- Email: [email protected]
Peripheral Cemento-ossifying Fibroma
Asian Peripheral J Oral Cemento-ossifying Maxillofac Surg. Fibroma 2007;19:160-2.
CASE REPORT
Peripheral Cemento-ossifying Fibroma Yuki Yokoyama,1 Yoshiro Matsui,1,2 Masao Nagumo,1 Tarou Irie3 Department of Oral and Maxillofacial Surgery, School of Dentistry, Showa University, Tokyo, 2 Department of Oral and Maxillofacial Surgery, Yokohama City University Graduate School of Medicine, Yokohama, and 3Department of Oral Pathology, School of Dentistry, Showa University, Tokyo, Japan 1
Abstract A case of peripheral cemento-ossifying fibroma of the edentulous upper gingiva in a 55-year-old woman is reported. Key words: Fibroma, ossifying, Gingival diseases, Maxilla
Introduction Cemento-ossifying fibroma (COF) was included in the nonodontogenic tumour group in the 1992 World Health Organization classification. The most characteristic histological appearance of COF is the presence of prominent areas of highly cellular connective tissue containing foci of mineralisation in the form of bone, cementum-like material, and/or a dystrophic type of calcification.1 Although the nature of the central COF (CCOF) is beyond dispute, controversy exists regarding that of its peripheral counterpart, i.e., the peripheral COF (PCOF).
Case Report A 55-year-old Japanese woman, with a history of Parkinson’s disease and hypertension, was referred to the Department of Oral and Maxillofacial Surgery, Showa University Dental Hospital, with a localised overgrowth located in the edentulous molar alveolus in the right maxilla (Figure 1). The patient had first noticed the lesion 10 years prior to visiting the hospital, and it had since slowly enlarged. The teeth in that region had been extracted prior to the occurrence of an exophytic growth due to advanced periodontitis. On examination, the lesion was well-circumscribed, sessile, firm, 25 × 10 × 20 mm in size, and partly ulcerated in a region corresponding to the artificial teeth in her lower denture. Panoramic radiography revealed a small and irregular radiopaque mass separate from the alveolar crest. Axial computed tomography examination revealed a distinct, irregular, radiopaque mass inside the soft tissue, 20 mm in Correspondence: Yoshiro Matsui, PhD, Fukuura 3-9, Kanazawa-ku, Yokohama City 236 0004, Kanagawa, Japan. Tel: (81 45) 787 2659; Fax: (81 45) 785 8438; E-mail: [email protected]
160
Figure 1. Oral examination. Localised overgrowth in the edentulous molar alveolus in the right maxilla.
diameter. Computed tomography images perpendicular to both the horizontal plane and the dental arch, reconstructed from the axial data, demonstrated interruption of the cortical bone contacting the lesion (Figure 2). Based on the clinical appearance and radiographic findings, a provisional clinical diagnosis of ossifying fibrous epulis was made. Complete excision of the lesion including the underlying periosteum, followed by curettage of the bone underneath, was performed under general anaesthesia. Wound healing was uneventful, and no recurrence has been detected more than 2 years postoperatively. Histopathologic examination revealed that the growth was well demarcated from the underlying tissue (Figure 3). The fibroblasts in the growth were plump and often arranged in parallel arrays or whorls and associated with psammomatous, cementum-like, or trabecular calcifications in a whorled pattern (Figure 4). No nuclear atypia or mitotic activity was detected. The histological diagnosis was PCOF. © 2007 AsianAsian Association J Oral Maxillofac of Oral andSurg. Maxillofacial Vol 19, No Surgeons. 3, 2007
Yokoyama, Matsui, Nagumo, et al
Figure 2. Reconstructed computed tomography images showing a compound of distinct, irregular, radiopaque mass within the overgrowth. The cortical bone contacting the lesion was interrupted.
Figure 3. Histopathologic examination of the tumour. The growth is well demarcated from the underlying tissue (haematoxylin and eosin; original magnification, × 50).
Discussion PCOF is considered by some to be a reaction to local irritants,2-5 since a great number of overgrowths which are reactive in nature occur in the gingiva. Mesquita et al, for Asian J Oral Maxillofac Surg. Vol 19, No 3, 2007
Figure 4. Histopathologic examination of the tumour. The fibroblasts are plump, mostly arranged in parallel arrays or whorls, and associated with psammomatous or cementum-like calcifications (haematoxylin and eosin; original magnification, × 200).
example, described peripheral ossifying fibroma as an ossifying fibrous epulis and included it among reactive lesions.5 They compared the proliferative activity of PCOF and CCOF, and concluded that CCOF exhibited higher proliferative activity than PCOF. However, they also reported that some PCOFs had proliferative activities either equal to or higher than that of some CCOFs, suggesting that cases of tumours of neoplastic origin were included. Some papers, on the other hand, have described PCOF as an entity completely different from reactive gingival overgrowths.6,7 Feller et al proposed the use of the term PCOF for such gingival growths, similar to its central variant, i.e., COF, which exhibited osteoid, bone or cementum-like deposits uniformly throughout and a cellular fibrous connective tissue component that failed to exhibit maturation towards scar-like connective tissue.8 They noted that the reactive lesions containing metaplastic bone in the center of the lesion, and a bland fibrous connective tissue component that is less cellular and tends to mature towards scar-like connective tissue, should be differentiated from PCOF as fibrous epulis. The histological findings of the case reported here meet all of Feller’s criteria for the neoplastic origin of PCOF. PCOF has a relatively high rate of recurrence, ranging between 14.2% 9 and 16%, 1 due to its potential for growth. Therefore, adequate surgical removal including the periosteum and/or the gingival portion of the periodontal ligament space and curettage of the underlying bone is recommended.
References 1.
Buchner A, Ficarra G, Hansen LS. Peripheral odontogenic fibroma. Oral Surg Oral Med Oral Pathol. 1987;64:432-8.
161
Peripheral Cemento-ossifying Fibroma 2. 3. 4.
1972;1:30-8.
Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol. 1987;14:551-4.
7.
Gardner DG. The peripheral odontogenic fibroma: an attempt at
and repair of the peripheral ossifying fibroma: a report of 3 cases. J
clarification. Oral Surg Oral Med Oral Pathol. 1982;54:40-8.
Periodontol. 2001;72:939-44.
Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with
8.
6.
162
131-5.
Mesquita RA, Orsini SC, Sousa M, de Araújo NS. Proliferative activity in peripheral ossifying fibroma and ossifying fibroma. J Oral Pathol
Feller L, Buskin A, Raubenheimer EJ. Cemento-ossifying fibroma: case report and review of the literature. J Int Acad Periodontol. 2004;6:
calcification: report of 376 cases. J Am Dent Assoc. 1966;73:1312-20. 5.
Walters JD, Will JK, Hatfield RD, Cacchillo DA, Raabe DA. Excision
9.
Kenney JN, Kaugars GE, Abbey LM. Comparison between the
Med. 1998;27:64-7.
peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol.
Maxillofac Surg. 1989;47:378-82.
Asian J Oral Maxillofac Surg. Vol 19, No 3, 2007
CASE REPORT
Peripheral Cemento-ossifying Fibroma Yuki Yokoyama,1 Yoshiro Matsui,1,2 Masao Nagumo,1 Tarou Irie3 Department of Oral and Maxillofacial Surgery, School of Dentistry, Showa University, Tokyo, 2 Department of Oral and Maxillofacial Surgery, Yokohama City University Graduate School of Medicine, Yokohama, and 3Department of Oral Pathology, School of Dentistry, Showa University, Tokyo, Japan 1
Abstract A case of peripheral cemento-ossifying fibroma of the edentulous upper gingiva in a 55-year-old woman is reported. Key words: Fibroma, ossifying, Gingival diseases, Maxilla
Introduction Cemento-ossifying fibroma (COF) was included in the nonodontogenic tumour group in the 1992 World Health Organization classification. The most characteristic histological appearance of COF is the presence of prominent areas of highly cellular connective tissue containing foci of mineralisation in the form of bone, cementum-like material, and/or a dystrophic type of calcification.1 Although the nature of the central COF (CCOF) is beyond dispute, controversy exists regarding that of its peripheral counterpart, i.e., the peripheral COF (PCOF).
Case Report A 55-year-old Japanese woman, with a history of Parkinson’s disease and hypertension, was referred to the Department of Oral and Maxillofacial Surgery, Showa University Dental Hospital, with a localised overgrowth located in the edentulous molar alveolus in the right maxilla (Figure 1). The patient had first noticed the lesion 10 years prior to visiting the hospital, and it had since slowly enlarged. The teeth in that region had been extracted prior to the occurrence of an exophytic growth due to advanced periodontitis. On examination, the lesion was well-circumscribed, sessile, firm, 25 × 10 × 20 mm in size, and partly ulcerated in a region corresponding to the artificial teeth in her lower denture. Panoramic radiography revealed a small and irregular radiopaque mass separate from the alveolar crest. Axial computed tomography examination revealed a distinct, irregular, radiopaque mass inside the soft tissue, 20 mm in Correspondence: Yoshiro Matsui, PhD, Fukuura 3-9, Kanazawa-ku, Yokohama City 236 0004, Kanagawa, Japan. Tel: (81 45) 787 2659; Fax: (81 45) 785 8438; E-mail: [email protected]
160
Figure 1. Oral examination. Localised overgrowth in the edentulous molar alveolus in the right maxilla.
diameter. Computed tomography images perpendicular to both the horizontal plane and the dental arch, reconstructed from the axial data, demonstrated interruption of the cortical bone contacting the lesion (Figure 2). Based on the clinical appearance and radiographic findings, a provisional clinical diagnosis of ossifying fibrous epulis was made. Complete excision of the lesion including the underlying periosteum, followed by curettage of the bone underneath, was performed under general anaesthesia. Wound healing was uneventful, and no recurrence has been detected more than 2 years postoperatively. Histopathologic examination revealed that the growth was well demarcated from the underlying tissue (Figure 3). The fibroblasts in the growth were plump and often arranged in parallel arrays or whorls and associated with psammomatous, cementum-like, or trabecular calcifications in a whorled pattern (Figure 4). No nuclear atypia or mitotic activity was detected. The histological diagnosis was PCOF. © 2007 AsianAsian Association J Oral Maxillofac of Oral andSurg. Maxillofacial Vol 19, No Surgeons. 3, 2007
Yokoyama, Matsui, Nagumo, et al
Figure 2. Reconstructed computed tomography images showing a compound of distinct, irregular, radiopaque mass within the overgrowth. The cortical bone contacting the lesion was interrupted.
Figure 3. Histopathologic examination of the tumour. The growth is well demarcated from the underlying tissue (haematoxylin and eosin; original magnification, × 50).
Discussion PCOF is considered by some to be a reaction to local irritants,2-5 since a great number of overgrowths which are reactive in nature occur in the gingiva. Mesquita et al, for Asian J Oral Maxillofac Surg. Vol 19, No 3, 2007
Figure 4. Histopathologic examination of the tumour. The fibroblasts are plump, mostly arranged in parallel arrays or whorls, and associated with psammomatous or cementum-like calcifications (haematoxylin and eosin; original magnification, × 200).
example, described peripheral ossifying fibroma as an ossifying fibrous epulis and included it among reactive lesions.5 They compared the proliferative activity of PCOF and CCOF, and concluded that CCOF exhibited higher proliferative activity than PCOF. However, they also reported that some PCOFs had proliferative activities either equal to or higher than that of some CCOFs, suggesting that cases of tumours of neoplastic origin were included. Some papers, on the other hand, have described PCOF as an entity completely different from reactive gingival overgrowths.6,7 Feller et al proposed the use of the term PCOF for such gingival growths, similar to its central variant, i.e., COF, which exhibited osteoid, bone or cementum-like deposits uniformly throughout and a cellular fibrous connective tissue component that failed to exhibit maturation towards scar-like connective tissue.8 They noted that the reactive lesions containing metaplastic bone in the center of the lesion, and a bland fibrous connective tissue component that is less cellular and tends to mature towards scar-like connective tissue, should be differentiated from PCOF as fibrous epulis. The histological findings of the case reported here meet all of Feller’s criteria for the neoplastic origin of PCOF. PCOF has a relatively high rate of recurrence, ranging between 14.2% 9 and 16%, 1 due to its potential for growth. Therefore, adequate surgical removal including the periosteum and/or the gingival portion of the periodontal ligament space and curettage of the underlying bone is recommended.
References 1.
Buchner A, Ficarra G, Hansen LS. Peripheral odontogenic fibroma. Oral Surg Oral Med Oral Pathol. 1987;64:432-8.
161
Peripheral Cemento-ossifying Fibroma 2. 3. 4.
1972;1:30-8.
Bodner L, Dayan D. Growth potential of peripheral ossifying fibroma. J Clin Periodontol. 1987;14:551-4.
7.
Gardner DG. The peripheral odontogenic fibroma: an attempt at
and repair of the peripheral ossifying fibroma: a report of 3 cases. J
clarification. Oral Surg Oral Med Oral Pathol. 1982;54:40-8.
Periodontol. 2001;72:939-44.
Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with
8.
6.
162
131-5.
Mesquita RA, Orsini SC, Sousa M, de Araújo NS. Proliferative activity in peripheral ossifying fibroma and ossifying fibroma. J Oral Pathol
Feller L, Buskin A, Raubenheimer EJ. Cemento-ossifying fibroma: case report and review of the literature. J Int Acad Periodontol. 2004;6:
calcification: report of 376 cases. J Am Dent Assoc. 1966;73:1312-20. 5.
Walters JD, Will JK, Hatfield RD, Cacchillo DA, Raabe DA. Excision
9.
Kenney JN, Kaugars GE, Abbey LM. Comparison between the
Med. 1998;27:64-7.
peripheral ossifying fibroma and peripheral odontogenic fibroma. J Oral
Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol.
Maxillofac Surg. 1989;47:378-82.
Asian J Oral Maxillofac Surg. Vol 19, No 3, 2007