Case Report

Peripheral ossifying fibroma associated with a neonatal tooth: case report

K. Kohli, DDS A. Christian,DDS R. Howell, DDS, MSD, BS

eripheral ossifying fibroma (POP) is a relatively only approximately half of the crown formed. The child common reactive gingival growth of uncertain was seen for a 1-week post-op check-up during which Ppathogenesis.' In the literature, this pathologic time it was noted that the extraction site was covered lesion sometimes has been described as an ossifying fi- by a mass that was 8x4x4 mm. A pathology consul- broid epulis, a peripheral fibroma with calcification or tation was requested and the lesion was clinically a calcifying granuloma.2 In 1982, Gardner recom- diagnosed as a pyogenic granuloma. Reevaluation was mended that the only term used to describe this entity recommended and if there was no reduction in size, should be POP.3 the lesion was to be surgically excised. The mass was POP are seen usually in teenagers and young adults, excised in the dental clinic at 4 weeks of age using lo- with an occurrance peak between the ages of 10 and cal anesthesia. Histologic examination of the excised 19 years.4 A literature review revealed the youngest re- mass revealed a .______, ported age of a POP was in a 7-month-old infant. The lesion consisting purpose of this report is to present a case in a neonate. primarily of granulation tis- Cose report sue with an A consultation was requested by the Nursery at Ruby ulcerated sur- Memorial Hospital of West Virginia University on a face. Also noted 2-hour-old, Caucasian female neonate, birth weight of was an eosino- 7 lbs, 5oz, gestational age of 37 weeks, who was deliv- philic material ered vaginally with no complications. The otherwise in the connective healthy neonate was said to have a small cyst-like mass tissue exhibiting Fig 2. Histology of granulation tissue with an in the anterior mandibular ridge area, approximately osteiod appear- ulcerated surface. 20 x 12x6 mm. Clinical examination revealed a soft, ance (Fig 2) a fluid-filled, pink fluctuant mass. The clinical differen- final diagnosis of a POP was rendered. The child was tial diagnosis was that of a gingival cyst of newborn or followed for 2 weeks after the excision, during which an eruption cyst (Fig 1). The infant was seen at the time the alveolar mucosa healed uneventfully. dental clinic a week later with a neonatal tooth erupt- ing through the site of the cyst. Radiographic Discussion examination The clinical features of a POP were described by was not at- Buchner and Hansen, and consisted of a localized tempted as the growth on the gingiva with a pedunculated or sessile parents did not base.' POFs usually range in color from pink to red and want the baby commonly occur on the interdental papilla. It is im- to be exposed possible to identify the cause of growth in most cases, to any radia- but a multitude of possible irritants have been identi- tion. Clinical fied including calculus, plaque, microorganisms, dental examination appliances, and ill-fitting crowns.5'6 The POP is a re- revealed that active lesion of soft tissue in contact with osseous Fig 1. Gingival cyst in newborn. the neonatal structures and is only seen in soft tissues over bone. tooth had third POFs differ from a clinically similar lesion, the periph- degree mobility and was causing a lot of discomfort to eral odontogenic fibroma, in that they lack the the mother during nursing. It was decided to extract odontogenic components found in this latter lesion. the tooth at 1 week of age. The extracted tooth had While ossification may occur in soft tissues associated

428 American Academy of Pediatric Dentistry Pediatric Dentistry - 20:7, 1998 with bone, they are generally consideredto be either a The recommendedtreatment of POFis a local sur- choristomas, such as an osteomaof the tongue, or an gical excision that extends to include the periosteum osseous metaplasia, such as bone or cartilage seen in with9 submission for histomorphologic examination. somesalivary gland tumors. While POFoccurrence is Inclusion of the periosteum during the excision de- uncommonin the neonate, it is’ not difficult to ratio- creases the recurrence of this lesion.1 Kenneyet al. nalize that the active growthof the alveolar bonein the reported a 14%recurrence rate of POF. Whentaking neonate jaw, whenstimulated by removal of the neo- into accountthe reactive nature of this lesion, this rate natal tooth, might respondwith an exuberantperiosteal mayreflect incompleteinitial removalor repeated in- response and form a reactive lesion with somepoten- jury. 4 Buchner and Hansen reported a recurrence of tial for bone production. Thelesions usually range in 16%, Levin and North reported a recurrence of 10- size from 0.1 to 1.0 cm.5 POFduration has been re- 20%, and Bhaskar and Jacowayreported recurrence of ported by Buchner and Hansen as two weeks to 20 8%. 1, 7, 10 years, with a mean of 11.5 months.1 Bhaskar and In summary,POF is an entity that can be seen in Jacowayreported that the average duration of the le- neonates. Therefore, it maybe necessary to include sion7 was 18.6 months. POFin the differential diagnosis of anterior alveolar According to Bodner and Dayan, POFs can occur masses in the neonate. The presence of POFcan be at any age, but rarely occur before age 10 and are most very overwhelmingto a new mother and it becomes commonin the second decade of life. < 5 Buchnerand imperative to educate newparents of the recurrence Hansenreported an age range of 7 to 90 years with a rate associated with POF.It also is advisable to biopsy meanof 30 years. 1 Kenneyreports incidence between the mass whenexcised to help arrive at the appropri- 54 and 25 years with incidence decreasing each decade. ate diagnosis. Bhaskar and Jacowayreported a 64%predilection for Dr. Kohli is an assistant professor and Interim Director in the occurrence of the lesion in females, which was very 1’7 Division of Pediatric Dentistry, Dr. Howellis professor and Chair similar to the 63%reported by Buchnerand Hansen. of Departmentof Oral and Maxillofacial Pathology. At the time According to Buchner and Hansen, POFs occurred this paper was written, AshleyChristian was a fourth-year dental 60%of the time in the maxilla and 40%in the man- student at WVU-Schoolof Dentistry, West Virginia. dible, and 54%occurred in the incisor/cuspid region, l Kenneyet al. reported that occurrencewas equal in the References maxilla and the mandible, with 80%of the lesions 4 1. Buchner A, Hansen LS: The histomorphological spectrum developingin the anterior region. of peripheral ossifying fibroma. Oral Surg Oral MedOral Histologically, POFsare a nonencapsulatedmass of Pathol 63:452-61, 1987. a cellular flbroblastic connectivetissue coveredby strati- 2. Zain RB,Fei YJ: Fibrous lesions of the gingiva: a histopatho- fied squamous epithelium. There exists a wide logic analysis of 204 cases. Oral Surg Oral MedOral Pathol histomorphologicspectrum for this entity, which can 70:466-70, 1990. makeit difficult to distinguish this fromother lesions. 3. Gardner DG: The peripheral odontogenic fibroma: an at- tempt at clarification. Oral Surg Oral MedOral Pathol In its early stages, the lesion maybe ulcerated and com- 54:40-48, 1982. posedof cellular, fibroblastic tissue with granular foci 4. KenneyJN, Kaugars GE, Abbey LM: Comparison between of dystrophic mineralization. Buchner and Hansen the peripheral ossifying fibroma and peripheral odontoge- state that at this early stage somelesions havebeen clini- nic flbroma. J Oral Maxillofac Surg 47:378-82, 1989. cally diagnosed as a pyogenicgranuloma. 1 This lesion 5. Bodner L, DayanD: Growthpotential of peripheral ossify- often appears ulcerated at first and is characterized by ing fibroma. J Clin Periodontol 14:551-54, 1987. 6. Poon CK, KwanPC, Chao SY: Giant peripheral ossifying a highly cellular fibroblastic connectivetissue with ar- fibroma of the maxilla: report of a case. J Oral Maxillofac eas of dystrophiccalcification and osteogenesis. Asthe Surg 53:695-98, 1995. ulcer heals, the dystrophic calcification matures into 7. Bhaskar SN, JacowayJR:Peripheral fibroma and peripheral bone and the cellular flbroblastic connective tissue fibroma with calcification: report of 376 cases. J AmDent maturesto give the appearanceof a fibrous epulis.l Assoc 73:1312-20, 1966. According to Michaelides, peripheral odontogenic 8. Michaelides PL: Recurrent peripheral odontogenic fibroma fibroma must be hisologically differentiated from of the attached gingiva: a case report. J Periodontol 63:645- POF.8 Themain histological difference is the presence 47, 1992. 9. Neville BW, DammDD, Allen CM, Bouquot JE: Oral and of odontogenic epithelium in peripheral odontogenic Maxillofacial Pathology, 1st Ed.,Philadelphia: WBSaunders, fibroma. pp 374-76, 1995. 10. Levin LS, North AF: Peripheral ossifying fibroma. A case report. J MdState Dent Assoc 28:89-90, 1985.

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