localized gingival growths are one of the most frequently encountered lesions in the oral cavity and peripheral ossifying fibroma ( pof ) is one of them .
pof is a focal , reactive , non - neoplastic tumor like growth of the soft tissue that often arises from the interdental papilla . though the etiopathogenesis is uncertain , an origin from cells of the periodontal ligament has been suggested .
it tends to occur in the 2 and 3 decades of life , with the peak prevalence between the ages of 10 and 19 years .
a 30-year - old female patient reported with the complain of discomfort during chewing and speaking due to a growth in the left lower posterior region of the jaw , which started as a small papule approximately 8 months ago and gradually increased in size with time to attain present size .
her medical history was non - significant and no h / o any medication at that time .
intraoral examination revealed an approximately 2 cm  2 cm sessile , non - tender , firm , pale pinkish growth present on the interdental gingiva in relation to the mandibular left canine - premolar region [ figures 1 and 2 ] .
the lesion was extending from mesial of left lateral incisor to the mesial of left first premolar and up to the level of the occlusal surface , causing occlusal interference .
radiographically , there was angular bone loss in relation to mandibular left canine and premolar with displacement of mandibular left canine [ figure 3 ] .
clinical presentation of the lesion with pathologic migration of 33 , left side view clinical presentation of the lesion , lingual view intraoral periapical radiograph of 33 , 34 showing angular bone loss the differential diagnosis included irritation fibroma , pyogenic granuloma and pof .
based on the clinical and radiographic findings , the provisional diagnosis of irritation fibroma was made .
the periodontal treatment plan included patient education and motivation for oral hygiene instructions and quitting the habit , scaling and root planing , reevaluation and surgical excision of the lesion under local anesthesia .
after 1 week of scaling and root planing , a reevaluation and surgical excision down to the periosteum were performed [ figure 4 ] and periodontal dressing was placed [ figure 5 ] .
patient was given post - operative instructions and was prescribed with analgesic ( tablet ibuprofen-400 mg tds every 4 - 6 h as needed for pain ) and antimicrobial rinse ( 0.2% chlorhexidine gluconate twice - a - day for 1 week ) .
the excised tissue [ figure 6 ] was placed in 10% neutral buffered formalin and sent for the histopathologic examination . immediately after excision , left side view periodontal dressing placed , left side view biopsy specimen microscopically consisted of hyperplastic parakeratinized stratified squamous epithelium with thin , long and anastomosing rete ridges and fibrous connective tissue containing several irregularly shaped trabeculae of bone , droplets of basophilic cementum - like material and numerous plump fibroblasts [ figure 7 ] .
histopathological slide ( 40 ) showing basophilic cementum - like material and numerous plump fibroblasts at 1 week post - operative visit , patient presented for periodontal dressing removal and follow - up examination .
patient is on regular follow - up at 6 months post - operative without any recurrence [ figure 9 ] .
post - operative 1 week showing uneventful recovery , left side view post - operative 6 months with no recurrence of the lesion and repositioning of 33 , left side view
the reasons for considering periodontal ligament origin for pof include exclusive occurrence of pof in the gingiva ( interdental papilla ) , the proximity of gingiva to the periodontal ligament and the presence of oxytalan fibers within the mineralized matrix of some lesions .
excessive proliferation of mature fibrous connective tissue is a response to gingival injury , gingival irritation , subgingival calculus or a foreign body in the gingival sulcus .
chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue and resultant initiation of formation of bone or dystrophic calcification .
almost two - third of all cases occur in females , with a predilection for the anterior maxilla .
hormonal influences may play a role , given the higher incidence of pof among females , increasing occurrence in the 2 decade and declining incidence after the 3 decade .
the size of the pof ranges from 0.4 to 4.0 cm and whites ( 71% ) are more frequently affected than blacks ( 36% ) .
histologically , when bone and cementum - like tissues are observed , the lesions have been referred to as cemento ossifying fibroma . the term  cemento ossifying  has been referred to as outdated and scientifically inaccurate . moreover , on h and e staining it is difficult to the distinguish histologically between cementum and bone .
mineralized products in the form of trabeculae of woven and/or lamellar bone , cementum like material and dystrophic calcification are noticed .
radiopaque foci of calcifications have been reported to be scattered in the central area of the lesion , but not all lesions demonstrate radiographic calcifications . underlying bone involvement is usually not visible on a radiograph . in rare instances , superficial erosion of bone
the following features are usually observed during the microscopic examination : ( 1 ) intact or ulcerated stratified squamous surface epithelium ; ( 2 ) benign fibrous connective tissue with varying numbers of fibroblasts ; ( 3 ) sparse to profuse endothelial proliferation ; ( 4 ) mineralized material consisting of mature , lamellar or woven osteoid , cementum - like material or dystrophic calcifications ; and ( 5 ) acute or chronic inflammatory cells in lesions .
moreover , histopathologically , lamellar or woven osteoid pattern predominates ; hence , the term  pof  is considered more appropriate .
the carbon dioxide laser can effectively excise the lesion and has been shown to allow diagnostic microscopic evaluation with a minimal distortion of the biopsy sample .
the advantages of laser excision are minimal post - surgical pain and no need for suturing the biopsy site .
this precise tissue destruction can also result in partial or incomplete removal of the base of the pathologic lesion , which can lead to recurrence .
thus , surgical excision including the involved periodontal ligament and periosteum is the preferred treatment , which was performed in this case .
pof is a benign , slowly progressive lesion , with limited growth . clinically difficult to diagnose , so histopathologic confirmation is mandatory .
complete surgical excision down to the periosteum is the preferred treatment and as the recurrence rate is high ( 8 - 20% ) , close post - operative follow - up is required .
 localized gingival growths are one of the most frequently encountered lesions in the oral cavity , which are considered to be reactive rather than neoplastic . different lesions with similar clinical presentation make it difficult to arrive at a correct diagnosis . 
 these lesions include pyogenic granuloma , irritation fibroma , peripheral giant cell granuloma , peripheral ossifying fibroma ( pof ) . among these lesions , 
 an infrequently occurring gingival lesion is the pof . 
 considerable confusion has prevailed in the nomenclature of pof due to its variable histopathologic features . 
 this is a case presentation of a 30-year - old female with gingival overgrowth in the mandibular left canine - premolar region . 
 clinically , the lesion was asymptomatic , firm , pale pinkish and sessile . surgical excision of the lesion was done followed by histopathologic confirmation with emphasis on the clinical aspect . 
 given the rate of recurrence for pof being 8 - 20% , close post - operative follow - up is required . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION