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Authors:Dr. Md. Asdullah,Dr. K.Srinivas,Dr. P.Ratnakar

Abstract
Irritation Fibroma is a bening fibrous connective tissue tumor. It is basically reactive proliferation of fibrous tissue. It considered as a second most common non- Odontogenic bening tumor of oral cavity. It occure at any age, but more common  in 3rd ,4th & 5th decades of life. Most common site is gingiva, buccal mucosa ,togue & Palate. Usually painless. Mostly sessile, dome shaped or slightly pedunculated with smooth cotour. However lesion on lip & togue present as circumscribe nodules. When irritated or inflamed shows superficial ulceration. The color of tumor is normal. The size of lesion is very small, rarely several cm in diameter. Conservative Surgical excision is the treatment of choice, prognosis is good.

Introduction
Irritation fibroma (IF), or traumatic fibroma, is a common sub-mucosal response to trauma from teeth or dental prostheses and was first reported in 1846 as fibrous polyp and polypus1.
It is also known as “Irritation fibroma, Traumatic fibroma, Peripheral fibroma, Focal fibrous hyperplasia, Inflammatory fibrous hyperplasia, Fibrous nodule, or Fibro-epithelial polyp”2.
The great majority of localized overgrowths of the oral mucosa are considered to be reactive inflammatory hyperplasia rather than neoplastic in nature.3 
Irritation or Traumatic Fibroma is the healed end product of inflammatory hyperplatic lesions. Clinically they appear either as pedunculated or sessile mass on any surface of the mucous membrane.4 Majorities of lesions are small measuring few millimeters. It occurs at any age, but more common  in 3rd ,4th & 5th decades of life. Most common site is gingiva, buccal mucosa , togue & Palate. Usually  painless4.

     
Fig-1 Fig-2, Wound after insion Fig-2a, Wound was sutured.
   
Fig-2b, Excised specimen Fig- 2c, Post operative photograph

 
This localized lesions of the oral cavity have been broadly differentiate  as: Irritation fibroma, Peripheral ossifying fibroma, Squamous papilloma, Giant cell fibroma, Pyogenic granuloma and Peripheral giant cell granuloma5.
The fibroma, is the most common oral fibrous tumor like growth. Most if not all fibromas represent reactive focal fibrous hyperplasia due to trauma or local irritation6.
Gingiva is a common site for either neoplastic or non neoplastic lesions. Non neoplastic lesions are usually inflammatory or represent a reaction to some kind of irritation or low grade injury7.
Conservative Surgical excision is the treatment of choice. They do not have malignant potential and recurrence is mostly as a result of failure to eliminate the irritation,4.

Case report-A 19 year old male patient was reported in Department of Oral Medicine & Radiology with chief complaint of growth in right cheek region of the mouth since four months. The lesion was first noticed four months back and its size has not increased since then. The growth has interfered in the normal functioning of the mouth. There was no significant medical and dental history. On intraoral examination, a solitary painless well-defined broadbase mass was present on right buccal mucosa along the Occlusal plane of maxillary & mandibular teeth (Fig. 1). The lesion was in whitish red color, measuring about 10x8 mm of size in longest diameter and extending from the buccal surfaces of 33 and 34.  The superficial surface of lesion was keratinized with well defined margin. Growth was firm in consistency. It was compressible, it does not bleed on pressure and non tender on palpation.
After hematological and general medical evaluation of patient. An excisional biopsy was performed, intraorally under local anesthesia and the wound was sutured. (Fig-2,Fig-2a,Fig-2b ) On histopathological examination, a stratified squamous arakeratinized epithelium without rete-ridges was seen covering a dense connective tissue stroma (Fig. 3). The collagen bundles were numerous and densely packed along with few fibroblasts (Fig. 3a). Moderate amount of lymphoplasmocp5ytic infiltration was also noted. A diagnosis of “Focal fibrous hyperplasia” (FFH) was made. Postoperative healing was uneventful(Fig-2c). No recurrence was reported on follow-up. 
                
Discussion
Irritation fibroma, lesions generally presents as a painless, sessile, round or ovoid, broad based growth that is lighter in color than surrounding tissue due to a reduced vascularity8.
Although the IF can occur anywhere in the mouth, the most common location is the buccal mucosa along the bite line8 Presumably, this is a consequence of trauma from biting the cheek. The present case had a similar clinical presentation. Other common8 sites are labial mucosa, tongue and gingiva9.
Treatment of choice of Fibroma include surgical excision with narrow margin10.Altrough the excision of Fibroma with the Nd:YAP laser is safe and quick procedure without postoperative complications11.

Conclusion
Oral soft tissue reactive lesions, although a common entity, can cause diagnostic dilemma for an inexperienced clinician. Identification of any reactive hyperplastic lesion requires the devising of a differential diagnosis to enable precise patient evaluation and there on its management. A correlation of clinical and histopathological findings is required to treat these patients.

Acknowledgement
Authors of this article acknowledge the contribution and help of the following DentistsProf. Jyoti Gupta, Dr. Parvez Alam Khan, Dr. Payal Tripathi, Dr. Arti Salja Sachdev, & Dr. Vasu S.Saxena.

Refrences
1.Alam MN, Chandrasekaran SC, Valiathan M.Fibroma of the Gingiva: A Case Report of a 20 Year old Lesion. Int Journal of Contemporary Dentistry 2010;1:107-9.
2.Toida M et al. Irritation fibroma of the oral mucosa: A clinicopathological study of 129lesions in 124 cases. Oral Med Pathol2001;6:91-94.
3.Maryam Assadat Hashemi Pour, Rad M, Mojtahedi A. A Survey of Soft Tissue Tumor-Like Lesions of Oral Cavity: A Clinicopathological Study. Iranian Journal of Pathology 2008;3:81-87.
4.Rangeeth et al;Mecocele and Fibroma of Lower lip;A case report, Contemporary Clinical Dentistry|Apr-Jan2010|Vol 1|issue 2.
5. Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg 1986;24:376-382.
6. Kolte AP, Kolte RA, Shrirao TS. Focal fibrous overgrowth- A case series and review of literature. Contemp Clin Dent 2010;1:271-274.
7. Zain R. Fibrous lesions of the gingiva- a histopathological analysis. Oral Surg Oral Med Oral Pathol 1990;70:466-470.
8. Regezi JA, Sciubba J. Oral Pathology: Clinical Pathologic Correlations. 2nd ed.Philadelphia, Pa: WB Saunders. 1997:142-145, 195, 202-204.
9.Neville BW et al. Oral and maxillofacial pathology. 2nd ed. Philadelphia, Saunders;2002. p 418-19.
10.Anjali Singh et al, traumatic fibroma –a saga of reaction against irritation, Dental Impact Vol. 4, Issue 1, June 2012.

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