Application of 810-nm diode laser in the management of peripheral ossifying fibroma

Abstract

Peripheral ossifying fibroma (POF) is a reactive gingival growth, which accounts for 9.6% of gingival lesions. It exhibits a peak incidence between the second and third decades of life with a female predilection. Treatment includes surgical excision down to the periosteum and periodontal ligament with thorough root planning. Another option available in place of conventional surgical excision is the excision using lasers. Here is a case of POF affecting anterior maxillary gingiva in 19-year-old male patient successfully managed using an 810-nm diode laser.

INTRODUCTION

Peripheral ossifying fibroma (POF) is a relatively uncommon gingival growth that is continued to be reactive in nature and postulated to appear secondary to irritation or trauma.[1] POF is described earlier as peripheral cementifying fibroma, peripheral odontogenic fibroma, and the peripheral fibroma with calcification.[2] Eversole coined the term POF.[3]

Surgical excision down to the periosteum and periodontal ligament with thorough root planning is the mainstay of treatment for POF. Another option available in place of conventional surgical excision is the excision using soft tissue lasers. This case report illustrates the application of 810-nm diode laser in the management of POF.

CASE REPORT

A 19-year-old healthy male patient reported to the Department of Periodontics, MNR Dental College and Hospital, Hyderabad, with the chief complaint of painless soft tissue overgrowth in the upper left incisor region. It was present since 1-year and had slowly grown to this size causing displacement of maxillary left lateral incisor.

Intraoral examination revealed a firm, erythematous, sessile mass of 19.2 mm × 4.8 mm × 5.5 mm size on the labial as well as palatal aspect of the maxillary left incisor region [Figures 1 and 2]. The mucosa overlying the lesion was intact and pinkish red in color. On palpation, it was firm in consistency. The lesion was painless unless traumatized by enthusiastic tooth brushing or chewing hard food substances. Patient's oral hygiene was satisfactory with minimal deposits. Based on the history and clinical findings, a provisional diagnosis of POF was reached.

Figure 1.

Intra oral picture showing lesion with respect to maxillary left central and lateral incisors

Figure 2.

Occlusal view showing palatal extension of the lesion

An intra-oral periapical radiograph (IOPA) was obtained. IOPA revealed buccal displacement of left upper lateral incisor and crestal interdental bone resorption [Figure 3].

Figure 3.

Intra-oral periapical radiograph showing buccal displacement of maxillary left lateral incisor and crestal interdental bone resorption

Oral prophylaxis was done, and oral hygiene instructions were given to the patient. Patient was recalled after 1-week. After ensuring that the hemogram of the patient was within the normal limits, excisional biopsy of the lesion down to the bone was performed using 810-nm diode laser at 2.5 watt under local anesthesia [Figure 4]. Excision of lesion was followed by curettage of the area and scaling and root planning of the involved tooth. Periodontal dressing was placed. Neither bleeding nor pain was experienced by the patient during the procedure.

Figure 4.

Appearance of the site after excisional biopsy using diode laser

Histological examination of the specimen revealed a parakeratinized stratified squamous epithelium with an underlying highly cellular connective tissue with a large number of fibroblasts. Areas of calcification were seen [Figure 5]. Presence of cellular connective tissue and foci of bone in the histological picture confirmed the diagnosis of POF.

Figure 5.

Photomicrograph showing areas of calcification in connective tissue

Patient was reviewed after 1-week, when progressive healing of the surgical site was seen [Figure 6]. Patient did not report of any pain or discomfort after the procedure. Patient was followed-up for 1-year and showed no signs of recurrence [Figure 7].

Figure 6.

1-week postoperative picture showing progressive healing of the surgical site

Figure 7.

Appearance of the site at 1-year follow-up visit

DISCUSSION

Soft tissue enlargements of the oral cavity represent a diverse group of pathologic processes and often pose a diagnostic challenge to the clinician. Reactive hyperplasia is a group of lesions that develop in response to a chronic recurring tissue injury that stimulates on exuberant or excessive tissue repair response. POF is a reactive gingival growth often confused clinically with pyogenic granuloma, peripheral giant cell granuloma and peripheral odontogenic fibroma.[1] It accounts for 9.6% of gingival lesions.[1]

Peripheral ossifying fibroma may occur at any age, but exhibits a peak incidence between the second and third decades. Almost 60% of the lesions occur in the maxilla and mostly occur anterior to the molars. This lesion shows female predilection with a female to male ratio of 5:1.[4] The reported lesion was on a male patient occurring on the incisor teeth with growth more than 2 cm, thus making it unique.

Clinically it appears as a well-defined, slow growing, nodular, sessile or pedunculated mass measuring less than 2 cm in size and located in the interdental papilla. The color ranges from red to pink with the surface often ulcerated.[1]

The etiology and pathogenesis of POF are uncertain. POF is thought to originate from oxytalan fibers of periodontal ligament or periosteum due to exuberant connective tissue response to chronic irritants such as plaque, calculus, restorations or orthodontic appliances. Moreover, persistent irritation can cause metaplasia of the mesenchymal cells resulting in calcifications. Fibroblastic and myofibroblastic nature of the lesion suggests a possible origin in periodontal ligament cells.[5,6] The etiology for the present case was unknown as the gingival growth was not concomitant with the amount of contributing factors.

The histological picture is diagnostic for these lesions. It shows fibrous connective tissue stroma containing various calcified osseous structures usually covered by stratified squamous epithelium.[7] Histologically, POF shows three types of calcification: Dystrophic calcification or lamellar osteoid or cementoid.[8] The present case showed all the three types of mineralizations.

A recurrence rate of 8-20% is typically observed with conventional surgical technique. Recurrence could be due to incomplete removal of the lesion, repeated injury or persistence of local irritants.[5]

Lasers are used in dentistry for various intraoral procedures such as removal of soft-tissue tumors, frenectomies, excision of gingival hyperplasias, vestibuloplasties, removal of hemangioma, and periimplant soft tissue surgery.[9]

The case described here was treated with 810-nm diode laser. Diode laser for excision of soft tissue growth was first used by Alam et al. He reported a case of cemento-ossifying fibroma that was successfully treated with diode laser.[10] Walsh has suggested laser excision as one of the best method for intra oral soft tissue management. Advantage of using laser is it provides a bloodless surgical field, reduces bacteremia at the surgical site, minimal scarring, and wound contraction accelerating recovery and postoperative function.[11] However, study of a series of such laser excisions with long term follow-up are recommended to evaluate recurrence patterns.

CONCLUSION

Peripheral ossifying fibroma, a reactive lesion of gingiva that can be treated successfully by eliminating the etiology with surgical excision extending until the bone. Treatment with diode laser showed excellent healing with minimal intra and postoperative complications. No signs of recurrence were seen in 1-year period. But as the recurrence rate of POF is high a long term follow-up is required.