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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 52-55

Platelet-rich fibrin for the management of an unusual case of gingival peripheral odontogenic myxoma


1 Department of Periodontology, HP Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
3 Department of Oral Medicine and Radiology, HP Government Dental College, Shimla, Himachal Pradesh, India

Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Deepak Sharma
Department of Periodontology, HP Government Dental College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GFSC.GFSC_9_19

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  Abstract 


Odontogenic myxoma (OM) is a rare, benign neoplasm and is often located in the maxillofacial region. Clinical, radiological, and histopathological features should be considered when making a diagnosis. Several of these characteristics overlap with those of other benign and some malignant tumors. Soft-tissue localization that is classified as a peripheral myxoma is rarely seen than central localization. Peripheral myxoma is slowly growing and less aggressive compared to central myxoma and has a low recurrence rate. The probability that small peripheral OMs (POMs) are interpreted as edematous irritation fibromas may contribute to the small number of POMs recorded in literature. The treatment plan should consider the age and sex of the patient and the site and size of the lesion. In this report, the application of platelet-rich fibrin in the management of an unusual case of POM located on the gingiva in the posterior maxillary gingival region is presented.

Keywords: Histopathological features, odontogenic myxoma, peripheral odontogenic myxoma, platelet-rich fibrin


How to cite this article:
Sharma D, Gulati A, Jhingta P, Kumar B. Platelet-rich fibrin for the management of an unusual case of gingival peripheral odontogenic myxoma. Int J Growth Factors Stem Cells Dent 2019;2:52-5

How to cite this URL:
Sharma D, Gulati A, Jhingta P, Kumar B. Platelet-rich fibrin for the management of an unusual case of gingival peripheral odontogenic myxoma. Int J Growth Factors Stem Cells Dent [serial online] 2019 [cited 2020 Apr 4];2:52-5. Available from: http://www.cellsindentistry.org/text.asp?2019/2/3/52/273715




  Introduction Top


WHO's classification of odontogenic tumors classifies myxoma as a tumor of the odontogenic mesenchyma, with or without the presence of odontogenic epithelium.[1]

Odontogenic myxoma (OM) is a locally invasive neoplasm unique to the tooth-bearing areas of the jaw bones and is believed to arise from odontogenic ectomesenchyme of the dental follicle. Remnants of odontogenic ectomesenchyme are found in the periodontal ligament (radicular part of the tooth follicle) and gingiva (coronal part of the tooth follicle) in adult jaw, so these locations could potentially serve as a stem cell population for neoplastic proliferations. Although OM is generally considered to be a rare odontogenic neoplasm, it appears to be more frequent in Africa than in other parts of the world.[2],[3] OMs are more common in females and occur over a wide age range, with an average age at presentation of 31.3 years.[2] By far, the most common type of OM is the central variety known as central OM (COM) which develops from odontogenic ectomesenchyme located within the periodontal ligament space. The reported incidences of peripheral OM (POM) are significantly below those of other peripheral odontogenic tumors such as peripheral ameloblastoma (1% of all ameloblastomas) and peripheral odontogenic fibroma (the total number of reported cases is over 150).[4]

Microscopic examination of a representative biopsy is important for the accurate diagnosis of myxoid soft-tissue neoplasms in any location. OMs show little encapsulation and the growth may be quite rapid due to the accumulation of mucoid ground substance, thereby mimicking an aggressive neoplasm. Histopathologically, POM is similar to COM consisting of cellular fibrous connective tissue composed of haphazardly arranged stellate, spindle-shaped, round cells in a loose myxoid stroma containing nonneoplastic vacuolated odontogenic epithelium ranging from scanty to numerous.[4]

Platelet-rich fibrin (PRF) represents a new revolutionary step in the platelet gel therapeutic concept. Unlike other platelet concentrates, this technique does not require any gelifying agent, but only centrifugation of the natural blood without additives. The slow polymerization mode confers to the resulting PRF membrane a particularly favorable physiologic architecture to support the healing process.[5]


  Case Report Top


A 38-year-old female reported to the outpatient clinic with complaints of a painless, gradually progressive firm swelling of 2-year duration on the right side of the maxilla in relation to the gingiva of the molars. The swelling was oval, reddish-pink, and sessile with smooth and shiny surface with dimensions of 2 cm × 2 cm × 1 cm [Figure 1]. On palpation, the swelling was nontender, firm in consistency, noncompressible, and fixed to the underlying mucosa located in the maxillary right second molar gingival region. A preoperative intraoral periapical radiograph revealed no radiographic changes [Figure 2]. Medical history was insignificant. On the basis of clinical and radiographic examination, the differential diagnoses were irritational fibroma, peripheral giant cell granuloma, pyogenic granuloma, and peripheral ossifying fibroma. Excisional biopsy and curettage were performed under local anesthesia [Figure 3]. PRF was prepared from the patient's blood using venipuncture and centrifuged at 3000 rpm for 10 min without any additive [Figure 4]. The PRF was collected and placed on the postoperative surgical site over the exposed bone [Figure 5] and sutured with 5–0 silk suture. Oral hygiene instructions which included the use of a 0.2% chlorhexidine mouthrinse was advised to the patient. The patient did not report any complaints of pain, swelling, bleeding, or discomfort during the postoperative phase. The lesion did not show any recurrence and was followed for 1 year [Figure 6].
Figure 1: Preoperative view of the lesion: oval shaped, reddish-pink-colored, sessile, well-circumscribed mass in the maxillary molar buccal gingiva

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Figure 2: Intraoral periapical radiograph view of the lesion with normal bone architecture

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Figure 3: Excision of the lesion

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Figure 4: Platelet-rich fibrin collection

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Figure 5: Placement of platelet-rich fibrin over denuded bone

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Figure 6: Postoperative healed lesion at 1-year follow-up visit

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Histopathological examination of the resected specimen with hematoxylin and eosin staining revealed stratified squamous epithelium with mild hyperkeratosis, parakeratosis, and acanthosis with subepithelial mild-to-moderate lymphoplasmacytic infiltrate. The subepithelial tissue revealed the lesion with loosely arranged stellate and fusiform cells with cytoplasmic processes and intertwining strands of collagen, dispersed in a background of loose and abundant mesenchyme. Vascularity was sparse, mainly of fine capillaries. Nests or islands of odontogenic epithelium were not seen, and a histopathological diagnosis of POM was made by the pathologist [Figure 7] and [Figure 8].
Figure 7: Histopathology microphotograph showing parakeratinized squamous epithelial cells in loosely arranged myxoid connective tissue

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Figure 8: Histopathology microphotograph showing stellate and spindle cells in myxoid connective tissue

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  Discussion Top


Myxoma of the jaw was first reported by Thoma and Goldman in the year 1947.[6] It usually occurs in the second and third decades of life and is more commonly seen in the maxilla than the mandible, with slightly more predilection for females.[7]

POM is reported to present clinically as an exophytic gingival mass; the overlying epithelium is generally unaffected and no bony involvement is present.[8] The same characteristic features of POM were present in this case. The total number of reported cases of POM in literature is <6.[9] In this case, POM is located peripherally in the gingiva of the posterior maxillary region, which is very uncommon. A differential diagnosis of OMs should include odontogenic mesenchymal tumors and nonodontogenic tumors with myxomatous degeneration, such as myxoid neurofibroma and myxoid chondrosarcoma.[10] Clinical, radiological, and histopathological features should be considered when making a diagnosis. Intraoral treatment approaches such as enucleation and curettage have been described as an effective treatment procedure for POMs due to the low recurrence rate.[10] Our case of soft-tissue myxoma was slow growing and localized in nature and was completely removed by local surgical excision and covered by PRF to accelerate epithelization and healing. Subjective symptoms of postoperative pain, sensitivity, and discomfort were minimal with the use of PRF as reported by the patient. There was no recurrence of the lesion 12 months after the surgery. Clinical evaluation showed excellent healing of the exposed bone where primary closure with sutures was not possible. Newly formed tissues blend well with color and texture to the surrounding tissue. Due to mechanical function, a rapid angiogenesis-promoting ability, and an easier remodeling of fibrin in a more resistant connective tissue, PRF membrane is a viable material for all types of superficial cutaneous and mucosal healing.[11]


  Conclusion Top


POM located in the posterior maxillary gingival region is an uncommon occurrence. The management includes surgical excision of the lesion. The exposed bone under the excised lesion is covered with PRF membrane. The PRF membrane protects open wounds and accelerates healing, favors the development of microvascularization, and also guides epithelial cell migration to its surface. The efficacy of the PRF treatment in sites where primary surgical closure cannot be achieved lies in the local delivery of a wide range of growth factors and proteins on a fibrin mesh, mimicking and supporting physiological wound healing and reparative tissue processes, thereby resulting in an uneventful esthetic wound healing. This case report shows an innovative technique of enhancement of healing by local application of PRF as a biological dressing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pindborg JJ, Kramer IR. Jaw cysts and allied lesions: International histological classification of tumors. Histological Typing of Odontogenic Tumors. No. 5. Geneva: World Health Organization; 1971.  Back to cited text no. 1
    
2.
Noffke CE, Raubenheimer EJ, Chabikuli NJ, Bouckaert MR. Odontogenic myxoma: Review of the literature and report of 30 cases from South Africa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:101-9.  Back to cited text no. 2
    
3.
Ladeinde AL, Ajayi OF, Ogunlewe MO, Adeyemo WL, Arotiba GT, Bamgbose BO, et al. Odontogenic tumors: A review of 319 cases in a Nigerian teaching hospital. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:191-5.  Back to cited text no. 3
    
4.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2nd ed. China: Saunders; 2002. p. 618-37.  Back to cited text no. 4
    
5.
Naik B, Karunakar P, Jayadev M, Marshal VR. Role of platelet rich fibrin in wound healing: A critical review. J Conserv Dent 2013;16:284-93.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Thoma KH, Goldman HM. Central myxoma of the jaw. Oral Surg Oral Med Oral Pathol 1947;33:B532-40.  Back to cited text no. 6
    
7.
Slootweg PJ, Wittkampf AR. Myxoma of the jaws. An analysis of 15 cases. J Maxillofac Surg 1986;14:46-52.  Back to cited text no. 7
    
8.
Perrotti V, Rubini C, Fioroni M, Piattelli A. Soft tissue myxoma: Report of an unusual case located on the gingiva. J Clin Periodontol 2006;33:76-8.  Back to cited text no. 8
    
9.
Raubenheimer EJ, Noffke CE. Peripheral odontogenic myxoma: A review of the literature and report of two cases. J Maxillofac Oral Surg 2012;11:101-4.  Back to cited text no. 9
    
10.
Aytac-Yazicioglu D, Eren H, Görgün S. Peripheral odontogenic myxoma located on the maxillary gingiva: Report of a case and review of the literature. Oral Maxillofac Surg 2008;12:167-71.  Back to cited text no. 10
    
11.
Corso MD, Toffler M, Ehrenfest DM. Use of an autologous leukocyte and platelet rich fibrin (L PRF) membrane in post avulsion sites: An overview of Choukroun's PRF. J Implant Adv Clin Dent 2010;1:27-35.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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