|DENTAL SCIENCE - CASE REPORT
|Year : 2014 | Volume
| Issue : 5 | Page : 204-207
Recurrent peripheral odontogenic fibroma associated with basal cell budding
C Sreeja1, N Vezhavendan2, F Shabana1, D Vijayalakshmi1, M Devi1, N Arunakiry1
1 Department of Oral and Maxillofacial Pathology, Adhiparasakthi Dental College, Melmaruvathur, Chennai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Indra Gandhi Dental College, Puducherry, India
|Date of Web Publication||25-Jul-2014|
Dr. C Sreeja
Department of Oral and Maxillofacial Pathology, Adhiparasakthi Dental College, Melmaruvathur, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Peripheral odontogenic fibroma (POdF) is a rare benign odontogenic neoplasm. It represents the soft tissue counterpart of central odontogenic fibroma. The embryonic source of POdF has been suggested by many as arising from the rest of dental lamina that has persisted in the gingiva following its disintegration. It presents clinically as a firm, slow growing and sessile gingival mass, which is difficult to distinguish with more common inflammatory lesions. Very few cases of recurrence have been documented. It has been stated that histological budding of basal cell layer of the surface squamous epithelium is associated with higher recurrence and the presence of calcification in direct apposition to the epithelial rest is associated with lower recurrence. Hereby, we present a case which histologically exhibited budding of the basal cell layer, which could have been the reason for its recurrence.
Keywords: Budding, dental lamina, peripheral odontogenic fibroma, recurrence
|How to cite this article:|
Sreeja C, Vezhavendan N, Shabana F, Vijayalakshmi D, Devi M, Arunakiry N. Recurrent peripheral odontogenic fibroma associated with basal cell budding. J Pharm Bioall Sci 2014;6, Suppl S1:204-7
|How to cite this URL:|
Sreeja C, Vezhavendan N, Shabana F, Vijayalakshmi D, Devi M, Arunakiry N. Recurrent peripheral odontogenic fibroma associated with basal cell budding. J Pharm Bioall Sci [serial online] 2014 [cited 2019 Nov 14];6, Suppl S1:204-7. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/204/137470
The World Health Organization (WHO) describes odontogenic fibroma as a rare benign odontogenic neoplasm.  The peripheral odontogenic fibroma (POdF) is considered to be the mucosal analog to the central odontogenic fibroma. 
Cases reported in the literature under the terms "odontogenic gingival epithelial harmartoma" "hamartoma of the dental lamina" and "peripheral ameloblastic fibrodentinoma" are actually examples of POdF. , They are rare and comprise only 0.05% of all biopsy specimens, but they are the most common peripheral odontogenic tumor.
The ratio of occurrence of the central to peripheral odonrtogenic fibroma is 1.4:1.4. About 207 cases are reported in the English literature with follow-up information on 31 cases. A very inadequate data on the biologic behavior and recurrence of this lesion exists. POdF should be considered a mixed odontogenic tumor because it is composed of active odontogenic epithelial and ectomesenchymal components. It has been stated that budding of the basal cell layer of the surface squamous epithelium was associated with higher recurrence. The presence of calcification in direct apposition to epithelial rests was associated with lower recurrence.  The purpose of this article is to report the clinical and histopathological features of a case of POdF in a 53-year-old male patient who exhibited recurrence.
| Case Report|| |
A 53-year-old male patient reported with the complaint of a painless swelling on upper back tooth region since 6 months. Patient gave a history of similar swelling 1 year back for which he had undergone excision in a private clinic, no other records was obtained from the patient regarding the same.
On intraoral examination, a localized, sessile, erythematous growth was present in the maxillary alveolar region of size 3 cm × 2 cm, extending from buccal gingiva of 15-16 [Figure 1] to the palatal gingiva of 15-16 by traversing the interdental papilla [Figure 2] with mild tooth displacement. The swelling was firm, nontender and exhibited bleeding on palpation. The periodontal examination revealed generalized periodontitis with the recession and Grade II mobility. No other relevant medical and family history was given by the patient.
|Figure 1: Buccal aspect showing localized, sessile, erythematous growth in the maxillary gingival region of size 3 cm × 2 cm, extending buccally from 14 to 16 regions by involving the interdental papilla|
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|Figure 2: Palatal aspect showing localized, sessile, firm growth extending from 15 to 16 by involving the interdental papilla|
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An excisional biopsy was performed and the specimen was sent for histopathological investigations. The gross specimen was greyish white, nodular, firm, measuring about 2.5 cm × 2 × 1.7 cm. A gritty texture was felt on sectioning. The hematoxylin and eosin stained section of the specimen under the light microscope exhibited stratified squamous parakeratinized surface epithelium associated with a fibromyxoid connective tissue. The surface epithelium exhibited slender, branching, and deep penetrating rete ridges with budding. The sub-basilar connective tissue showed abundant capillaries [Figure 3] and [Figure 4].
|Figure 3: Surface epithelium exhibiting slender, branching, deep penetrating rete ridges with basal cell budding. The sub-basilar connective tissue showing abundant capillaries|
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|Figure 4: Surface epithelium exhibiting slender, branching, deep penetrating rete ridges with basal cell budding. The sub-basilar connective tissue showing abundant capillaries|
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Islands and strands of odontogenic epithelium were found to be scattered throughout the connective tissue [Figure 5], which was more cellular in the fibrous areas [Figure 6] than the myxoid areas [Figure 7]. Few foci showed cementoid and osteoid calcifications [Figure 8]. Considering these features, the case was finally diagnosed as POdF with a comment on its chances to recur.
On account of the firm, sessile swelling in the gingiva a provisional diagnosis of pyogenic granuloma (PG), peripheral ossifying fibroma (POF), and peripheral giant cell granuloma (PGG) were given. Commonly given differential diagnosis of peripheral swellings are PG, POF, PGG, peripheral ameloblastoma, parulis, POdF, and fibroma. 
Oral prophylaxis was done and a complete surgical excision of the lesion was performed. The patient was advised for a periodic follow-up.
Outcome and follow-up
Our patient exhibited recurrence of a similar lesion of the same size and site after a period of 1 month [Figure 9].
The recurrence rate of POdF has been reported to be from very low to high as 38.9%.  Ritwik and Brannon have reported a 50% recurrence rate in their study of 151 cases and also stated that neither the size of the lesion nor the race of the patient was associated with recurrence. They concluded that the recurrence was associated with the histological presence of budding in basal cell layer of the surface epithelium and lower recurrence was associated with the presence of calcification in opposition to the odontogenic epithelial rests. 
Our patient's histopathology exhibited budding of the basal cell layer, which could have been the reason for recurrence in our case.
| Discussion|| |
The World Health Organization defined odontogenic fibroma as "a benign odontogenic neoplasm of fibroblastic origin characterized by relatively mature collagenous fibrous tissue and varying amounts of odontogenic epithelium with potential to occur in either a central or an extraosseous location. The extraosseous counterpart is designated as POdF."  "The recent WHO emphasized more on the central odontogenic fibroma and briefly mentioned about the POdF as being the extraosseous counterpart of the central odontogenic fibroma.
Lesions so-called as odontogenic gingival epithelial hamartoma, odontogenic epithelial hamartoma, hamartoma of dental lamina, and peripheral ameloblastic fibrodentinoma added to the controversy surrounding POdF and are currently included under the histologic spectrum of the POdF."  Several studies from different places around the world show differences in the relative frequency of odontogenic tumors. In a study of 127 cases of odontogenic tumors diagnosed at an oral diagnosis center, only one case of POdF was reported.  Peripheral odontogenic tumors are very rare. In a study with 1113 odontogenic tumors, only 4% were composed by PODF. Four out of the 207 cases are reported in the English literature with follow-up information on 31 cases recurred. 
Peripheral odontogenic fibroma can affect a wide age range, but its peak incidence occurs between the second and fourth decades of life with a slight female predilection. A higher incidence in the mandibular region, particularly on its anterior area has been reported. ,, Our case was a male patient of 53 years with the lesion in the maxillary premolar region. POdF appears as a firm, slow growing, and usually sessile gingival mass covered by normal appearing mucosa. Most lesions range between 0.5 and 1.5 cm in diameter and they rarely cause displacement of the teeth.  Our patient also exhibited a painless, firm, sessile swelling, which measured 3 cm × 2 cm with duration of 6 months. The embryonic source of POdF has been suggested by many as arising from the rest of dental lamina that has persisted in the gingiva following its disintegration. 
The histopathological features of the POdF is similar to that of the WHO type of central odontogenic fibroma.  It exhibits interwoven fascicles of cellular fibrous connective tissue, which may be interspersed with areas of less cellular myxoid connective tissue. Islands or strands of odontogenic epithelium are scattered throughout the connective tissue. The epithelial cells may show vacuolization with the presence of cementoid, dentinoid, or osteoid areas. , Similar features were evident in the histopathology of our case. The clinical differential diagnosis of POdF includes all nodular lesions which occur on the gingiva. The most common being PG, POF, and PGG. ,
Histologically, it is important to differentiate between these lesions. PG shows a vascular proliferation similar to granulation tissue. The mass also presents numerous endothelium-lined channels filled with red blood cells and a mixed inflammatory infiltrate with lymphocytes, neutrophils, and plasma cells. The surface is usually ulcerated. However, the odontogenic epithelium, a fibromyxomatous connective tissue and occasionally, sites of calcification (dentinoid, cementicles, or osteoid) which are typically presented by POdF is not seen in PG.
In peripheral ossifying fibroma, fibroblastic proliferation admixed with mineralization foci are commonly observed, presenting a cementum-like, bone or dystrophic calcification. The presence of the odontogenic epithelium seen only in POdF and the highly cellular connective tissue seen in POF are the main differences between POF and POdF.
Histologically, PGG shows more quantity of multinucleate giant cells when compared with POdF. It also presents areas of bone or dystrophic calcifications. However, PGG mass has a characteristic hemorrhage, deposits of hemosiderin, and a high quantity of ovoid spindle cells - commonly on its peripheral region.
A study on histological predictors of recurrence concluded that budding of basal cell layer of the surface squamous epithelium was associated with higher recurrence and the presence of calcification in direct apposition to the epithelial rest was associated with lower recurrence.  Our case exhibited budding of the basal cell, which might have been the reason for its recurrence.
Learning points/take home messages
- POdF should be included in the differential diagnosis of swellings involving the gingiva
- Presence of basal cell layer budding is associated with increased recurrence
- These issues necessitate regular postoperative follow-up for early detection of recurrence.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]