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INTRODUCTION

 In oral cavities most frequently found
overgrowths are local and benign in nature. The etiological factors for these
lesions can be attributed to irritants like plaque, calculus, restorations,
overhanging margins of crowns & bridges.1 Different types of
localized reactive lesions may occur in the oral cavity, including focal
fibrous hyperplasia, pyo-genic granuloma, peripheral giant cell granuloma and
peripheral ossifying fibroma. It is said that the majority of the fibromas (a benign fibrous tumour of connective
tissue) occurring in the oral cavity are reactive in nature and represent
a reactive hyperplasia of fibrous connective tissue in response to local
irritation or trauma rather than being a true neoplasm.2 Traumatic
or irritational fibroma is a common benign exophytic and reactive oral lesion
that develops secondary to injury. Fibroma is a result of a chronic repair
process that includes granulation tissue and scar formation resulting in a
fibrous submucosal mass. Recurrences of traumatic fibroma are rare and may be caused
by repetitive trauma at the same site.3 Mobility
and/or migrations of adjacent teeth are occasionally observed. The lesion
does not have a risk for malignancy and could be excised surgically. Traumatic
or irritational fibromas are very common e.g. denture epulis but we report such
a case of traumatic fibroma on the hard palate in the age of 14 years old
female patient.

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CASE REPORT

 

A
14 year old female patient reported to the department of Periodontology of Teerthankar
Mahaveer College of dentistry and research centre, Moradabad with a complaint
of soft tissue growth behind upper front teeth. The growth started as a peanut
size six months back and was interfering with chewing and felt
uncomfortable and then diagnosed to current size. Clinical examination revealed
that lower anterior teeth was impinging on anterior palatal region, having deep
bite with 4 mm over jet (fig 1) which causes whites red colored exophytic
growth which was oval in shape with a pedunculated base. It was present on the anterior
palate region of 11 and 21 as shown in (fig 2). Labial migration of tooth 21 is
also seen with increase of lesion (fig 3).  On palpation tenderness was present and growth
was pedunculated with base stalk
is attached at base, it was soft to firm in consistency and did not bleed on
palpation and surface was not smooth. On the basis of history and clinical
findings, it was diagnosed as traumatic fibroma. Pyogenic granuloma, Peripheral
giant cell granuloma, and neurofibroma were considered under differential
diagnosis. Routine blood investigation was within normal limits. IOPAR of 11, 21,
revealed slight
horizontal bone loss, widening of pdl space around tooth and loss of lamina
dura at apical region to cervical 1/3 region of teeth (fig 4), pulp vitality
test i.r.t. 21, 22, 11, 12 shows vital pulp with base line 3 of all teeth.
Under local anesthesia with adrenalin 1:80000, the mass was excised completely
with Bard Parker handle no. 3 and 15 no. blade with aggressive curettage of the
surrounding tissue with universal curette of Hu friedy no. 2r/2l (fig 5),
followed by application of coe-pack retained by pre-fabricated customized
splint (fig 6). The removed mass measured 10mm x 15mm in width and length
respectively (fig 7). The tissue was sent for histological examination. The H
& E stained section under low magnification, 4x: shows epithelium overlying
fibro-vascular connective tissue stroma (fig 8). Under higher magnification,
40x: the epithelium was para- keratinized stratified squamous type showing few
areas of hyperplasia showing degenerative changes of superficial epithelial
cells (fig 9). Connective tissue stroma was fibro vascular comprising of
numerous budding and proliferating endothelial lined blood capillaries of
varying sizes filled with RBC’s. stroma also showed dense bundles of collagen
fiber along with fibroblasts and few inflammatory cells infiltrate chiefly
consisting of lymphocytes,
confirming
the diagnosis of traumatic fibroma. Patient reported for follow up examination
at 7 days (splint was removed) (fig 10) and at 1 months interval (fig 11) post-operatively
and was free of recurrence.

 

Learning
points

·       
Aetiology
of irritational fibroma may be traumatic tooth or restoration or prosthesis, which
should be corrected.

·       
Surgical
excision is the treatment of choice.

·       
Histology
will show typical dense fibrous tissue with relatively few cells.

 

 

DISCUSSION

Traumatic
fibroma is most commonly seen in older adults but can occur at any age. It
affects 1-2% of adults. It is usually due to chronic irritation such as rubbing
from a rough tooth, cheek or lip biting, dentures or other dental prostheses.4

Hormonal
influences may play a role too, as the lesions have shown a female
predilection, with increasing occurrence in the second decade of age and
declining incidence after the third decade.5

According
to Barker and Lucas, irritation
fibroma is to be differentiated from true fibroma by pattern of collagen
arrangement (radiating and circular pattern in irritation fibroma) and has 66%
female predilection and can occur at any age, but is usually seen in the 4th
to 6th decades of life.6
This pedunculated and uncapsulated lesion with pseudoepitheliomatous
hyperplasia, chronic inflammatory infiltrate mainly plasma cells in submucosa
and typical collagen pattern favours the diagnosis of traumatic or irritation
fibroma than true fibroma.7

 

Cooke called all the pedunculated
swelling from a mucosal surface as “polyp” (fibro epithelial polyp), where
maximum number of lesions occurred on the mucosa in the line of occlusion, and
the entire pedunculated and sessile lesion in the gingiva as “epulides”
(fibrous epulides), which commonly occurred in the maxillary anterior region.8

 

Fibroma mostly affects the buccal
mucosa along plane of occlusion of maxillary and mandibular teeth,9 but in our case traumatic
injury might be the main causative factor. This asymptomatic and pedunculated
growth having epithelial hyperplasia and connective tissue stroma with mature
collagen fibers and scattered fibroblast and fibrocytes and moderate
vascularity favors the diagnosis of traumatic fibroma at anterior palate.

 

Traumatic fibroma presents
as a firm smooth soft tissue growth in the mouth. It is usually the same colour
as the rest of the mouth lining but is sometimes paler or, if it has bled, may
look a dark colour. The surface may be ulcerated due to trauma, or become rough
and scaly. It is usually dome-shaped but may be on a short stalk like a polyp
(pedunculated). Common sites include the sides of the hard palate, tongue, gums
and inside the lower lip.4

 

Apart from the feel
and appearance, traumatic fibroma does not cause any symptoms. It develops over
weeks or months to reach a maximum size usually about 1cm in diameter, but can
sometimes be larger. Traumatic fibroma is usually a solitary lesion. When
mutiple lesions are seen, associated diagnoses need to be considered including
tuberous sclerosis, familial fibromatosis and fibrotic papillary hyperplasia of
the palate.

 

Pyogenic
granuloma (PG) is another condition which can occur in any sites of oral
mucosa. Usual character of PG is bleeding on trauma but longlasting untreated
case becomes fibrosed and bleeding may not occur. In fibrotic PG, residual
granulation tissue usually persists,10
 which is accordance to
histological findings of this case report.

 

The diagnosis of traumatic fibroma will be suspected
clinically when it presents with the usual history and examination findings. An
excisional biopsy may be taken to exclude other conditions or to remove the
lesion. Histology will then show typical dense fibrous tissue with relatively
few cells. The overlying epithelium may be ulcerated, thinned or thickened.

 

Treatment
is usually with surgical excision. Prognosis of traumatic fibroma is usually
good, recurrence is rare or uncommon; However cook
in his review reported 3 cases recurrences out of 78 biopsy specimens.8 The recurrence
has been attributed to incomplete initial removal, repeated injury and/or the
persistent of local irritants. It is therefore also important to manage the
source of the irritation and regular follow-up is required.11

 

 

 

CONCLUSION

Traumatic
fibroma clinically resembles with other lesions named as peripheral giant cell
granuloma and pyogenic granuloma. So there should be proper histo-pathological
investigation and radiographic evaluation are necessary for accurate and final
diagnosis.

 

 

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