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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 7  |  Issue : 1  |  Page : 30-33

Management of peripheral ossifying fibroma using an 810-nm gallium-aluminum-arsenide diode laser with 1-year-follow up


Department of Periodontics, PMS College of Dental Science and Research, Trivandrum, Kerala, India

Date of Web Publication19-Sep-2013

Correspondence Address:
S Anoop
Geetham, Geethanjali Lane, Kariyam, Sreekariyam P. O, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.118447

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  Abstract 

Peripheral ossifying fibroma (POF) is a non-neoplastic enlargement of gingiva that is classified as a reactive hyperplastic inflammatory lesion. Surgical excision down to the periosteum and periodontal ligament with thorough root planing is the mainstay of treatment for peripheral ossifying fibroma. Deep surgery may lead to a gingival defect, which would require gingival grafting. This article illustrates a case of peripheral ossifying fibroma successfully managed using a diode laser with 1-year-follow up. The results showed that diode lasers are an excellent alternative to conventional approach so that a conservative surgical excision can be accomplished with minimal esthetic problems and recurrence.

Keywords: Diode laser, laser excision, peripheral ossifying fibroma


How to cite this article:
Anoop S, Abraham S, Ambili R. Management of peripheral ossifying fibroma using an 810-nm gallium-aluminum-arsenide diode laser with 1-year-follow up. J Dent Lasers 2013;7:30-3

How to cite this URL:
Anoop S, Abraham S, Ambili R. Management of peripheral ossifying fibroma using an 810-nm gallium-aluminum-arsenide diode laser with 1-year-follow up. J Dent Lasers [serial online] 2013 [cited 2022 Jul 4];7:30-3. Available from: https://www.jdentlasers.org/text.asp?2013/7/1/30/118447


  Introduction Top


Peripheral ossifying fibroma (POF) is a non-neoplastic enlargement of gingiva that is classified as a reactive hyperplastic inflammatory lesion. [1] As a common gingival growth, it is typically seen on the interdental papilla as a polypoid, pink lesion and is believed to comprise about 9% of all gingival growths. It may appear from the first to the sixth decade of life with a peak incidence in the second decade of life. [2] About 60% of the cases involve the anterior segment of the dental arch with a 1:1 ratio between the mandibular and the maxillary gingiva and a definite predilection for female over male individuals (4:1). [3] Although they are reported to reach more than 6 cm, POFs are usually less than 1.5 cm in diameter, and the diagnosis can be made by clinical examination and biopsy. [4] Histologically, this malady is a noncapsulated mass of cellular fibrous connective tissue with randomly distributed calcifications and/or mature bone. [2] The etiology of POF is unclear. Trauma or local irritants such as plaque, calculus, microorganisms, masticatory forces, ill-fitting dentures, and poor-quality restorations are all known to precipitate it. [5] Surgical excision down to the periosteum and periodontal ligament with thorough root planing is the mainstay of treatment for peripheral ossifying fibroma. [6] However, an 8-20% recurrence rate is typically observed and justifies follow up of the patient. [3] Deep surgery may lead to a gingival defect, which would require gingival grafting, especially if it is located on the anterior buccal gingiva. [7]

Diode lasers are solid-state semiconductor laser that uses some combination of aluminum, gallium, and arsenide to change electric energy into light energy. The machine delivers laser energy fiberoptically in continuous wave and gated pulse modes, ordinarily used in contact with the tissue. The wavelength range puts this laser into the invisible non-ionizing infrared radiation portion of the electromagnetic spectrum. These lasers are relatively poorly absorbed by the tooth structure, so that soft tissue surgery can be performed safely in close proximity to enamel, dentin, and cementum.

This article illustrates a case of peripheral ossifying fibroma successfully managed using a diode laser with 1-year-follow up.


  Case Report Top


A 26-year-old female patient reported to the Department of Periodontics at PMS College of Dental Science and Research in Trivandrum, India, with a chief complaint of a painless growth on gums in relation to her upper right back teeth. The swelling started as a small nodule that progressed gradually to the present size within a span of 6 months. The patient did not give any history of trauma, injury, or food impaction, and there was no significant medical history. An intraoral examination revealed generalized pink gingiva with a well-demarcated, non-tender, firm, and sessile nodular growth arising from the interdental papilla of the maxillary right second premolar and first molar; covering cervical third of the crown of the maxillary right second premolar [Figure 1]. The oval-shaped mass was 1.5 cm × 1 cm in size, with a reddish pink color and an ulcer in the centre of the lesion with erythematous border. Edges are smooth and distinct. Bleeding on probing was noted. An intraoral periapical radiograph of the area showed no underlying bone involvement [Figure 2]. Patient's oral hygiene was satisfactory with minimal deposits. Clinically, differential diagnoses for the growth were fibroma, POF, pyogenic granuloma, and peripheral giant cell granuloma. A provisional diagnosis of fibroma was made for the gingival growth. Oral prophylaxis was done and oral hygiene instructions were given to the patient. After 2 weeks, the growth was excised conservatively using a diode laser to prevent the development of an unsightly gingival defect. The excised tissue was sent for histopathological examination.
Figure 1: Pre-operative view showing sessile nodular growth arising from the interdental papilla of the maxillary right second premolar and first molar

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Figure 2: Intraoral periapical radiograph of the area shows no underlying bone involvement

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A diode of 810 nm laser was used. Procedure started with the application of topical anesthesia. Laser tip was activated and placed on one side of the lesion at its base. Light sweeping strokes were given to the tip, while tip is in contact with the tissue till the base of the lesion is completely separated from the attached gingiva [Figure 3] and [Figure 4]. Starting from 1.5 W, the power of the laser equipment was gradually increased to 2.3 W because of the less cutting efficiency at low power. Neither bleeding nor pain was experienced by the patient during the procedure. Following the procedure, analgesics were administered. Patient was reviewed after 2 weeks, when progressive healing of the surgical site was seen. Patient did not report of any pain or discomfort after the procedure and no analgesic pills were used. Healing was uneventful. Gingiva appeared pink and firm with normal appearance and no gingival recession in surgical site after 4 weeks [Figure 5]. The patient was reviewed for 1 year and the post-operative result remains stable.
Figure 3: Intra-operative view during laser excision using an 810 nm diode laser

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Figure 4: Immediate post-operative view showing completely excised lesion with charred areas

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Figure 5: One month post-operative view showing pink and firm gingiva with no gingival recession in surgical site

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Histologically, the specimen showed a circumscribed lesion covered by stratified squamous epithelium showing pseudoepitheliomatos proliferation. Underlying connective tissue is moderately collagenous and highly cellular. Discrete areas of woven bone are seen scattered in the connective tissue [Figure 6]. Based on clinical and histological findings, the lesion was diagnosed as POF.
Figure 6: H and E stained section of the lesion showing a circumscribed lesion covered by stratified squamous epithelium, moderately collagenous and highly cellular connective tissue and discrete areas of woven bone scattered in the connective tissue

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  Discussion Top


Ossifying fibroma occurs mostly in craniofacial bones and is generally categorized into two types: Central and peripheral. [8] The central type of ossifying fibroma arises from the endosteum or the periodontal ligament (PDL) adjacent to the root apex and expands from the medullary cavity of the bone. On the other hand, the peripheral type shows a contiguous relationship with the PDL, occurring solely on the soft tissues overlying the alveolar process. The reasons for considering a PDL origin for POF include exclusive occurrence of POF in the gingiva (interdental papilla); the proximity of the gingival lesion to the periodontal ligament; the presence of oxytalan fibers within the mineralized matrix of some lesions, age distribution, which is inversely related to the number of lost permanent teeth, and the fibrocellular response in POF, which is similar to the other reactive gingival lesions of PDL origin. [9] Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue, which initiates formation of bone or dystrophic calcification. [10] Prasad et al., [11] observed that POF in some cases may initially develop as a pyogenic granuloma that undergoes subsequent fibrous maturation and calcification. In the present case, hormonal influences due to the patient's age and sex might have been the cause for the gingival growth.

Neville et al., [12] suggested that the lesion be removed down to the periosteum and the adjacent teeth be scaled to remove any remaining irritants. This will assist in lowering the rate of recurrence. But in this case the growth is conservatively excised without exploring the deeper tissues. One-year-follow up of the patient showed no recurrence. Shorter laser wave-lengths (diode, 810, 980 nm; Nd:YAG, 1,064 nm) transverse the epithelium and penetrate 2-6 mm into the tissue, whereas longer wavelengths have minimal penetration. [13] Because of this penetration power the deeper lesional tissues will be destroyed till the PDL. So, there is no need of deeper excision and curettage to prevent recurrence. In a case report, Carrera et al., documented management of recurrent POF with carbon dioxide lasers and found no more recurrences. [14]

As surgical cutting proceeds, the heat generated seals small blood and lymphatic vessels, reducing or eliminating bleeding and edema. Denatured proteins within tissue and plasma give rise to a surface zone of a tenacious layer, termed 'coagulum' or 'char', which serves to protect the surgical wound from frictional or bacterial action. Clinically, during 48-72 hours post-surgery, this layer undergoes hydration from saliva, swells and disintegrates, and eventually is lost to reveal an early healing bed of new tissue. [13] During the surgical procedure, the power of the laser equipment was increased to 2.3 W. Since POF is a mixed tissue (both hard and soft tissue) and because of its dense fibrous nature usual power what we needed for soft tissue excision will not be enough.


  Conclusion Top


In conclusion, a slowly growing soft-tissue mass with speckled calcifications in the oral cavity of young adults or children should raise a suspicion of a reactive gingival lesion such as POF. Histopathological examination is essential for accurate diagnosis. Once diagnosed, POF should be treated by total excision to prevent recurrence. Diode lasers seem to be an excellent alternative to conventional approach so that a conservative surgical excision can be accomplished with minimal esthetic problems and recurrence. However, long-term follow up studies are needed to confirm the same.

 
  References Top

1.Buduneli E, Buduneli N, Unal T. Long-term follow-up of peripheral ossifying fibroma: Report of three cases. Periodontol Clin Investig 2001;23:11-4.  Back to cited text no. 1
    
2.Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol 1987;63:452-61.  Back to cited text no. 2
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3.Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972;1:30-8.  Back to cited text no. 3
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4.Cuisia ZE, Brannon RB. Peripheral ossifying fibroma: A clinical evaluation of 134 pediatric cases. Pediatr Dent 2001;23:245-8.  Back to cited text no. 4
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5.Gardner DG. The peripheral odontogenic fibroma: An attempt at clarification. Oral Surg Oral Med Oral Pathol 1982;54:40-8.  Back to cited text no. 5
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6.Kendrick F, Waggoner WF. Managing a peripheral ossifying fibroma. ASDC J Dent Child 1996;63:135-8.  Back to cited text no. 6
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7.Walters JD, Will JK, Hatfield RD, Cacchillo DA, Raabe DA. Excision and repair of the peripheral ossifying fibroma: A report of 3 cases. J Periodontol 2001;72:939-44.  Back to cited text no. 7
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8.Saito I, Ide F, Inoue M, Teratani K, Satoh M, Kiuchi K, et al. Periosteal ossifying fibroma of the palate. J Periodontol 1984;55:704-7.  Back to cited text no. 8
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9.Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva. J Am Dent Assoc 1990;121:559-60.  Back to cited text no. 9
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10.Orkin DA, Amaidas VD. Ossifying fibrous epulis. An abbreviated case report. Oral Surg Oral Med Oral Pathol 1984;57:147-8.  Back to cited text no. 10
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11.Prasad S, Reddy SB, Patil SR, Kalburgi NB, Puranik RS. Peripheral ossifying fibroma and pyogenic granuloma. Are they interrelated? N Y State Dent J 2008;74:50-2.  Back to cited text no. 11
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12.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3 rd ed. St. Louis, MO: Elsevier; 2009. p. 451-2.  Back to cited text no. 12
    
13.Parker S. Lasers and soft tissue: 'Loose soft tissue surgery'. Br Dent J 2007;202:185-91.  Back to cited text no. 13
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14.Carrera Grañó I, Berini Aytés L, Escoda CG. Peripheral ossifying fibroma. Report of a case and review of the literature. Med Oral 2001;6:135-41.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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