Case Report

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 59-63

Peripheral Cemento-Ossifying Fibroma - A Case Report with

a glimpse on the differential diagnosis

Manuscript Reference
Number: Njmdr_241_14

Talreja NidhiA, Shashikiran N. DB, Singla Shilpy SC, Tiwari ShilpiD, Tijare ManishaE
APost-Graduate Student, Department Of Paedodontics And Preventive Dentistry,
Peoples College Of Dental Sciences And Research Centre
BProfessor and Head of the Department, Department Of Paedodontics And Preventive Dentistry, Peoples College Of Dental Sciences And Research Centre
CReader, Department Of Paedodontics And Preventive Dentistry, Peoples College
Of Dental Sciences And Research Centre
DSenior Lecturer, Department Of Paedodontics And Preventive Dentistry, Peoples
College Of Dental Sciences And Research Centre
EProfessor and Head of the Department, Department Of Oral Pathology, Peoples
College Of Dental Sciences And Research Centre
Abstract:
Peripheral cemento-ossifying fibroma is a relatively rare tumour (commonly
misdiagnosed) classified amid fibroosseous lesions. It is a reactive gingival overgrowth occurring in the maxillary anterior region. This article presents a case of a
peripheral cemento-ossifying fibroma in a 15 year old female. Taking in account the
suspicion of the etiology and pathogenesis of the lesion and a variety of differential
diagnosis that are based on the clinical features, an attempt has been made to discuss
and analyse the histologic and radiographic features emphasizing the differential
diagnosis.
Key Words: Gingival over-growth, Peripheral cemento-ossifying fibroma, differential
diagnosis.

Introduction:

Date of submission: 16 July 2014

Date of Editorial approval: 19 July 2014
Date of Peer review approval: 28 July 2014
Date of Publication: 30 September 2014
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Nidhi Talreja
Room No 18, PCDS PG Girls Hostel,
Peoples Campus, Bhanpur
Bhopal-462037
Ph-09669145200
nidhitalreja@gmail.com
Conflicting Interest: Nil

The concept of fibro-osseous lesions of

bone has evolved over the last several
decades and now includes two major
entities, one of which is ossifying fibroma.
There are two types of ossifying fibromas:
the central type and the peripheral type.
The central type originates from the
endosteum or the periodontal ligament
and causes expansion of medullary cavity.
Peripheral type appears solely on the soft
tissue covering the tooth areas of the jaws
[1].
Cemento-ossifying fibroma is a benign
fibro-osseous neoplasm [2]. In 1872,
Menzel
first
described
ossifying
fibroma whereas Montogmery in 1927
attributed a terminology to it [2]. The

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Cementifying fibroma is usually classified

as an odontogenic tumor [3]. The ossifying
fibroma is classified as an fibro-osseous
lesion. It is composed of (histologically)
cellular fibrous connective tissue containing
various amounts of osteoid and bone
whereas rounded cementoid calcifications
are present in cementifying fibroma [3].
This terminology was first used by Hamner
et al [4] but is not of much significance
because of the far-reaching range of
behaviour of these lesions with identical
histopathological features. Moreover there
are many types of tumors that show both
the type of calcifications. Therefore these
lesions exhibit features that tend to overlap
the histological appearances extending
from bone to cementum. Waldron thus
concluded that they probably originated
from the same progenitor cells, which

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 59-63

were to be found within the periodontium. In 1992, WHO

revised its nomenclature and referred the separate lesions
as a single term as cement-ossifying fibroma [5].
Peripheral cemento-ossifying fibroma (PCOF) accounts for
3.1% of all oral tumors [4] and for 9.6% of gingival lesions
[6]. Clinical manifestation of PCOF is as a pedunculated
or sessile nodular mass, which usually arises from the
interdental papilla. About 60% of the tumors ensue in the
maxilla and more than 50% of all cases of all cases affect
the region of the incisors and canines. It may occur at any
range, but exhibits a peak incidence between the second
[7] and third decades [8]. However, according to Neville
et al [9] it affects adolescents and young adults, with peak
prevalence between 10 and 19 years. PCOF affects both
genders, but a higher predilection for females has been
reported in the literature.5A possibility of tooth migration
and bone destruction has also been proclaimed [10].
PCOF is frequently said to be caused by irritant agents
such as calculus, bacterial plaque, orthodontic appliances,
ill adapted crowns, and uneven restorations. Due to their
clinical and histopathological similarities, some PCOFs are
believed to develop as pyogenic granuloma that undergoes
fibrous maturation and subsequent calcification [11]. Just
as with pyogenic granuloma PCOF bears resemblance with
various other entities and is difficult to diagnose. Hence,
the purpose of this paper is to present a case of PCOF and
emphasize on the importance of the differential diagnosis.

papilla, reaching the gingival margin palatally. The lesion

revealed impingement made by the occluding mandibular
canine and the first premolar which was confirmed by the
indentations that were present palatally.
On palpation it was non-tender, firm in consistency.
Bleeding was not seen on palpation whereas diascopy was
positive. The lesion was not fluctuant nor did it blanch on
pressure. The patient also showed bilateral cross-bite in the
canine region. The oral hygiene was fair according to the
OHIS index.

Radiographic Examination:
Intra-oral periapical, maxillary occlusal radiographs
and OPG (Fig. 3) were done for the patient .A diffused
radiolucency was seen distal to the canine. No signs of
bone involvement were noted however a slight cortical
expansion could be seen on the occlusal radiograph. A
slight mesial shift of the maxillary canine could also be
appreciated.

Investigations:
The complete Haemogram was done for the patient and
was found to be normal.

Surgical Procedure:

Case Report:
A 15 year old female reported to the Department of
Pedodontics, with a chief complaint of swelling in upper
right maxillary anterior region since 2 months (Fig.1). It
was initially a pea-sized lesion which gradually evolved
painlessly. Pain was experienced by the patient only at
the time of mastication. Pain was localised, sharp and
intermittent and got relieved on its own. It was associated
with bleeding while brushing. There was no history of any
trauma.
Intra-oral examination revealed an oval, exophytic growth
with an overlying erythematous mucosa (approx. 1 cm)
located on the labial gingival in the space present distal
to the upper right canine and mesial to the first pre-molar
(Fig 2).It extended from the attached gingival inferiorly
covering the occlusal surface, involved the inter-dental

Under all aseptic conditions and precautions Local

anaesthesia was administered. The lesion was completely
excised with through curettage of the surrounding tissue.
Sutures were placed (3-0 black silk) and coe pack applied
(Fig. 4). The excisional biopsy was sent for histopathological
analysis to the department of oral pathology (Fig. 5).
Enameloplasty of the lower mandibular canine and first
premolar was also done to avoid any chances of trauma in
the region of the lesion.

Diagnosis:
A confirmatory diagnosis of peripheral cemento-ossifying
fibroma was made by histopathologic evaluation of biopsy
specimens. The following features were observed during
microscopic examination: 1) Sections show presence

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 59-63

of hyperplastic parakeratinised stratified squamous

epithelium with numerous connective tissue cores giving
appearance of pseudoepitheliomatous hyperplasia.(Fig.
6A). 2) Underlying fibro-cellular connective tissue exhibits
dense collagen fibre bundles along with numerous small
to medium sized blood vessels and inflammatory cells
throughout the connective tissue. 3) The deeper area reveals
the presence of osteoid (Fig. 6B) and cementoid (Fig. 6C)
like material surrounded by vascular and fibrous cellular
stroma and focal areas show basophilic calcification.4)
Dense perivascular chronic inflammatory cell infiltration is
present.

Fig 3- Intra-oral periapical, maxillary occlusal radiographs and OPG

Follow up:

Fig 4- Sutures in situ

Patient was recalled after 7 days for suture removal. The

healing was uneventful and the patient was completely
asymptomatic (Fig. 7). The patient also reported to the
department after 15 days and was absolutely fine with no
signs of any type of recurrence. The patient is on regular
follow up and orthodontic treatment is being planned for
the correction of bilateral cross-bites.
Fig 5- Specimen after excisional biopsy

Fig 6A- Sections showing presence of pseudoepitheliomatous hyperplasia

Fig 6B- Sections showing osteoid like material
Fig 6C- Sections showing cementoid like material

Fig 1- A 15 year old female reported to the Department

of Pedodontics, with a swelling in upper right maxillary anterior region since 2 months

Fig 2- An oval, exophytic growth located on the labial

gingival in the space present distal to the upper right
canine and mesial to the first pre-molar

Fig 7- 7th day post-operative view

Discussion:
Peripheral ossifying fibroma is thought to be a reactive

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 59-63

lesion in nature. Various synonyms are being used

for peripheral ossifying fibroma, such as peripheral
cementifying fibroma, ossifying fibroepithelial polyp,
peripheral fibroma with osteogenesis, peripheral fibroma
with cementogenesis, peripheral fibroma with calcification,
calcifying or ossifying fibroma epulis, and calcifying
fibroblastic granuloma ,therefore confusion still exists in
its nomenclature and classification [9]. Ossifying fibromas
encompass bone, cementum and spheroidal calcifications,
which has given rise to various terms for these benign
fibroosseous lesion. When bone and cementum-like tissues
are observed, the lesions have been referred to as cementoossifying fibroma [12]. The term cemento-ossifying has
been referred to as obsolete [13] because the clinical
features and histopathology of cemento-ossifying fibroma
are similar in areas where there is lack of cementum. Thus
these are all categorised as ossifying fibromas and the
term cement-ossifying fibroma for the lesions associated
with tooth structure is not justified as there is no histologic
or biochemical difference between cementum and bone.
Cemento-ossifying fibroma is the term assigned due to
presence of the so called cementicles which are dysmorphic
round basophilic bone particles within ossifying fibroma.
However,these cementicles do not originate from cementum
but instead represent a dysmorphic product of this tumour
that resemble the keratin pearls, which are a dysmorphic
product of squamous cell carcinoma [13].
One of the most common etiology of peripheral ossifying
fibroma is recurrent trauma. Chronic irritation of the
periosteal and periodontal membrane causes metaplasia of
the connective tissue and resultant initiation of formation
of bone or dystrophic calcification. Thus the increase in
the size of the lesion which was seen in the present case
could be attributed to the continued irritation caused by the
mandibular canine and the first premolar. Fibrosis of the
granulation tissue is also considered one of the etiological
factors [14].
It is a mixed radiolucent/radio-opaque lesion. The pattern
is similar to fibrous dysplasia when predominantly bone is
present. Lesions that produce more cementum like material
are analogous to cemental dysplasias to a great extent.

but it can be differentiaed histologically by the presence of

cellular vascular stroma with giant cells, scarce collagen,
small ossicles surrounded by a osteoid halo and they do not
have a fibrous capsule.
Osteoid Osteoma: Is associated with the history of night
pain, whereas PCOF is mostly painless.
Benign Cementoblastoma: Is characteristically attached
to the part of the root frequently causing resorption.
Sometimes manifests as pain and swelling.
Fibrous Dysplasia: Various researches have observed
more oxytalan fibers in ossifying fibroma than in fibrous
dysplasia. Studies by Hamner, Scofield and Cornyn on
fibro-osseous lesions showed greater amount of oxytalan
fibers in the lesions associated with periodontal membrane
origin as compared to those of fibro-osseous origin [15].

Conclusion:
A slowly growing pink soft-tissue nodule in the anterior
maxilla of an adolescent female should raise suspicion of a
PCOF. Diagnosis of the lesion is quite perplexed and should
be based on both clinical and histopathological features
as clinically it may be disguised as a variety of lesions.
Treatment consists of surgical excision with complete
curettage and regular follow up of the lesion

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Differential Diagnosis: [5]

Juvenile ossifying fibroma can be considered as a separate
entity. Clinically and radiographically it has similar features

5. Ghom A Textbook of oral medicine. New Delhi: Jaypee

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