Chapter 12 SOFT TISSUE TUMORS
Fig. 12-6 Fibroma. Low-power view showing an exophytic
nodular mass of dense fibrous connective tissue.
Fig. 12-7 Fibroma. Higher-power view demonstrating
dense collagen beneath the epithelial surface.
HISTOPATHOLOGIC FEATURES
Microscopic examination of the irritation fibroma
shows a nodular mass of fibrous connective tissue
covered by stratified squamous epithelium (Figs. 12-6
and 12-7). This connective tissue is usually dense and
collagenized, although in some cases it is looser in
nature. The lesion is not encapsulated; the fibrous
tissue instead blends gradually into the surrounding
connective tissues. The collagen bundles may be
arranged in a radiating, circular, or haphazard fashion.
The covering epithelium often demonstrates atrophy of
the rete ridges because of the underlying fibrous mass.
However, the surface may exhibit hyperkeratosis from
secondary trauma. Scattered inflammation may be
509
Fig. 12-8 Giant cell fibroma. Exophytic nodule on the
dorsum of the tongue.
seen, most often beneath the epithelial surface. Usually
this inflammation is chronic and consists mostly of
lymphocytes and plasma cells.
TREATMENT AND PROGNOSIS
The irritation fibroma is treated by conservative surgical
excision; recurrence is extremely rare. However, it is
important to submit the excised tissue for microscopic
examination because other benign or malignant tumors
may mimic the clinical appearance of a fibroma.
Because frenal tags are small, innocuous growths
that are easily diagnosed clinically, no treatment is
usually necessary.
GIANT CELL FIBROMA
The giant cell fibroma is a fibrous tumor with distinc-
tive clinicopathologic features. Unlike the traumatic
fibroma, it does not appear to be associated with
chronic irritation. The giant cell fibroma represents
approximately 2% to 5% of all oral fibrous proliferations
submitted for biopsy.
CLINICAL FEATURES
The giant cell fibroma is typically an asymptomatic
sessile or pedunculated nodule, usually less than 1 cm
in size (Fig. 12-8). The surface of the mass often appears
papillary; therefore, the lesion may be clinically mis-
taken for a papilloma. Compared with the common
irritation fibroma, the lesion usually occurs at a younger
age. In about 60% of cases, the lesion is diagnosed
during the first 3 decades of life. Some studies have
suggested a slight female predilection. Approximately
50% of all cases occur on the gingiva. The mandibular
gingiva is affected twice as often as the maxillary
gingiva. The tongue and palate also are common sites.
510 ORAL AND MAXILLOFACIAL PATHOLOGY
Fig. 12-9 Retrocuspid papilla. Bilateral papular lesions on
the gingiva lingual to the mandibular canines (arrows).
The retrocuspid papilla is a microscopically similar
developmental lesion that occurs on the gingiva lingual
to the mandibular cuspid. It is frequently bilateral and
typically appears as a small, pink papule that measures
less than 5 mm in diameter (Fig. 12-9). Retrocuspid
papillae are quite common, having been reported in
25% to 99% of children and young adults. The preva-
lence in older adults drops to 6% to 19%, suggesting that
the retrocuspid papilla represents a normal anatomic
variation that disappears with age.
HISTOPATHOLOGIC FEATURES
Microscopic examination of the giant cell fibroma
reveals a mass of vascular fibrous connective tissue,
which is usually loosely arranged (Fig. 12-10). The hall-
mark is the presence of numerous large, stellate fibro-
blasts within the superficial connective tissue. These
cells may contain several nuclei. Frequently, the surface
of the lesion is pebbly. The covering epithelium often
is thin and atrophic, although the rete ridges may
appear narrow and elongated.
TREATMENT AND PROGNOSIS
The giant cell fibroma is treated by conservative surgi-
cal excision. Recurrence is rare. Because of their char-
acteristic appearance, retrocuspid papillae should be
recognized clinically and do not need to be excised.
EPULIS FISSURATUM (INFLAMMATORY
FIBROUS HYPERPLASIA; DENTURE
INJURY TUMOR; DENTURE EPULIS)
The epulis fissuratum is a tumorlike hyperplasia of
fibrous connective tissue that develops in association
with the flange of an ill-fitting complete or partial
denture. Although the simple term epulis sometimes is
B
Fig. 12-10 Giant cell fibroma. A, Low-power view
showing a nodular mass of fibrous connective tissue covered
by stratified squamous epithelium. Note the elongation of the
rete ridges. B, High-power view showing multiple large
stellate-shaped and multinucleated fibroblasts.
used synonymously for epulis fissuratum, epulis is actu-
ally a generic term that can be applied to any tumor of
the gingiva or alveolar mucosa. Therefore, some authors
have advocated not using this term, preferring to call
these lesions inflammatory fibrous hyperplasia or other
descriptive names. However, the term epulis fissuratum
is still widely used today and is well understood by
virtually all clinicians. Other examples of epulides
include the giant cell epulis (peripheral giant cell
granuloma) (see page 520), ossifying fibroid epulis
(peripheral ossifying fibroma) (see page 521), and
congenital epulis (see page 537).
CLINICAL FEATURES
The epulis fissuratum typically appears as a single or
multiple fold or folds of hyperplastic tissue in the alveo-
lar vestibule (Figs. 12-11 and 12-12). Most often, there
are two folds of tissue, and the flange of the associated
denture fits conveniently into the fissure between the
folds. The redundant tissue is usually firm and fibrous,
although some lesions appear erythematous and ulcer-
 Chapter 12 SOFT TISSUE TUMORS
Fig. 12-11 Epulis fissuratum. Hyperplastic folds of tissue
in the anterior maxillary vestibule.
A The epulis fissuratum most often occurs in middle-
B narrow stalk (Fig. 12-14). Usually, the flattened mass
Fig. 12-12 Epulis fissuratum. A, Several folds of
hyperplastic tissue in the maxillary vestibule. B, An ill-fitting
denture fits into the fissure between two of the folds. (Courtesy
of Dr. William Bruce.)
ated, similar to the appearance of a pyogenic granu-
loma. Occasional examples of epulis fissuratum
demonstrate surface areas of inflammatory papillary
hyperplasia (see page 512). The size of the lesion can
vary from localized hyperplasias less than 1 cm in size
to massive lesions that involve most of the length of the
511
Fig. 12-13 Epulis fissuratum. Redundant folds of tissue
arising in the floor of the mouth in association with a
mandibular denture.
vestibule. The epulis fissuratum usually develops on
the facial aspect of the alveolar ridge, although occa-
sional lesions are seen lingual to the mandibular alveo-
lar ridge (Fig. 12-13).
aged and older adults, as would be expected with a
denture-related lesion. It may occur on either the
maxilla or mandible. The anterior portion of the jaws
is affected much more often than the posterior areas.
There is a pronounced female predilection; most
studies show that two thirds to three fourths of all cases
submitted for biopsy occur in women.
Another similar but less common fibrous hyperpla-
sia, often called a fibroepithelial polyp or leaflike
denture fibroma, occurs on the hard palate beneath
a maxillary denture. This characteristic lesion is a flat-
tened pink mass that is attached to the palate by a
is closely applied to the palate and sits in a slightly
cupped-out depression. However, it is easily lifted up
with a probe, which demonstrates its pedunculated
nature. The edge of the lesion often is serrated and
resembles a leaf.
HISTOPATHOLOGIC FEATURES
Microscopic examination of the epulis fissuratum
reveals hyperplasia of the fibrous connective tissue.
Often multiple folds and grooves occur where the
denture impinges on the tissue (Fig. 12-15). The overly-
ing epithelium is frequently hyperparakeratotic and
demonstrates irregular hyperplasia of the rete ridges.
In some instances, the epithelium shows inflammatory
papillary hyperplasia (see page 513) or pseudoepithe-
liomatous (pseudocarcinomatous) hyperplasia. Focal
areas of ulceration are not unusual, especially at the
512 ORAL AND MAXILLOFACIAL PATHOLOGY
Fig. 12-14 Fibroepithelial polyp. Flattened mass of tissue
arising on the hard palate beneath a maxillary denture; note
its pedunculated nature. Because of its serrated edge, this
lesion also is known as a leaflike denture fibroma. Associated
inflammatory papillary hyperplasia is visible in the palatal
midline.
Fig. 12-15 Epulis fissuratum. Low-power photomicrograph
demonstrating folds of hyperplastic fibrovascular connective
tissue covered by stratified squamous epithelium.
base of the grooves between the folds. A variable
chronic inflammatory infiltrate is present; sometimes,
it may include eosinophils or show lymphoid follicles.
If minor salivary glands are included in the specimen,
then they usually show chronic sialadenitis.
In rare instances, the formation of osteoid or chon-
droid is observed. This unusual-appearing product,
known as osseous and chondromatous metaplasia,
is a reactive phenomenon caused by chronic irritation
by the ill-fitting denture (see page 318). The irregular
nature of this bone or cartilage can be microscopically
disturbing, and the pathologist should not mistake it for
a sarcoma.
The denture-related fibroepithelial polyp has a
narrow core of dense fibrous connective tissue
covered by stratified squamous epithelium. Like the
epulis fissuratum, the overlying epithelium may be
hyperplastic.
TREATMENT AND PROGNOSIS
The treatment of the epulis fissuratum or fibroepithe-
lial polyp consists of surgical removal, with microscopic
examination of the excised tissue. The ill-fitting denture
should be remade or relined to prevent a recurrence
of the lesion.
INFLAMMATORY PAPILLARY
HYPERPLASIA (DENTURE
PAPILLOMATOSIS)
Inflammatory papillary hyperplasia is a reactive
tissue growth that usually, although not always, devel-
ops beneath a denture. Some investigators classify this
lesion as part of the spectrum of denture stomatitis (see
page 216). Although the exact pathogenesis is unknown,
the condition most often appears to be related to the
following:
● An ill-fitting denture
● Poor denture hygiene
● Wearing the denture 24 hours a day
Approximately 20% of patients who wear their den-
tures 24 hours a day have inflammatory papillary hyper-
plasia. Candida organisms also have been suggested as a
cause, but any possible role appears uncertain.
CLINICAL FEATURES
Inflammatory papillary hyperplasia usually occurs on
the hard palate beneath a denture base (Figs. 12-16
and 12-17). Early lesions may involve only the palatal
vault, although advanced cases cover most of the palate.
Less frequently, this hyperplasia develops on the eden-
tulous mandibular alveolar ridge or on the surface of
an epulis fissuratum. On rare occasions, the condition
occurs on the palate of a patient without a denture,
especially in people who habitually breathe through
their mouth or have a high palatal vault. Candida-
associated palatal papillary hyperplasia also has been
Chapter 12 SOFT TISSUE TUMORS
Fig. 12-16 Inflammatory papillary hyperplasia.
Erythematous, pebbly appearance of the palatal vault.
Fig. 12-17 Inflammatory papillary hyperplasia. An
advanced case exhibiting more pronounced papular lesions
of the hard palate.
reported in dentate patients with human immunodefi-
ciency virus (HIV) infection.
Inflammatory papillary hyperplasia is usually
asymptomatic. The mucosa is erythematous and has a
pebbly or papillary surface. Many cases are associated
with denture stomatitis.
HISTOPATHOLOGIC FEATURES
The mucosa in inflammatory papillary hyperplasia
exhibits numerous papillary growths on the surface
that are covered by hyperplastic, stratified squamous
epithelium (Fig. 12-18). In advanced cases, this hyper-
plasia is pseudoepitheliomatous in appearance, and
the pathologist should not mistake it for carcinoma
(Fig. 12-19). The connective tissue can vary from loose
and edematous to densely collagenized. A chronic
inflammatory cell infiltrate is usually seen, which con-
sists of lymphocytes and plasma cells. Less frequently,
513
Fig. 12-18 Inflammatory papillary hyperplasia. Medium-
power view showing fibrous and epithelial hyperplasia
resulting in papillary surface projections. Heavy chronic
inflammation is present.
Fig. 12-19 Inflammatory papillary hyperplasia. Higher-
power view showing pseudoepitheliomatous hyperplasia of
the epithelium. This epithelium has a bland appearance that
should not be mistaken for carcinoma.
polymorphonuclear leukocytes are also present. If
underlying salivary glands are present, then they often
show sclerosing sialadenitis.
TREATMENT AND PROGNOSIS
For very early lesions of inflammatory papillary hyper-
plasia, removal of the denture may allow the erythema
and edema to subside, and the tissues may resume a
more normal appearance. The condition also may
show improvement after topical or systemic antifungal
therapy. For more advanced and collagenized lesions,
many clinicians prefer to excise the hyperplastic tissue
before fabricating a new denture. Various surgical
methods have been used, including the following:
514 ORAL AND MAXILLOFACIAL PATHOLOGY

● Partial-thickness or full-thickness surgical blade

excision
● Curettage

● Electrosurgery

● Cryosurgery

● Laser surgery

After surgery, the existing denture can be lined with

a temporary tissue conditioner that acts as a palatal
dressing and promotes greater comfort. After healing,
the patient should be encouraged to leave the new
denture out at night and to keep it clean.

FIBROUS HISTIOCYTOMA
Fibrous histiocytomas are a diverse group of tumors Fig. 12-20 Fibrous histiocytoma. Nodular mass on the
dorsum of the tongue.
that exhibit fibroblastic and histiocytic differentia-
tion. Although the cell of origin is still uncertain, it
may arise from the tissue histiocyte, which then
assumes fibroblastic properties. Because of the variable
nature of these lesions, an array of terms has been used
for them, including dermatofibroma, sclerosing
hemangioma, fibroxanthoma, and nodular sub-
epidermal fibrosis. Unlike other fibrous growths
discussed previously in this chapter, the fibrous
histiocytoma is generally considered to represent a
true neoplasm.

CLINICAL FEATURES
The fibrous histiocytoma can develop almost anywhere
in the body. The most common site is the skin of the
extremities, where the lesion is called a dermatofibroma.
Tumors of the oral and perioral region are uncommon.
Although oral tumors can occur at any site, the most Fig. 12-21 Fibrous histiocytoma. Low-power view
frequent location is the buccal mucosa and vestibule. showing a moderately cellular nodular tumor of the tongue.
Rare intrabony lesions of the jaws have also been
reported. Oral fibrous histiocytomas tend to occur in
middle-aged and older adults; cutaneous examples are
most frequent in young adults. The tumor is usually
a painless nodular mass and can vary in size from a
few millimeters to several centimeters in diameter
(Fig. 12-20). Deeper tumors tend to be larger.

HISTOPATHOLOGIC FEATURES
Microscopically, the fibrous histiocytoma is character-
ized by a cellular proliferation of spindle-shaped fibro-
blastic cells with vesicular nuclei (Figs. 12-21 and
12-22). The margins of the tumor often are not sharply
defined. The tumor cells are arranged in short, inter-
secting fascicles, known as a storiform pattern because
of its resemblance to the irregular, whorled appear-
ance of a straw mat. Rounded histiocyte-like cells, Fig. 12-22 Fibrous histiocytoma. High-power view
lipid-containing xanthoma cells, or multinucleated demonstrating storiform arrangement of spindle-shaped cells
giant cells can be seen occasionally, as may scattered with vesicular nuclei.
Chapter 12 SOFT TISSUE TUMORS 517

Fig. 12-27 Oral focal mucinosis. Nodular mass arising Fig. 12-28 Oral focal mucinosis. Low-power view showing
from the gingiva between the mandibular first and second a nodular mass of loose, myxomatous connective tissue.
molars.

HISTOPATHOLOGIC FEATURES
Microscopic examination of oral focal mucinosis shows
a well-localized but nonencapsulated area of loose,
myxomatous connective tissue surrounded by denser,
normal collagenous connective tissue (Figs. 12-28 and
12-29). The lesion is usually found just beneath the
surface epithelium and often causes flattening of the
rete ridges. The fibroblasts within the mucinous area
can be ovoid, fusiform, or stellate, and they may dem-
onstrate delicate, fibrillar processes. Few capillaries
are seen within the lesion, especially compared with
the surrounding denser collagen. Similarly, no signifi-
cant inflammation is observed, although a perivascular
lymphocytic infiltrate often is noted within the sur- Fig. 12-29 Oral focal mucinosis. High-power view
demonstrating the myxomatous change.
rounding collagenous connective tissue. No apprecia-
ble reticulin is evident within the lesion, and special
stains suggest that the mucinous product is hyaluronic
acid. Instead, the pyogenic granuloma is thought to repre-
sent an exuberant tissue response to local irritation
or trauma. In spite of its name, it is not a true
TREATMENT AND PROGNOSIS granuloma.
Oral focal mucinosis is treated by surgical excision and
does not tend to recur.
CLINICAL FEATURES
The pyogenic granuloma is a smooth or lobulated mass
PYOGENIC GRANULOMA that is usually pedunculated, although some lesions are
The pyogenic granuloma is a common tumorlike sessile (Figs. 12-30 to 12-32). The surface is character-
growth of the oral cavity that traditionally has been istically ulcerated and ranges from pink to red to
considered to be nonneoplastic in nature.* Although it purple, depending on the age of the lesion. Young pyo-
was originally thought to be caused by pyogenic organ- genic granulomas are highly vascular in appearance;
isms, it is now believed to be unrelated to infection. older lesions tend to become more collagenized and
pink. They vary from small growths only a few millime-
ters in size to larger lesions that may measure several
*However, some pyogenic granulomas (also known as lobular capillary
hemangiomas) currently are categorized as vascular tumors under the clas-
centimeters in diameter. Typically, the mass is painless,
sification scheme of the International Society for the Study of Vascular although it often bleeds easily because of its extreme
Anomalies (see Box 12-2, page 539). vascularity. Pyogenic granulomas may exhibit rapid
518 ORAL AND MAXILLOFACIAL PATHOLOGY
Fig. 12-30 Pyogenic granuloma. Erythematous,
hemorrhagic mass arising from the maxillary anterior gingiva.
Fig. 12-31 Pyogenic granuloma. Ulcerated and lobulated
mass on the dorsum of the tongue.
Fig. 12-32 Pyogenic granuloma. Unusually large lesion
arising from the palatal gingiva in association with an
orthodontic band. The patient was pregnant.
growth, which may create alarm for both the patient
and the clinician, who may fear that the lesion might
be malignant.
Oral pyogenic granulomas show a striking predilec-
tion for the gingiva, which accounts for 75% of all
cases. Gingival irritation and inflammation that result
from poor oral hygiene may be a precipitating factor in
many patients. The lips, tongue, and buccal mucosa
are the next most common sites. A history of trauma
before the development of the lesion is not unusual,
especially for extragingival pyogenic granulomas.
Lesions are slightly more common on the maxillary
gingiva than the mandibular gingiva; anterior areas are
more frequently affected than posterior areas. These
lesions are much more common on the facial aspect of
the gingiva than the lingual aspect; some extend
between the teeth and involve both the facial and the
lingual gingiva.
Although the pyogenic granuloma can develop at
any age, it is most common in children and young
adults. Most studies also demonstrate a definite female
predilection, possibly because of the vascular effects of
female hormones. Pyogenic granulomas of the gingiva
frequently develop in pregnant women, so much so
that the terms pregnancy tumor or granuloma gravidarum
often are used. Such lesions may begin to develop
during the first trimester, and their incidence increases
up through the seventh month of pregnancy. The
gradual rise in development of these lesions through-
out pregnancy may be related to the increasing levels
of estrogen and progesterone as the pregnancy pro-
gresses. After pregnancy and the return of normal
hormone levels, some of these pyogenic granulomas
resolve without treatment or undergo fibrous matura-
tion and resemble a fibroma (Fig. 12-33).
Epulis granulomatosa is a term used to describe
hyperplastic growths of granulation tissue that some-
times arise in healing extraction sockets (Fig. 12-34).
These lesions resemble pyogenic granulomas and
usually represent a granulation tissue reaction to bony
sequestra in the socket.
HISTOPATHOLOGIC FEATURES
Microscopic examination of pyogenic granulomas
shows a highly vascular proliferation that resembles
granulation tissue (Figs. 12-35 and 12-36). Numerous
small and larger endothelium-lined channels are
formed that are engorged with red blood cells. These
vessels sometimes are organized in lobular aggregates,
and some pathologists require this lobular arrange-
ment for the diagnosis (lobular capillary hemangioma).
The surface is usually ulcerated and replaced by a thick
fibrinopurulent membrane. A mixed inflammatory cell
infiltrate of neutrophils, plasma cells, and lymphocytes
 Chapter 12 SOFT TISSUE TUMORS
Fig. 12-33 Pyogenic granuloma. A, Large gingival mass in
a pregnant woman just before childbirth. B, The mass has
decreased in size and undergone fibrous maturation 3
months after childbirth. (Courtesy of Dr. George Blozis.)
Fig. 12-34 Epulis granulomatosa. Nodular mass of
granulation tissue that developed in a recent extraction site.
is evident. Neutrophils are most prevalent near the
ulcerated surface; chronic inflammatory cells are found
deeper in the specimen. Older lesions may have areas
with a more fibrous appearance. In fact, many gingival
fibromas probably represent pyogenic granulomas that
have undergone fibrous maturation.
519
Fig. 12-35 Pyogenic granuloma. Low-power view showing
an exophytic mass of granulation-like tissue with an ulcerated
surface. Note the lobular endothelial proliferation in the
deeper connective tissue.
Fig. 12-36 Pyogenic granuloma. Higher-power view
showing capillary blood vessels and scattered inflammation.
TREATMENT AND PROGNOSIS
The treatment of patients with pyogenic granuloma
consists of conservative surgical excision, which is
usually curative. The specimen should be submitted for
microscopic examination to rule out other more serious
diagnoses. For gingival lesions, the excision should
extend down to periosteum and the adjacent teeth
should be thoroughly scaled to remove any source of
continuing irritation. Occasionally, the lesion recurs
and reexcision is necessary. In rare instances, multiple
recurrences have been noted.
For lesions that develop during pregnancy, usually
treatment should be deferred unless significant func-
tional or aesthetic problems develop. The recurrence
rate is higher for pyogenic granulomas removed during
pregnancy, and some lesions will resolve spontane-
ously after parturition.
520 ORAL AND MAXILLOFACIAL PATHOLOGY
Fig. 12-37 Peripheral giant cell granuloma. Nodular
blue-purple mass of the mandibular gingiva.
PERIPHERAL GIANT CELL
GRANULOMA (GIANT CELL EPULIS)
The peripheral giant cell granuloma is a relatively
common tumorlike growth of the oral cavity. It proba-
bly does not represent a true neoplasm but rather is a
reactive lesion caused by local irritation or trauma. In
the past, it often was called a peripheral giant cell repara-
tive granuloma, but any reparative nature appears doubt-
ful. Some investigators believe that the giant cells show
immunohistochemical features of osteoclasts, whereas
other authors have suggested that the lesion is formed
by cells from the mononuclear phagocyte system. The
peripheral giant cell granuloma bears a close micro-
scopic resemblance to the central giant cell granu-
loma (see page 626), and some pathologists believe
that it may represent a soft tissue counterpart of this
central bony lesion.
CLINICAL AND RADIOGRAPHIC
FEATURES
The peripheral giant cell granuloma occurs exclusively
on the gingiva or edentulous alveolar ridge, presenting
as a red or red-blue nodular mass (Figs. 12-37 and
12-38). Most lesions are smaller than 2 cm in diameter,
although larger ones are seen occasionally. The lesion
can be sessile or pedunculated and may or may not be
ulcerated. The clinical appearance is similar to the
more common pyogenic granuloma of the gingiva (see
page 517), although the peripheral giant cell granu-
loma often is more blue-purple compared with the
bright red of a typical pyogenic granuloma.
Peripheral giant cell granulomas can develop at
almost any age, especially during the first through
sixth decades of life. The mean age in several large
series ranges from 31 to 41 years. Approximately 60%
of cases occur in females. It may develop in either the
anterior or posterior regions of the gingiva or alveolar
Fig. 12-38 Peripheral giant cell granuloma. Ulcerated
mass of the mandibular gingiva.
mucosa, and the mandible is affected slightly more
often than the maxilla. Although the peripheral giant
cell granuloma develops within soft tissue, “cupping”
resorption of the underlying alveolar bone sometimes
is seen. On occasion, it may be difficult to determine
whether the mass arose as a peripheral lesion or as a
central giant cell granuloma that eroded through the
cortical plate into the gingival soft tissues.
HISTOPATHOLOGIC FEATURES
Microscopic examination of a peripheral giant cell
granuloma shows a proliferation of multinucleated
giant cells within a background of plump ovoid and
spindle-shaped mesenchymal cells (Figs. 12-39 and
12-40). The giant cells may contain only a few nuclei
or up to several dozen. Some of these cells may have
large, vesicular nuclei; others demonstrate small, pyk-
notic nuclei. Mitotic figures are fairly common in the
background mesenchymal cells. Abundant hemor-
rhage is characteristically found throughout the mass,
which often results in deposits of hemosiderin pigment,
especially at the periphery of the lesion.
The overlying mucosal surface is ulcerated in about
50% of cases. A zone of dense fibrous connective tissue
usually separates the giant cell proliferation from the
mucosal surface. Adjacent acute and chronic inflam-
matory cells are frequently present. Areas of reactive
bone formation or dystrophic calcifications are not
unusual.
TREATMENT AND PROGNOSIS
The treatment of the peripheral giant cell granuloma
consists of local surgical excision down to the underly-
ing bone. The adjacent teeth should be carefully scaled
to remove any source of irritation and to minimize the
risk of recurrence. Approximately 10% of lesions are
reported to recur, and reexcision must be performed.
Chapter 12 SOFT TISSUE TUMORS
Fig. 12-39 Peripheral giant cell granuloma. Low-power
view showing a nodular proliferation of multinucleated giant
cells within the gingiva.
Fig. 12-40 Peripheral giant cell granuloma. High-power
view showing scattered multinucleated giant cells within a
hemorrhagic background of ovoid and spindle-shaped
mesenchymal cells.
On rare occasions, lesions indistinguishable from
peripheral giant cell granulomas have been seen in
patients with hyperparathyroidism (see page 838).
They apparently represent the so-called osteoclastic
brown tumors associated with this endocrine disorder.
However, the brown tumors of hyperparathyroidism
are much more likely to be intraosseous in location and
mimic a central giant cell granuloma.
PERIPHERAL OSSIFYING FIBROMA
(OSSIFYING FIBROID EPULIS;
PERIPHERAL FIBROMA WITH
CALCIFICATION; CALCIFYING
FIBROBLASTIC GRANULOMA)
The peripheral ossifying fibroma is a relatively
common gingival growth that is considered to be reac-
tive rather than neoplastic in nature. The pathogenesis
of this lesion is uncertain. Because of their clinical and
521
Fig. 12-41 Peripheral ossifying fibroma. Red, ulcerated
mass of the maxillary gingiva. Such ulcerated lesions are
easily mistaken for a pyogenic granuloma.
histopathologic similarities, researchers believe that
some peripheral ossifying fibromas develop initially as
pyogenic granulomas that undergo fibrous maturation
and subsequent calcification. However, not all periph-
eral ossifying fibromas may develop in this manner.
The mineralized product probably has its origin from
cells of the periosteum or periodontal ligament.
Considerable confusion has existed over the nomen-
clature of this lesion, and several terms have been used
to describe its variable histopathologic features. In
the past, the terms peripheral odontogenic fibroma (see
page 727) and peripheral ossifying fibroma often were
used synonymously, but the peripheral odontogenic
fibroma is now considered to be a distinct and separate
entity. In addition, in spite of the similarity in names,
the peripheral ossifying fibroma does not represent the
soft tissue counterpart of the central ossifying fibroma
(see page 646).
CLINICAL FEATURES
The peripheral ossifying fibroma occurs exclusively on
the gingiva. It appears as a nodular mass, either pedun-
culated or sessile, that usually emanates from the inter-
dental papilla (Figs. 12-41 and 12-42). The color ranges
from red to pink, and the surface is frequently, but not
always, ulcerated. The growth probably begins as an
ulcerated lesion; older ones are more likely to demon-
strate healing of the ulcer and an intact surface. Red,
ulcerated lesions often are mistaken for pyogenic gran-
ulomas; the pink, nonulcerated ones are clinically
similar to irritation fibromas. Most lesions are less than
2 cm in size, although larger ones occasionally occur.
The lesion often has been present for many weeks or
months before the diagnosis is made.
The peripheral ossifying fibroma is predominantly a
lesion of teenagers and young adults, with peak preva-
lence between the ages of 10 and 19. Almost two thirds
522 ORAL AND MAXILLOFACIAL PATHOLOGY

Fig. 12-42 Peripheral ossifying fibroma. Pink, Fig. 12-43 Peripheral ossifying fibroma. Ulcerated
nonulcerated mass arising from the maxillary gingiva. The gingival mass demonstrating focal early mineralization
remaining roots of the first molar are present. (arrow).

of all cases occur in females. There is a slight predilec-

tion for the maxillary arch, and more than 50% of all
cases occur in the incisor-cuspid region. Usually, the
teeth are unaffected; rarely, there can be migration and
loosening of adjacent teeth. A

HISTOPATHOLOGIC FEATURES
The basic microscopic pattern of the peripheral ossify-
ing fibroma is one of a fibrous proliferation associated
with the formation of a mineralized product (Figs.
12-43 and 12-44). If the epithelium is ulcerated, then
the surface is covered by a fibrinopurulent membrane
with a subjacent zone of granulation tissue. The deeper
fibroblastic component often is cellular, especially in
areas of mineralization. In some cases, the fibroblastic
proliferation and associated mineralization is only a B
small component of a larger mass that resembles a
fibroma or pyogenic granuloma.
The type of mineralized component is variable and
may consist of bone, cementum-like material, or dys-
trophic calcifications. Frequently, a combination of
products is formed. Usually, the bone is woven and
trabecular in type, although older lesions may demon-
strate mature lamellar bone. Trabeculae of unmineral- Fig. 12-44 Peripheral ossifying fibroma. A, Nonulcerated
ized osteoid are not unusual. Less frequently, ovoid fibrous mass of the gingiva showing central bone formation.
droplets of basophilic cementum-like material are B, Higher-power view showing trabeculae of bone with
formed. Dystrophic calcifications are characterized adjacent fibrous connective tissue.
by multiple granules, tiny globules, or large, irregular
masses of basophilic mineralized material. Such dys-
trophic calcifications are more common in early, ulcer- TREATMENT AND PROGNOSIS
ated lesions; older, nonulcerated examples are more The treatment of choice for the peripheral ossifying
likely to demonstrate well-formed bone or cementum. fibroma is local surgical excision with submission of
In some cases, multinucleated giant cells may be found, the specimen for histopathologic examination. The
usually in association with the mineralized product. mass should be excised down to periosteum because
Chapter 12 SOFT TISSUE TUMORS 523

recurrence is more likely if the base of the lesion is

allowed to remain. In addition, the adjacent teeth
should be thoroughly scaled to eliminate any possible
irritants. Periodontal surgical techniques, such as repo-
sitioned flaps or connective tissue grafts, may be neces-
sary to repair the gingival defect in an aesthetic manner.
Although excision is usually curative, a recurrence rate
of 8% to 16% has been reported.

LIPOMA
The lipoma is a benign tumor of fat. Although it rep-
resents by far the most common mesenchymal neo-
plasm, most examples occur on the trunk and proximal
portions of the extremities. Lipomas of the oral and Fig. 12-45 Lipoma. Soft, yellow nodular mass in the floor
maxillofacial region are much less frequent. The patho- of the mouth. (Courtesy of Dr. Michael Tabor.)
genesis of lipomas is uncertain, but they appear to be
more common in obese people. However, the metabo-
lism of lipomas is completely independent of the
normal body fat. If the caloric intake is reduced, then
lipomas do not decrease in size, although normal body
fat may be lost.

CLINICAL FEATURES
Oral lipomas are usually soft, smooth-surfaced nodular
masses that can be sessile or pedunculated (Figs. 12-45
and 12-46). Typically, the tumor is asymptomatic and
often has been noted for many months or years before
diagnosis. Most are less than 3 cm in size, but occa-
sional lesions can become much larger. Although a
Fig. 12-46 Lipoma. Nodular mass of the posterior buccal
subtle or more obvious yellow hue often is detected mucosa.
clinically, deeper examples may appear pink. The
buccal mucosa and buccal vestibule are the most
common intraoral sites and account for 50% of all
cases. Some buccal cases may not represent true
tumors, but rather herniation of the buccal fat pad
through the buccinator muscle, which may occur after
local trauma in young children or subsequent to surgi-
cal removal of third molars in older patients. Less
common sites include the tongue, floor of the mouth,
and lips. Most patients are 40 years of age or older;
lipomas are uncommon in children. Lipomas of the
oral and maxillofacial region have shown a fairly bal-
anced sex distribution in some studies, although one
recent large series demonstrated a marked male
predilection.
Fig. 12-47 Lipoma. Low-power view of a tumor of the
tongue demonstrating a mass of mature adipose tissue.
HISTOPATHOLOGIC FEATURES
Most oral lipomas are composed of mature fat cells that ment of the cells often is seen. On rare occasions,
differ little in microscopic appearance from the sur- central cartilaginous or osseous metaplasia may occur
rounding normal fat (Figs. 12-47 and 12-48). The within an otherwise typical lipoma.
tumor is usually well circumscribed and may demon- A number of microscopic variants have been
strate a thin fibrous capsule. A distinct lobular arrange- described. The most common of these is the fibroli-