International Journal of Surgery Case Reports 114 (2024) 109161

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International Journal of Surgery Case Reports

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Case report

A giant peripheral ossifying fibroma of the mandible: A rare case report

Rajae El Gaouzi a, *, Leila Benjelloun a, Hafsa EL Ouazzani b, Nadia Cherradi b, Saliha Chbicheb a
a
Department of Oral Surgery, Faculty of Dentistry, Mohammed V University in Rabat, Morocco
b
Pathological Anatomy Laboratory HSR, Ibn Sina University Hospital Center, Mohammed V University in Rabat, Morocco

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Peripheral ossifying fibroma (POF) is an unusual localized, reactive benign gingival growth. POF is
Peripheral ossifying fibroma usually small in size, it’s measure <2 cm in diameter, but rarely reaches important sizes. The aim of this work
Peripheral myxoma was to present a rare case report of a giant peripheral ossifying fibroma of the mandible measuring >2 cm in
Mandible
diameter, misdiagnosed as peripheral myxoma.
Benign tumor
Case presentation: We present the case of a 42-year-old woman with a large peripheral ossifying fibroma in the
Case report
oral cavity measuring 6 × 4 cm in diameter. The patient presented with an asymptomatic, slowly growing
gingival mass in the left anterior and posterior region of the mandible. It gradually increased in size for more
than two years. The patient had a mild mental deficit; however, we performed biopsy surgery, which revealed a
peripheral myxoma, and then treated the tumor by excision under local anesthesia. The final histopathological
examination revealed a peripheral ossifying fibroma.
Clinical discussion: This case report shows that POF can grow and reach unusual dimensions that may contribute
to occlusal problems. The diagnosis of POF is based on clinical and radiographic features. The histopathological
examination of the biopsy specimen can misdiagnose the lesion; therefore, the final diagnosis is based on the
histopathological examination of the complete excised lesion.
Conclusion: POF is usually small, but can reach a larger size. The histopathological examination of the entire
lesion is of paramount importance to make a final diagnosis.

1. Introduction histopathologically has a fibrous stroma with varying amounts of

mineralized materials [7]. Incidence of recurrence is 16–20 %; conse­
Peripheral ossifying fibroma (POF) is a relatively uncommon quently, POF must be treated by excision with a deep and large margin
gingival growth [1] that accounts for 3 % of all oral tumors [2] and 9.6 [8].
% of all gingival lesions [3]. It is reactive focal overgrowth originating In most of the reported cases, POF measuring <2 cm in the greatest
from periodontal ligament cells. It occurs in response to irritants such as dimension. POF measured more is relatively rare in the literature with
dental calculus, plaque, microorganisms, dental appliances, and resto­ only a few cases. Our case report aims to present the management of a
rations. Females are more commonly affected. POF may occur at any age large POF measuring >2 cm, involving the mandibular anterior and
range, but exhibits a peak incidence between the second and third posterior gingival region, which is rare, and which was misdiagnosed as
decade of life. Approximately, 60 % of these tumors occur in the maxilla, a peripheral myxoma. This case report is had been reported with the
and >50 % of maxillary POF are found in the incisors and canine areas. SCARE Criteria [7].
POF occurs as a rare growth of the mandible, especially of the anterior
region [4]. Clinically, POF arises as a gingival mass with a slow and 2. Case report
progressive growth potential [5]. It is often located in the interdental
papilla region. The base may be sessile or pedunculated, and the color is A 42-years-old woman presented to the oral surgery department of
identical to that of gingiva or slightly reddish. The surface may appear consultation and treatment center of Rabat, with a chief complaint a
ulcerated [6]. Generally, it presents without any radiographic alter­ voluminous mass in the left mandibular region. The patient had a mild
ations, but radiopaque areas may be identified [5]. This lesion mental deficit, she takes no medication, and she has no other health

* Corresponding author at: Faculty of Dentistry, BP:1044, Rabat, Morocco.

E-mail address: rajouaga@yahoo.fr (R. El Gaouzi).

https://doi.org/10.1016/j.ijscr.2023.109161
Received 25 October 2023; Received in revised form 6 December 2023; Accepted 8 December 2023
Available online 20 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
R. El Gaouzi et al. International Journal of Surgery Case Reports 114 (2024) 109161

Fig. 1. a. Extraoral front view b. Extraoral profile view showing a large swelling at the left mandibular region. c. Intraoral view showing a voluminous mass involving
left mandibular anterior and posterior region. d. Intraoral view showing the interference of the mass with the occlusion.

Fig. 2. a. Orthopantomogram evaluation showed the presence of a radiopacity at the center of the soft tissue shadow. b. Curvilinear panoramic reconstruction of
CBCT revealed hyperdensity inside the soft tissue in the left mandibular region, without any osseous lesion. c. 3D reconstruction showing teeth displacement. d.
Sagittal reconstructions showing vestibular displacement of 36, without any osseous lesion.

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Fig. 3. a. Intraoral view showing incisional biopsy of pedunculated area of the mass.
b. Postoperative view showing the incisional biopsy.
c. View of the specimen after the incisional biopsy.
d. Intraoral view of the excision of the lesion on cutting it into two halves.
e. Intraoral view of the vestibular part of the lesion.
f. Intraoral view of the ossification.
g. Postoperative view after the complete excision of the lesion.
h. Vestibular soft tissue specimen.
i. Lingual soft tissue specimen.
j. Osseous specimen.

issues. Her relatives reported that the lesion was asymptomatic, Orthopantomogram (OPG) evaluation (Fig. 2a) showed a radiopacity
appeared more than two years ago, and had been increasing gradually in at the center of the soft tissue shadow, between 34 and 36 region. It also
size. The family history revealed no genetic condition. The patient was showed a radiolucent image at the distal side of 35, and around 36
from low socioeconomic class explaining the deplorable oral condition, apexes. Displacement of 33, 34, 35, and 36 was confirmed. Cone-beam
and the delay in the consultation. computed tomography (Fig. 2b, d, c) revealed hyperdensity inside the
Extraoral examination (Fig. 1a, b) showed a large swelling at the left soft tissue in the left mandible region, without any osseous lesion.
mandibular region, hard in palpation and with no skin color change, The differential diagnosis is based on the patient’s history, clinical
causing a facial asymmetry. Cervical lymph node areas were intact, also, presentation, and radiographic findings, and it includes peripheral
facial sensibility was normal. ossifying fibroma, peripheral myxoma, and malignant tumor.
Intraoral examination revealed a voluminous mass involving the left Periodontal treatment was carried out, and many tooth roots were
mandibular anterior and posterior region extending from 31 to 36 removed, which allowed us to assess patient cooperation. Anxiolytic
(Fig. 1c). The mass measured approximately 6 cm × 4 cm in size. It was a premedication was taken the night before, and 1 h before intervention
rubbery, pinkish-red soft tissue growth, pedunculated on the vestibular (Hydroxyzine tablet 1 mg/kg/day). Incisional biopsy was performed
mesial side, and sessile on the other sides. It was painless, firm to under local anesthesia (Articaine 68 mg/1.7 ml with 1/200,000 adren­
palpation, and interfering with the occlusion (Fig. 1d). Vestibular aline) (Fig. 3a, b). The specimen measured 3 × 1.5 cm in size, and was
displacement of 33 and 34 was noted 35, and 36 were completely sent for histopathological examination (Fig. 3c). Histology revealed a
covered by the lesion. Imprint of the teeth was observed on the mass. peripheral myxoma with myxoid stroma and multiple calcifications.

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Fig. 4. a. Histopathological view of osseous tissue showing bony trabeculae bordered by a border of osteoblasts without cytonuclear atypia. Hematoxylin-Eosin ×20.
b. Histopathological view of soft tissue showing a dual-component proliferation, an osteoforming component made up of globular trabeculae and a benign fibro­
blastic stromal component. Hematoxylin-Eosin ×10.

Fig. 5. Intraoral view of follow up. a. Follow up after 2 weeks. b. Follow up after 6 weeks. c. Follow up after 3 months.

After biopsy, surgery was performed by cold scalpel under local reported by Sacks et al. measuring 10.5 cm [13]. POF rarely occurs in
anesthesia (Articaine 68 mg/1.7 ml with 1/200,000 adrenaline). The the mandible, especially at the anterior region, like our case [4].
fibrous tissue was completely removed by cutting it into two halves Radiographic evaluation of these lesions revealed radiopaque opa­
(Fig. 3d, e, f, g). 34, 35, and 36 were extracted. cification in soft tissues and sometimes the presence of associated bone
The specimen (Fig. 3h, i, j) (4 soft tissues and 3 calcifications) was destruction. The case presented below, showed radiopacity at the center
sent to histopathological examination, and the longest specimen of the soft tissue shadow, associated with radiolucent in places. How­
measured 6 × 3 cm (soft tissue). The results revealed a peripheral ever, in some cases there are no radiographic signs. In only 5 % of the
ossifying fibroma with poorly vascularized fibro-osseous proliferation, cases, the radiographic appearance of tooth migration is seen, as in our
which consisted of monotonous fibroblasts organized in anarchic bun­ case [14,15].
dles surrounding mature lobulated bone formations (Fig. 4a) sheltering The differential diagnoses in many studies included fibrous hyper­
small regular osteoclastic cells and bordered by osteoblastic cells. The plasia, pyogenic granuloma and peripheral giant cell granuloma and
fibrous component nuclei are monotonously plump in shape with fine peripheral odontogenic fibroma [4] and osteosarcoma [14]. In our case,
chromatin showing one or two small nucleoli. They are devoid of mitotic because of the radiographic findings especially the presence of radio­
activity (Fig. 4b). pacity, we excluded most of those differential diagnoses and suspected a
The patient was seen after 2 weeks, 6 weeks, and 3 months (Fig. 5a, peripheral ossifying fibroma.
b, c), and wound healing was good without any recurrences. Histopathologically, POF is described as a lesion with a fibrous
stroma in which mineralized tissues such as bone and/or cementum-like
3. Discussion are present. The mineralized material may be lamellar or woven bone.
There are no giant cells reported. Some authors have reported the
Peripheral ossifying fibroma originates from periodontal ligament or presence of odontogenic epithelium and that the proliferating cells may
from the soft tissue overlying the alveolar process (periosteum) [9]. be of myofibroblastic origin [16]. Childers et al. [11] presented many
There is a female predilection for the lesion due to hormonal influences cases of POF in which histopathological examination showed ossified
[10], in our case the patient was a woman. material in a fibrous to fibromyxoid stroma. In our case report, fibro­
Clinically POF presents as a smooth lobulated pink mass on a myxoid stoma was observed on biopsy incisional histology, which led to
pedunculated or sessile base. More often, POF measured in size <2 cm in misdiagnosis of the lesion as a peripheral myxoma. The final diagnosis is
greatest diameter. However, there is only few cases of large POF in possible only after histological examination of the entire excised lesion.
literature measuring >2 cm, such as the case presented below. Childers The treatment of choice for POF is local resection with peripheral
et al. [11] reported only 10 cases, including the case of giant POF re­ and deep margins, including both the periodontal ligament and the
ported by Poon et al. [12] measuring approximately 9 cm, and the case affected periosteal component. In addition, elimination of local

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R. El Gaouzi et al. International Journal of Surgery Case Reports 114 (2024) 109161

etiological factors, such as bacterial plaque and calculus must be done Consent written informed
before the surgery [17]. In the case presented, despite having a mild
mental deficit, the patient was treated under local anesthesia and not Consent was obtained from the patient for publication of this case
under general anesthesia. The psychological approach is of paramount report and accompanying images. A copy of the written consent is
importance to avoid general anesthesia side effects and risks. available for review by the Editor-in-Chief of this journal on request.
Recurrence probably occurs because of incomplete initial removal,
repeated injury, or persistence of local irritants. Consequently, due to Patient perspective
the high relapse rate of these lesions, excision with deep margins must
be performed, as in our case, and periodic follow-up is required. The patient was satisfied of the result.

4. Conclusion References

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