|Year : 2013 | Volume
| Issue : 3 | Page : 387-390
Ipsilateral idiopathic gingival enlargement and it's management using conventional gingivectomy and diode laser: A recurrent case after 15 years
Potharaju Kamala Devi, Gudi Pavan Kumar, Yendluri Durga Bai, Annamdevula Durga Ammaji
Department of Periodontics, Government Dental College and Hospital, Hyderabad, Andhra Pradesh, India
|Date of Submission||20-Apr-2012|
|Date of Acceptance||24-May-2013|
|Date of Web Publication||25-Jul-2013|
Gudi Pavan Kumar
H No 207/3rt, Near Ramalayam, Saidabad Colony, Hyderabad - 500 059, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Idiopathic gingival fibromatosis is a relatively rare condition characterized by the proliferation of the gingival tissues resulting in masticatory, esthetics, phonetics and psychological disturbances. The severity of the overgrowth can range from a solitary isolated mass to a more generalized and diffused enlargement. The etiopathogenesis of this bizarre condition is poorly understood and has been attributed to various factors. It can present as a single disorder or may manifest as part of a syndrome. This case reports an ipsilateral diffused idiopathic gingival enlargement in a middle aged adult recurring after a gap of 15 years. External bevel gingivectomy on the buccal aspects of maxillary and mandibular gingiva and diode laser for excision of the enlarged tissue on the lingual/palatal aspect was carried out to eliminate the excessive tissue. Periodic recalls showed maintenance of good oral hygiene and 1 year follow-up revealed no recurrence.
Keywords: Diode laser, gingival enlargement, gingivectomy, idiopathic gingival fibromatosis
|How to cite this article:|
Devi PK, Kumar GP, Bai YD, Ammaji AD. Ipsilateral idiopathic gingival enlargement and it's management using conventional gingivectomy and diode laser: A recurrent case after 15 years. J Indian Soc Periodontol 2013;17:387-90
|How to cite this URL:|
Devi PK, Kumar GP, Bai YD, Ammaji AD. Ipsilateral idiopathic gingival enlargement and it's management using conventional gingivectomy and diode laser: A recurrent case after 15 years. J Indian Soc Periodontol [serial online] 2013 [cited 2020 Jan 17];17:387-90. Available from: http://www.jisponline.com/text.asp?2013/17/3/387/115649
| Introduction|| |
Gingival enlargement (GE) is an overgrowth characterized by an expansion and accumulation of the connective tissue with seldom increase in a number of cells.  It is a heterogeneous group of disorders causing esthetic, functional, masticatory and psychological disturbances. The etiopathogenesis of GE is poorly understood but can be directly or indirectly attributed to factors like plaque accumulation, inadequate nutrition or systemic hormonal stimulation.  GE is also evidenced in blood dyscrasias or may result from factors like inflammation, drugs and inheritance. 
Idiopathic gingival fibromatosis (IGF) is a rare hereditary condition with no definite cause.  The overgrowth varies from mild enlargement of an isolated inter dental papillae to segmental or uniform and marked enlargement affecting one or both the jaws.  It is known to affect 1 in 3/4 th of a million and can present as a single entity or as part of a syndrome.  Clinically the enlargement exhibits a normal color, is firm, non-hemorrhagic, non-exudative and asymptomatic. It has no sex predilection and can affect either of the jaws. 
IGF is synonymous with nomenclatures like gingivomatosis, elephantiasis gingivae, diffuse fibroma, familial elephantiasis, hereditary gingival hyperplasia, hereditary gingival fibromatosis (HGF), congenital familial fibromatosis.  It's syndromic association can be autosomal dominant or recessive and has been evidenced in Zimmerman-Laband, Murray-Puretic-Drescher, Rutherford, Cowden, Cross and Ramon syndromes,  to name a few.
The HGF gene has been mapped to 2p21-p22 (HGF1)  and the locus has been localized to 37CM and chromosome 5q13-q22 (HGF2).  Recently, a mutation in the Son of Sevenless-1 gene has been linked to non-syndromic enlargements, but unequivocal evidence has not been established. 
The treatment of gingival fibromatosis is of prime importance as it can cause difficulty in mastication, phonetics, esthetics, malposition of teeth and can lead to considerable cosmetic and psychological concerns. The severity of the enlargement precludes the treatment plan. Minimal overgrowth is treated through scaling of teeth and maintenance of good oral hygiene. Surgical intervention with gingivectomy and gingivoplasty is advocated for excessive enlargements. 
Traditional surgical procedures using scalpel and blade causes discomfort, elicits more bleeding and has patient cooperation issues. The use of diode laser for gingivectomy seems to address the above issues to a large extent.  We present a case of recurrent ipsilateral idiopathic GE affecting the buccal and lingual/palatal aspect of maxillary and mandibular arches on the right side and its management using conventional external bevel gingivectomy and diode laser.
| Case Report|| |
A middle aged Indian male patient reported to the Department of Periodontics, Government Dental College and Hospital, Hyderabad, India with a chief complaint of swelling of the gums in the upper and lower jaws on the right side of the face since 1 year. The patient also complained of difficulty and pain during mastication. An informed consent to be examined was given. Patient gave the history of similar lesion in the maxillary right jaw 15 years back and was treated at the same institute. There was no relevant medical, family or drug history and the patient is a known smoker for the past 20 years.
On visual examination, right facial asymmetry with fullness of the cheek was apparent [Figure 1]. Intraoral inspection revealed a deviation of the tongue to the left side. Clinical examination exposed the enlarged gingivae involving the right maxilla and mandible. The overgrowth extended from 11 to 18 in the maxilla and 32-48 in the mandible. The lesion appeared pale pink in color, was diffuse, firm and fibrotic with a smooth surface [Figure 2] and [Figure 3]. Inflammatory changes secondary to local plaque and calculus deposits was evident and periodontal probing elicited bleeding and presence of pseudo pockets.
|Figure 2: Pre-operative photograph showing the enlargement on buccal/labial sides|
Click here to view
|Figure 3: Pre-operative photograph showing the enlargement on lingual side|
Click here to view
Complete blood picture was within normal limits on a hemogram. The orthopantamograph showed crestal bone loss in the maxilla and horizontal bone loss in the mandible extending from distal aspect of 44 to mesial aspect of 48 [Figure 4].
Following Phase I therapy, gingivectomy using external bevel incisions was planned on the buccal aspects of the maxillary and mandibular gingiva and diode laser was used for excision of the enlarged tissue on the lingual/palatal aspect. Incisions on the buccal aspect were made using the Kirkland knives and Orban's knife was used for interdental incisions. After arresting bleeding, a periodontal dressing (Coe-Pak, GC America Inc., Alsip) was placed to protect the raw wound and promote healing. The excised tissue was sent for histopathological analysis. Patient was recalled after 2 weeks, periodontal dressing was removed and next surgical phase involving the lingual/palatal side using diode laser was carried out [Figure 5]. The diode laser had a wavelength of 940 nm and was used at 3 watts in continuous mode. The patient was placed on periodic recall visits for supportive periodontal care. No recurrence was observed at 1 year post surgery [Figure 6] and [Figure 7].
| Discussion|| |
The present report describes as case of ipsilateral IGF in a middle aged adult patient, recurring after a gap of 15 years. As there was no contributing family, medical, prenatal or drug histories, a diagnosis of IGF was made. The etiology of IGF is poorly understood and has been attributed to congenital or hereditary factors. Disturbances in the homeostatic equilibrium between synthesis and degradation of collagen and/or alterations in fibroblast function and proliferation have also been drawn in the etiopathogenesis of IGF. The enlargement is confined to fibroblasts in the gingiva and does not involve the periodontal ligament. It occurs peripheral to the alveolar bone in the attached gingiva.  In such cases, periodontitis and bone resorption is secondary to plaque accumulation due to the enlargement. Therefore, oral hygiene maintenance and supportive periodontal care is of paramount importance not only to minimize the periodontal involvement but also to prevent or delay the recurrence. There is a tendency for these lesions to recur after surgery but the time taken for recurrence is unpredictable and could range from months to years. One study reported no recurrence in 14 years in patients with good oral hygiene  whilst mild recurrence was evident in another study 20 months post surgery due to poor plaque control.  In the present case report, recurrence was noted after 15 years. Oral hygiene maintenance of the patient was good and reported for regular periodic checkups. This could be a significant factor in delaying the recurrence. Similar views are reported in the literature. ,
The histopathology of the enlarged tissue consisted of increased collagen fiber bundles, irregular elongated retepegs in the stromal tissue with sparse cellularity and multiple small blood vessels. The nodular appearance can be attributed to hyperparakeratinized epithelium. These findings are consistent with the observations of other studies mentioned. ,,, Another reason for delayed recurrence in the present report could be linked to sparse cellularity of the lesion as greater the number of fibroblasts, more likely for the lesion to recur. 
Various treatment modalities for the management of IGF include external or internal bevel gingivectomy in association with gingivoplasty, an apically positioned flap, electrocautery and the use of lasers. The most effective method for removing the enlarged tissue when there is no attachment loss and all the pocketing is false, is the conventional external bevel gingivectomy. 
The present case was treated using external bevel gingivectomy on the labial/buccal gingiva of maxillary/mandibular arches and diode laser was used to excise the excess tissue on the lingual/palatal sides. The use of laser reduced the amount of bleeding, lowered pain during and after the procedure and significantly decreased the quantity of local anesthetic used. It also led to better visibility thereby reducing the chair side time resulting in minimized operator fatigue and better patient acceptance. Similar views are shared by Gontiya et al. 
IGF is prone for unpredictable recurrence. There could be a need for repeated surgical procedures depending upon the severity. This could dent the patient psychologically and emotionally. Henceforth, psychological counseling should be part of the comprehensive treatment plan for such patients, especially those belonging to the younger age group. Moreover, the benefits of the surgery in eliminating the masticatory difficulties, providing access for better oral hygiene maintenance and significant improvement of phonetics and esthetics should not be underestimated. These views are in accordance with those of Lobão et al.  and Shetty et al. 
| Conclusion|| |
IGF is a relatively rare condition with poorly understood etiopathogenesis and recurrence rates. The benefits of the surgery outweigh the risks of recurrence and should be employed whenever deemed crucial. Patient education, periodic recall and proper oral hygiene maintenance reduce and delay the chances of recurrence. Further studies at cellular, molecular and genetic levels are required to understand the etiology and pathogenesis of this bizarre condition.
| References|| |
|1.||Takagi M, Yamamoto H, Mega H, Hsieh KJ, Shioda S, Enomoto S. Heterogeneity in the gingival fibromatoses. Cancer 1991;68:2202-12. |
|2.||Regezi JA, Sciuba JJ. Connective tissue lesions. In: Oral Pathology: Clinical pathologic Correlations. Philadelphia, PA, USA: W.B. Saunders; 1999. p. 179-83. |
|3.||Dongari-Bagtzoglou A, Research, Science and Therapy Committee, American Academy of Periodontology. Drug-associated gingival enlargement. J Periodontol 2004;75:1424-31. |
|4.||Carranza FA, Hogan EL. Gingival enlargement. In: Newman MG, Takei HH, Carranza FA, editors. Clinical Periodontology. 9 th ed. Philadelphia, PA, USA: Saunders; 2002. p. 279-96. |
|5.||Tiwana PS, De Kok IJ, Stoker DS, Cooper LF. Facial distortion secondary to idiopathic gingival hyperplasia: Surgical management and oral reconstruction with endosseous implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:153-7. |
|6.||Pappachan B, Narayan JV, Nayak A. Idiopathic gingival fibromatosis: A neglected case. Indian J Radiol Imaging 2002;12:335-8. |
|7.||Bittencourt LP, Campos V, Moliterno LF, Ribeiro DP, Sampaio RK. Hereditary gingival fibromatosis: Review of the literature and a case report. Quintessence Int 2000;31:415-8. |
|8.||Nayak PA, Nayak UA, Khandelwal V, Ninave N. Idiopathic gingival fibromatosis. Int J Clin Pediatr Dent 2011;4:77-81. |
|9.||Xiao S, Bu L, Zhu L, Zheng G, Yang M, Qian M, et al. A new locus for hereditary gingival fibromatosis (GINGF2) maps to 5q13-q22. Genomics 2001;74:180-5. |
|10.||Hart TC, Zhang Y, Gorry MC, Hart PS, Cooper M, Marazita ML, et al. A mutation in the SOS1 gene causes hereditary gingival fibromatosis type 1. Am J Hum Genet 2002;70:943-54. |
|11.||Birkedal-Hansen H. Role of matrix metalloproteinases in human periodontal diseases. J Periodontol 1993;64 (Suppl 5):474-84. |
|12.||Ramer M, Marrone J, Stahl B, Burakoff R. Hereditary gingival fibromatosis: Identification, treatment, control. J Am Dent Assoc 1996;127:493-5. |
|13.||Gontiya G, Bhatnagar S, Mohandas U, Galgali SR. Laser-assisted gingivectomy in pediatric patients: A novel alternative treatment. J Indian Soc Pedod Prev Dent 2011;29:264-9. |
|14.||Sapp JP, Eversole LR, Wysocki GP. Connective tissue lesions. In: Contemporary Oral and Maxillofacial Pathology. 2 nd ed. London, UK: Mosby; 2004. p. 294-7. |
|15.||Günhan O, Gardner DG, Bostanci H, Günhan M. Familial gingival fibromatosis with unusual histologic findings. J Periodontol 1995;66:1008-11. |
|16.||Baptista IP. Hereditary gingival fibromatosis: A case report. J Clin Periodontol 2002;29:871-4. |
|17.||Seki K, Sato S, Asano Y, Akutagawa H, Ito K. Improved pathologic teeth migration following gingivectomy in a case of idiopathic gingival fibromatosis. Quintessence Int 2010;41:543-5. |
|18.||Ramnarayan BK, Sowmya K, Rema J. Management of idiopathic gingival fibromatosis: Report of a case and literature review. Pediatr Dent 2011;33:431-6. |
|19.||Lobão DS, Silva LC, Soares RV, Cruz RA. Idiopathic gingival fibromatosis: A case report. Quintessence Int 2007;38:699-704. |
|20.||Shetty AK, Shah HJ, Patil MA, Jhota KN. Idiopathic gingival enlargement and its management. J Indian Soc Periodontol 2010;14:263-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]