extending from the distal aspect of 42 to the mesial aspect of 46 with two pedunculated bases. The overgrowth was dome-shaped; overlying mucosa was reddish-pink in colour. No ulceration was observed. The mass was not fixed to underlying bone. Salivary flow was adequate, and no abnormality was detected in the labial and buccal mucosa, tongue, hard and soft palate, tonsillar pillars, or pharynx. Extraoral examination revealed no gross asymmetry. Regional lymph nodes were not palpable. Considering the history and clinical findings, a provisional diagnosis of pyogenic granuloma was made with a differential diagnosis of fibroma, peripheral odontogenic fibroma, peripheral ossifying fibroma, fibrous hyperplasia, and peripheral myxoma. Radiographic evaluation (CBCT) revealed a diffused focus of radiopacity on the lingual aspect of 44 and 45.

Figure 1: Intraoral Preoperative Photo Depicting the Site of the Lesion.

Figure 2: Captured CBCT Images Demonstrate The Fibro-Osseous Lesion In All Three Planes.

Figure 3: Excised Tissue Specimen.

There was no evidence of the expansion of the buccal and lingual cortical plates. A radiological provisional diagnosis of peripheral ossifying fibroma was made for the fibro-osseous lesion on the lingual aspect of the fourth quadrant with a differential diagnosis of fibrous dysplasia, adamantinoma, osteoid osteoma, and osteofibrous dysplasia. The irritating factors (plaque & calculus) were eliminated by thorough oral prophylaxis, and there was considerable shrinkage of the lesion as inflammation subsided. Informed consent was obtained from the patient for the operative procedure. A complete haemogram revealed all blood cell counts within normal limits. Under local anaesthesia, using #12 and #15 surgical blades, an excision was given on the base of the lesion. Thorough curettage was done in the depth of the lesion and surrounding tissues. The excised mass was sent for histopathological examination. Postoperative instructions were given, and antibiotics and analgesics were prescribed. The patient was called after seven days; healing was uneventful. Oral hygiene instructions were reinforced; the patient was kept on regular follow-up for the past six months, and satisfactory healing was present. No recurrence was observed.

Figure 4: Six Months Post-Operative Follow-Up.

Histopathological Report

Under 40X power, an H&E-stained section shows fibrocellular connective tissue stroma surrounded by stratified squamous epithelium. The connective tissue is fibrocellular, showing plump to spindle-shaped fibroblasts admixed with blood vessels. Certain areas showing numerous scattered basophilic metaplastic bone-like masses with increased cellularity typically around these masses. Overall features suggestive of peripheral ossifying fibroma.

Figure 5: Histopathological Findings Revealing Features Suggestive Of Peripheral Ossifying Fibroma.

Discussion

POF is a relatively common benign tumour of the oral cavity that primarily affects the gingiva or alveolar mucosa. Despite its non-neoplastic nature, POF can cause significant discomfort and affect oral health if left untreated [6]. There are two forms of POF, central and peripheral. The peripheral variant of ossifying fibroma emerges on the soft tissues enveloping the alveolar process, whereas the central form originates from the endosteum or the PDL adjacent to the root apex and grows from the medullary cavity of the bone [7]. POF typically presents as a firm, pink or red, nodular mass on the gingiva or alveolar mucosa. It may vary in size and can be either sessile or pedunculated. Some common symptoms associated with POF include swelling or enlargement of the gums, bleeding from the affected area, especially during brushing or eating, ulceration or erosion of the overlying mucosa, discomfort or pain, particularly when pressure is applied to the lesion, and tooth mobility or displacement in severe cases [8].

The exact aetiology of POF remains unclear, although it is believed to arise from the PDL or gingival connective tissue in response to chronic irritation or trauma [9]. Factors such as poor oral hygiene, ill-fitting dental appliances, and hormonal changes may predispose individuals to the development of POF. Additionally, local irritants such as dental plaque, calculus and foreign objects lodged in the gingiva have been implicated in its pathogenesis [10]. The lesions' histopathology reveals stratified squamous epithelium overlying an extraordinarily dense mass of connective tissue, consisting of plump fibrocytes, fibrillar stroma and plump fibroblasts, as well as areas of mineralization and, occasionally, multinucleated giant cells nearby. Bone, cementum-like material or dystrophic calcifications can be found in the mineralisation. Early ulcerated lesions typically exhibit dystrophic calcifications, but older, mature, non-ulcerated lesions display well-formed bone and cementum-like material [11]. The clinical presentation of POF can mimic other oral lesions, making differential diagnosis challenging. Conditions that may resemble POF include pyogenic granuloma, peripheral giant cell granuloma, fibroma and peripheral odontogenic fibroma. Pyogenic granuloma can occur anywhere in the oral cavity, whereas POF occurs in the gingival and alveolar mucosa [12]. It is observed that peripheral giant cell granuloma occurs in the edentulous area; however, POF occurs in the edentulous area, though not as observed in our case [13]. Histologically peripheral odontogenic fibroma contains giant cells, whereas POF contains odontogenic epithelium and dysplastic dentin [14]. A thorough clinical examination, along with histopathological evaluation, is essential to differentiate POF from other oral pathologies accurately [15]. The management of POF usually involves surgical excision of the lesion followed by histopathological examination to confirm the diagnosis and ensure complete removal. Depending on the size and location of the tumour, various surgical techniques may be employed, including conventional scalpel excision, laser ablation or electrosurgery [16]. Neodymium-doped yttrium aluminium garnet (Nd: YAG) has been reported for the successful excision of POF with minimal bleeding. A case report has demonstrated the removal of a POF measuring 1 x 1.5 cm located on the maxillary right central incisor using a laser with no spontaneous bleeding and showed a minimal recurrence rate of up to one year [17]. The usage of electrocautery will help to achieve a bloodless field, and making it useful for the excision of bigger POF lesions [18]. It is essential to remove the entire lesion along with a margin of healthy tissue to prevent recurrence. Adjunctive therapies such as topical or systemic medications may be prescribed to manage symptoms or prevent recurrence. Recurrence of POF can be due to the presence of local irritants, repeated injury to the same area and inadequate removal [19].

Conclusion

POF is a reactive, benign, slowly progressing gingival growth. POF may reach >4 cm in the longest dimension. An early clinical definitive diagnosis followed by histopathological confirmation of the biopsy specimen is necessary to avoid functional problems and teeth loss. Moreover, as reported, this lesion has a high recurrence rate; therefore, complete excision of the lesions down to the periosteum along with periodic post-surgical follow-ups is highly recommended.

Journal of Oral and Dental Health Research