peripheral ossifying fibroma ( pof ) is a reactive soft tissue growth that is usually seen on the interdental papilla .
it may be pedunculated or 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 .
a 12-year - old girl reported with the chief complaint of soft tissue growth in the palate .
intraoral examination revealed a painless pedunculated , cauliflower - like rubbery mass on the palatal aspect of the maxillary left permanent molar extending towards the occlusal surface [ figure 1 ] .
the lesion was abnormally large about 2.5 cm mesiodistally and 1.5 cm buccopalatally and the side of the lesion facing the occlusal surface was focally ulcerated . the maxillary first permanent molar was buccally displaced .
history revealed that the lesion started growing on its own since she first noticed it about a month back when it was a small nodule .
the lesion was painless and occasionally bled on its own or when traumatized with toothbrush and in its present state was interfering with occlusion .
radiograph revealed only soft tissue shadow and space between maxillary second premolar and first molar [ figure 2 ] .
soft tissue growth extending toward the occlusal surface iopa showing the soft tissue shadow and space between premolar and molar after routine blood examinations , excisional biopsy of the growth was done [ figure 3 ] under antibiotic coverage and thorough curettage of the adjacent periodontal ligament , and periosteum was carried out to prevent recurrence .
histomorphological examination revealed evidence of calcifications in the hypercellular fibroblastic stroma [ figure 4 ] confirming the lesion as pof .
the follow - up of the case showed normal healing of the area [ figure 5 ] .
pof has also been described by various synonyms such as peripheral cemento ossifying fibroma , peripheral odontogenic fibroma ( podf ) with cementogenesis , peripheral fibroma with osteogenesis , peripheral fibroma with calcification , fibrous epulis , calcifying fibroblastic granuloma , etc .
almost 60% of the lesions occur in the maxilla and mostly occur anterior to molars .
dental calculus , plaque , microorganisms , dental appliances , and restorations are considered to be the irritants triggering the lesion .
the lesion though usually smaller than 1.5 cm in diameter can reach a much larger size and can cause separation of the adjacent teeth , resorption of the alveolar crest , destruction of the bony structure and cosmetic deformity .
the term pof should not be confused with podf , which is the rare peripheral counterpart of central odontogenic fibroma . in north america
, it is still synonymously used by many for pof as the lesion is thought by them to be derived from the periodontal ligament and hence to be odontogenic .
the evidence for its odontogenic origin is circumstantial , being based partly on the demonstration of oxytalan fibers within its calcified structures and its exclusive occurrence on gingiva .
however , oxytalan fibers have also been reported in the sites other than the periodontal ligament .
a pof is more common in females and in the anterior maxilla , but podf has a predilection for males and the posterior mandible .
the pof and ossifying fibroma ( of ) are the lesions that exhibit similar histomorphologic features and both originate from periodontal ligament cells . but a pof is a reactive lesion where as an of is a benign neoplastic lesion included in the group of benign fibro - osseous lesions of the jaws and both pof and of show different proliferative activities .
the ulcerated lesions are more likely to be painful but in this case it was not painful .
gingival lesions that imitate pof are peripheral giant cell granuloma , pyogenic granuloma , fibroma , calcifying epithelial odontogenic cyst , calcifying odontogenic cyst , etc .
radiographically radiopaque foci within the soft tissue tumor mass are observed if the calcified element is significant , but in this case no radiopaque foci were seen but only shadow of the lesion was seen probably because the lesion was of short duration of time .
histologically , pof can exhibit either ulcerated or intact stratified squamous epithelium . in a typical ulcerated lesion ,
three zones could be identified : zone i : the superficial ulcerated zone covered with the fibrinous exudate and enmeshed with polymorphonuclear neutrophils and debris .
zone ii : the zone beneath the surface epithelium composed almost exclusively of proliferating fibroblasts with diffuse infiltration of chronic inflammatory cells mostly lymphocytes and plasma cells .
zone iii : more collagenized connective tissue with less vascularity and high cellularity ; osteogenesis consisting of osteoid and bone formation is a prominent feature , which can even reach the ulcerated surface in some cases .
the calcified material can generally take one or more of the following four forms : ( a ) mature lamellated trabecular bone ; ( b ) immature , highly cellular bone ; ( c ) circumscribed amorphous , almost acellular , eosinophilic , or basophilic bodies , and ( 4 ) minute microscopic granular foci of calcification .
the nonulcerated lesions are typically identical to the ulcerated type except for the presence of surface epithelium .
cementum - like material is found in less than one - fifth of the lesions and dystrophic calcifications are more prevalent in ulcerated lesions .
treatment requires proper surgical intervention that ensures deep excision of the lesion including periosteum and affected periodontal ligament .
thorough root scaling of adjacent teeth and/or removal of other sources of irritants should be accomplished . in children
, reactive gingival lesions can exhibit an exuberant growth rate and reach significant size in a relatively short period of time .
in addition , the pof can cause erosion of bone , can displace teeth , and can interfere or delay eruption of teeth . early recognition and definitive surgical intervention result in less risk of tooth and bone loss .
it is suggested that there is no absolute histological distinction between bone and cementum , and as the so - called cementum - like globules of calcification are seen in fibro - osseous lesions in all membrane bones , it is unrealistic to separate the ossifying and cementifying lesions and it is speculated that the fibro - osseous lesions might represent stages in the evolution of a single disease process passing through the stages of fibrous dysplasia to ossifying fibroma to cementoid lesions . in conclusion , clinically it is difficult to differentiate between most of the reactive gingival lesions particularly in the initial stages .
regardless of the surgical technique employed , it is important to eliminate the etiological factors and the tissue has to be histologically examined for confirmation .
 the gingiva is often the site of localized growths that are considered to be reactive rather than neoplastic in nature . 
 many of these lesions are difficult to be identified clinically and can be identified as specific entity only on the basis of typical and consistent histomorphology . 
 peripheral ossifying fibroma is one such reactive lesion . 
 it has been described with various synonyms and is believed to arise from the periodontal ligament comprising about 9% of all gingival growths . 
 the size of the lesion is usually small , located mainly in the anterior maxilla with a higher predilection for females , and it is more common in the second decade of life . a clinical report of a 12-year - old girl with a large peripheral ossifying fibroma in the posterior maxilla showing significant growth and interference with occlusion is presented . 
Introduction
Clinical report
Discussion