|Year : 2016 | Volume
| Issue : 2 | Page : 113-116
Esthetic management of a recurrent gingival fibroma
Sue Ann Loe, Vivek Vijay Gupta, Srinivas Sulugodu Ramachandra
Faculty of Dentistry, SEGi University, Selangor, Malaysia
|Date of Web Publication||19-Dec-2016|
Srinivas Sulugodu Ramachandra
Faculty of Dentistry, SEGi University, No. 9, Jalan Teknologi, Taman Sains, Kota Damansara, Selangor
Source of Support: None, Conflict of Interest: None
Peripheral reactive lesions of gingiva are common lesions of the oral cavity that dentists come across in daily life. Among these are focal fibrous hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, and peripheral ossifying fibroma. Localized irritation fibroma is a gingival growth, usually arising from interdental papilla due to the presence of some chronic irritation due to dental calculus or other iatrogenic factors. This article reports a case of a 39-year-old male with a recurrent irritation fibroma in the maxillary anterior gingiva treated by excision. The presence of growth in the esthetic maxillary anterior segment and the possibility of unesthetic defect due to excision of the growth have been discussed. The importance of treating the chronic infectious irritational factor and regular follow-up to prevent long-term recurrence of the growth has been discussed.
Keywords: Chronic periodontitis, esthetics, excision, irritation fibroma, maintenance therapy
|How to cite this article:|
Loe SA, Gupta VV, Ramachandra SS. Esthetic management of a recurrent gingival fibroma. Indian J Oral Health Res 2016;2:113-6
| Introduction|| |
Irritation fibroma is the most common tumor-like and submucosal reactive lesion in the oral cavity.  The presence of low-grade irritation or injury from mastication, food lodgement, presence of calculus, and other iatrogenic factors such as broken tooth and overhanging restorations are usually the etiologic factors for the development for these irritation fibromas. Chronic mechanical irritation can be seen very commonly due to the presence of dental calculus in moderate to deep periodontal pockets, which cannot be maintained by the patient using normal oral hygiene aids.  Hence, among the treatment options in such cases are the pocket reduction therapy and nonsurgical periodontal maintenance therapy. Inability to remove the dental calculus causing chronic mechanical irritation completely or accumulation of such local factors again can lead to the recurrence of irritation fibromas. Surgical excision of irritation fibroma is required which can be more challenging in anterior region due to esthetic concerns. 
As slight excess of gingival tissue is required to be excised to prevent the recurrence of the lesion, it might lead to gingival recession or a gingival defect which could be unacceptable in the anterior region or might require an additional root coverage procedures. 
This article reports esthetic management of a case with recurrent gingival fibroma in the maxillary anterior region.
| Case report|| |
A 39-year-old male patient reported to the Faculty of Dentistry, SEGi University, for cleaning his teeth. Clinical examination revealed abundance of plaque and calculus deposits, especially in the mandibular anterior region. Intraoral examination also revealed a localized gingival growth present around right maxillary central and lateral incisors [Figure 1]. Gingival growth was sessile, well-defined, firm in consistency and nontender on palpation with a size of 1 cm × 1 cm. The gingival overgrowth was pale pink. The patient provided with a history of similar growth in the same region and was surgically excised by a local dentist. The growth had recurred over the past couple of years. The patient was medically fit as there was no history of any systemic disease. A basic periodontal examination (BPE) was carried out, and BPE score of 3 was obtained for all the maxillary and mandibular sextants. Detailed periodontal charting revealed periodontal pocket of 6 mm around the right maxillary central incisor. An orthopantomogram (OPG) and intraoral periapical (IOPA) radiography in relation to maxillary anteriors were advised. OPG revealed generalized interproximal bone loss. IOPA showed interproximal bone loss up to coronal one-third of the root [Figure 2]. Based on the clinical features and history, a provisional diagnosis of fibroma, peripheral ossifying fibroma, was made. A treatment plan involving scaling and polishing, root debridement in teeth with residual periodontal pockets, and excision of the gingival growth was formulated. The patient was explained about the growth and the proposed treatment plan. The patient was concerned about the esthetics in the upper front region due to possible loss of gingiva during excision. An informed consent was obtained from the patient.
|Figure 1: Clinical image showing localized gingival growth around right maxillary central and lateral incisors. Abundance of local deposits can be appreciated, especially in the mandibular anterior region. Inset shows a sessile growth attached to the attached gingiva and extending up to coronal one-third of maxillary right central incisor|
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|Figure 2: Orthopantomogram showing generalized interproximal bone loss. Inset shows intraoral periapical radiograph with crestal interproximal bone loss|
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Nonsurgical periodontal therapy in the form of scaling and root debridement was initiated. Thorough removal of all the supra- and sub-gingival calculus was carried out. The patient was recalled after 10 days for review and excision of the growth [[Figure 3] inset]. Excision of the gingival growth was done under local anesthesia using B.P. blade no 15 [Figure 3]. Care was excised not to sacrifice unnecessary portions of the attached gingiva which would result in an unesthetic defect in the anterior gingiva. However, a small uninvolved portion of the gingiva around the growth was removed so that chances of recurrence are decreased. Hemostasis was achieved using pressure packs. Small specks of subgingival calculus were noticed beneath the gingival growth. Remnants of subgingival calculus were removed using curettes. Periodontal dressing was placed to cover the surgical area. Postoperative instructions were given, and the patient was advised to use oral analgesics if needed. The excised tissue was sent for histopathological examination.
|Figure 3: Clinical image after excision of the growth. Calculus present beneath the growth can be appreciated. Inset shows the growth during the follow-up after completion of Phase I therapy|
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Histological examination revealed that the growth contained abundance of acellular, dense, collagenous fibrous tissue covered with stratified squamous epithelium was noticed [Figure 4]. The collagen bundles were arranged in radiating haphazard pattern, and the overlying epithelium appeared hyperplastic. Scattered chronic inflammatory cell infiltrates are seen in the subepithelium [[Figure 4] inset]. No giant cells or ossifying tissues were found even on a higher magnification. The patient was examined 2 weeks later with the area around 11 showing signs of normal healing and minimal gingival recession. Three months later, area showed uneventful healing [Figure 5]. The patient was put on periodontal maintenance therapy to prevent the recurrence of the lesion. At 6 months follow-up, there has been no recurrence of the growth [Figure 6].
|Figure 4: Histomicrograph shows abundant acellular, collagenous fibrous tissue with stratified squamous hyperplastic epithelium (×10). Inset showing scattered chronic inflammatory cells with no giant cells or ossifying tissues (×40)|
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|Figure 5: Clinical image of the patient after 3 months of follow-up. Inset shows image at 10 days of follow-up|
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|Figure 6: Clinical image of the patient after 6 months of follow-up. Absence of recession or unesthetic defect at the excision site can be noticed|
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| Discussion|| |
Fibromas are reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma.  They are most commonly seen in the fourth to sixth decades of life, with a male: female ratio of approximately 1:2. Buccal mucosa along the occlusal line, labial mucosa, tongue, and gingiva are the most common intraoral sites.  Oral hygiene of the oral cavity in this case was poor with abundance of plaque and calculus. However, the growth was localized in the maxillary anterior region as a deep periodontal pocket of 6 mm was noticed in the maxillary right central incisor. The presence of chronic infection (subgingival plaque and calculus in the periodontal pocket) as an irritating factor could be the reason for localization of the gingival growth in the right maxillary anterior region. The gingival growth in this case was a recurrent growth. The growth had been excised around 5 years back by a local dentist. Incomplete excision of the growth and incomplete removal of the chronic irritating factors could be the reasons for recurrence of the growth. Hence, complete excision of the growth with removal of the chronic irritating factors was carried out. Thorough scaling and root debridement, followed by removal of the residual calculus after excision of the growth, ensured removal of all chronic irritational factors. This highlights the importance of removal of all the chronic infections in such cases. Vitality testing was also performed to ensure that possible chronic endodontic infection is to be ruled out as a cause for recurrence of the growth.
Gingival growths can be sessile or pedunculated. Sessile growths are attached to the underlying tissue with a wide base whereas the pedunculated lesion is attached to the underlying tissue by a stalk or pedicle. The technique/method of excision is dependent on whether the growth is sessile or pedunculated. Pedunculated growths are excised at the base of the stalk/pedicle whereas the sessile growths are excised from the base with some amount of normal tissue. Both sessile and pedunculated lesions flatten out due to pressure from the cheeks, tongue, and lips. The growth in this case was sessile and was attached to attached gingiva in the maxillary anterior region. Excision of gingival growths with their base attached to the gingiva has the risk of creating unesthetic defect in the gingiva. This defect could result in a niche for future plaque accumulation or could simply be unesthetic. ,, Conservative and careful excisions of the lesion will save avoid the unesthetic defects, but carries the risk of chances of recurrence. ,,
Histologically, dense mass of fibrous connective tissue covered by was noticed epithelium. Atrophy of the rete ridges because of the underlying fibrous mass is seen.  As various types of reactive lesions of gingiva can present a similar clinical picture, only the histological examination showing specific cells such as giant cells or some mineralized tissue can help us reach the final diagnosis.  In the present case of localized reactive gingival overgrowth, collagen bundles were arranged in radiating haphazard pattern and the overlying epithelium appears hyperplastic. Scattered chronic inflammatory cell infiltrates are seen in the subepithelium. However, no giant cells or ossifying tissues were found even on a higher magnification.
Pyogenic granuloma occurs most frequently on the gingiva and that has a strong tendency to recur after simple excision if the associated irritant is not removed. Sometimes, it might be difficult to identify the causative agent; however, lesion's proximity to the gingiva suggests local irritating factors playing an important role in their occurrence.  Long-standing pyogenic granulomas can convert into fibromas showing a reactive fibrogenesis to wall off the chronic long-standing inflammation.  In this case, it is possible that the lesion would have initially started as pyogenic granuloma and later converted to fibroma. Following thorough scaling and root planing with proper oral hygiene instructions, the patient has maintained good oral hygiene, and there was no evidence of recurrence after 6 months.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]