Introduction
The cemento-ossifying fibroma is a relatively uncommon tumor like growth of oral cavity. It probably does not represent a true neoplasm but rather is a reactive lesion caused by local irritation or trauma. The overgrowth shows various histological tissue components in the connective tissue like cementum & bone. Management of such lesion is a difficult task which needs careful clinical, radiographic, histopathological evaluation & well planned aseptic surgical procedures.
Case Report
A 43 year old female patient reported with complaints of increase in size and change in color of gums in the maxillary anterior region since 1 year. Patient’s medical history was not contributory. However, he reported intermittent bleeding from gums & food lodgment in the interdental area of the teeth associated with the lesion. He used a wooden stick to clean the lodged food. Overall oral hygiene of the patient was poor. She also complained of mobility of maxillary anterior & foul smell from the oral cavity.
Intra-oral examination revealed a solitary, reddish-pink, non-ulcerated, soft, slightly bleeding, non tender, pedunculated lesion approximately of size 2 X 3 cm which was present in relation with maxillary central & lateral incisors on labial side. The lesion was extending from papillary gingiva of maxillary central & lateral incisors and apico-coronally from the base of the vestibule to the incisor 2/3rd of the incisors. The associated teeth were grade III mobile.
The intra-oral periapical (IOPA) radiograph showed severe horizontal bone loss associated with maxillary anterior teeth. The bone loss was extending up to the apical 1/3rd of roots of maxillary anterior teeth.(central & lateral incisors)
Based on clinical & radiographic findings a provisional diagnosis of Inflammatory Fibrous Hyperplasia / Pyogenic Granuloma was made.
Treatment
Laboratory investigations for the hematological parameters were done, which were found to be within normal range. Thorough scaling and root planning was done to eliminate the local irritating factors from the oral cavity & also to reduce the inflammatory component in the tissue. Patient was recalled after 1 week for surgical excision of gingival overgrowth.
After 1 week patient reported back. A surgical excision of the lesion was planned. The area was anaesthetized by local anesthesia given by local infiltration. The area was swabbed with 2% chlorhexidine digluconate. The lesion was then completely excised, involving normal tissue peripherally with the help of bard parker blade number 11. The adjacent teeth i.e. maxillary left central & lateral incisors were extracted as they were having hopeless prognosis. The adjacent tooth surfaces were scaled & root planed to remove the local irritating factors. The excised tissue measured approximately 2 X 3 cm. the rough wound surface was thoroughly cleaned and debridement was done. The surgical site was sutured with 3-0 mersilk suture. Patient was given post surgical medications & instructions. He was prescribed Tablet Ibupara (Ibuprofen + Paracetamol), twice daily for 5 days & 0.2 % chlorhexidine digluconate mouth rinse, 10-15 ml, twice daily for 7 days. The excised tissue was sent for histological examination. Patient was recalled after 1 week.
Following 1 week, the three sutures were removed & operated area was gently irrigated with normal saline & local deposits were removed with the help of curette. Healthy appearing granulation tissue was observed which was left undisturbed. Patient was again discharged with instructions regarding oral hygiene maintenance and was asked to continue the use of 0.2 % chlorhexidine digluconate mouth rinse, 10-15 ml, twice daily for 7 days. He was recalled after 3 weeks.
Patient reported after 1 month, at this time, a complete epithelization of wound was observed. Marginal plaque deposits were observed, the plaque was removed and the patient was informed about the recurrence potential of the lesion following persistence of local irritating factors. Patient was again recalled after 1 month. After which he was planned to send for prosthetic treatment to replace the extracted maxillary left central & lateral incisor.
Histopathology
The lesional tissue was lined by parakeratinized stratified squamous epithelium. The connective tissue was composed of fibro cellular stroma, inflammatory cell infiltration chiefly composed of lymphocytes & plasma cells, numerous blood vessels & basophilic masses resembling osseous & cemental tissue. The histological examination of the lesion confirmed the diagnosis of peripheral cemento-ossifying fibroma.
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