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and neoplastic conditions. Some of these conditions are discussed elsewhere in Medscape
Reference. For example, the term epulis fissuratum refers to epithelial and fibrous hyperplasia
specifically related to, and the result of, trauma from the border of a removable denture. It may
be viewed as the mucosal counterpart of acanthoma fissuratum.
See the image below depicting fibrous tumorlike growth of the oral soft tissues.
Fibroma
The fibroma, also referred to as irritation fibroma, is by far the most common of the oral fibrous
tumorlike growths. While the terminology implies a benign neoplasm, most if not all fibromas
represent reactive focal fibrous hyperplasia due to trauma or local irritation. Although the term
focal fibrous hyperplasia more accurately describes the clinical appearance and pathogenesis of
this entity, it is not commonly used.
A fibroma may occur at any oral site, but it is seen most often on the buccal mucosa along the
plane of occlusion of the maxillary and mandibular teeth as depicted below. It is a round-toovoid, asymptomatic, smooth-surfaced, and firm sessile or pedunculated mass. The diameter may
vary from 1 mm to 2 cm. The surface may be hyperkeratotic or ulcerated, owing to repeated
trauma.
The clinical differential diagnosis of a fibroma includes giant cell fibroma, neurofibroma,
peripheral giant cell granuloma, mucocele, and benign and malignant salivary gland tumors (eg,
see Salivary Gland Neoplasms).
Histologically, a fibroma is an unencapsulated, solid, nodular mass of dense and sometimes
hyalinized fibrous connective tissue that is often arranged in haphazard fascicles. A mild chronic
inflammatory infiltrate may be present. The surface epithelium may be hyperkeratotic, either
hyperplastic or atrophic, and it may be ulcerated. Conservative excisional biopsy is curative, and
its findings are diagnostic. Recurrence is possible, however, if the offending irritant persists.[1, 2]
Unusual subtypes
Sclerotic fibroma: The sclerotic fibroma was first described as a component of Cowden
syndrome. It is an uncommon benign fibrous neoplasm that occurs most commonly in the
skin and may be solitary or multifocal. Both sporadic sclerotic fibromas and those
associated with the syndrome have also been described in the oral cavity, mainly in the
buccal and labial mucosa. The tumor is a well-delineated but unencapsulated mass of
densely collagenized, hypocellular fibrous tissue with a storiform pattern and prominent
clefts between collagen bundles. The tumor cells are CD34 and vimentin positive.[5, 6]
Conservative excisional biopsy is curative, and its findings are diagnostic. Recurrence is rare.[2, 7]
Peripheral odontogenic fibroma of the mandibular gingiva in a 9year-old girl. Courtesy of Dr W. Reid.
The clinical differential diagnosis of a peripheral odontogenic fibroma includes inflammatory
gingival hyperplasia, peripheral cemento-ossifying fibroma, and peripheral giant cell granuloma.
Microscopically, the tumor consists of an unencapsulated mass of interwoven cellular fibrous
connective tissue that contains scattered nests or strands of odontogenic epithelium. Myxoid foci,
osteoid, cementoid, or dystrophic calcifications are sometimes seen. The surface generally is not
ulcerated.
Treatment consists of conservative excision performed with care to maintain or reestablish the
gingival architecture and periodontal integrity. Recurrence is rare.[10]
Fibromatosis
The fibromatoses represent a group of infiltrating fibrous proliferations with a biologic behavior
and microscopic appearance intermediate between those of benign fibrous lesions and
fibrosarcomas. In the head and neck region, they are sometimes referred to as juvenile or
aggressive juvenile fibromatoses. Patients of any age may be affected, but three quarters of all
cases are diagnosed when the patient is younger than 10 years. No significant sex predilection is
apparent.
The most frequent site of occurrence is the soft tissues adjacent to the mandible. Intraoral
presentations are rare, but they most often involve the tongue or buccal mucosa. Lesions appear
as firm, painless, poorly demarcated masses with a variable growth rate. They are locally
aggressive and often cause resorption of the underlying bone when present. A desmoplastic
fibroma occurring within the medullary cavity of bone is considered to be the intraosseous
counterpart of the soft tissue fibromatosis.[16]
The differential diagnosis of a soft tissue fibromatosis is myofibroma and rhabdomyosarcoma.
Microscopically, fibromatosis is characterized by a poorly delineated, infiltrating cellular
proliferation of mature spindle cells arranged in streaming and interlacing fascicles. Collagen
production is usually prominent. Infiltration of the adjacent structures is common at the
periphery, but cellular atypia is not present.
Treatment consists of wide excision. The reported recurrence rate of 24% for oral fibromatosis is
considerably lower than the 50-70% rate reported for fibromatoses of the entire head and neck
region.[17, 18, 19, 20, 21, 22, 23, 24]
Gingival fibromatosis deserves separate consideration. It may be hereditary, idiopathic, or drug
induced. The hereditary and idiopathic forms manifest as isolated or diffuse firm,
noninflammatory enlargements of the keratinized gingiva. Although the process is typically
nonpainful, the enlarged gingiva may eventually cover large portions of the clinical crowns of
teeth and erode the underlying bone. Recurrence is common following surgical excision. The
hereditary form may also manifest as a component of a larger complex syndrome (eg, gingival
fibromatosis with hypertrichosis syndrome, Zimmermann-Laband syndrome, Cross syndrome).
Both the idiopathic and hereditary forms are rare, limited to the gingiva, and most often affect
children. Drug-induced gingival overgrowth has been associated with systemic use of phenytoin,
cyclosporin, and calcium channel blockers.[25, 26, 27]