MANAGEMENT OF IDIOPATHIC GINGIVAL FIBROMATOSIS - A CASE REPORT

Presented byDr.Nagesh DolarePost graduate student

Guided byDr. R.K. YeltiwarProf & Head

Department of periodonticsGovernment Dental College & Hospital, Nagpur

Gingival enlargement is defined as an overgrowth or increase in the size of gingiva

Classification

Based on the etiological factors and pathological factors:

I. Inflammatory enlargement

II. Drug induced enlargement

III. Enlargements associated with systemic disease or conditions

IV. Neoplastic enlargement

V. False enlargement

Degree of enlargement

Grade I: No signs of gingival enlargement

Grade ΙΙ: confined to interdental papilla

Grade ΙΙΙ: involve papilla and marginal gingiva

Grade VI: enlargement covers three quarters or more of the crown

• Idiopathic gingival enlargement is a rare (1:750000) condition of undermined cause

• The term “Gingival fibromatosis” is used for those cased which have an hereditary pattern, are part of a more extensive syndrome or idiopathic

• It appears as an isolated disorder or may sometimes be associated with other conditions like epilepsy, hypettrichosis and mental retardation or associated with syndromes

• Males and females are equally affected

• Idiopathic gingival fibromatosis primarily present in childhood

Clinical features

The facial and lingual surfaces of mandible and maxilla are generally affected or either jaws

Pink, firm, leathery in consistency and pebbled surfaces

In severe cases, the jaws appear bulbous.

Clinical features

The resultant effect may include speech difficulty and painful mastication as food deflects onto the enlarged tissue.

Other common side effects : diastema, malocclusion and prolonged retention of primary teeth.

The enlarged tissue creates retention for plaque

Management

• Factors to consider in treatment planning :

- esthetic

-functional needs

-onset of puberty because recurrence is predominately observed in children and teenagers rather than in adults.

Management

• Controversy regarding when treatment should be performed.

Minimal Gingival Enlargement:- Thorough scaling and home care.

Severe Gingival Enlargement:- Surgical removal of enlarged gingiva and extraction of all teeth and reduction of the alveolar bone to prevent recurrence.

Management

Technique

Internal or external bevel gingivectomy

Electrocautery Lasers

External bevel Gingivectomy

Advantages: Simplicity and quickness

Disadvantages :

Post-operative discomfort Increased chance post-operative bleeding Sacrifices keratinized tissue Does not allow for osseous recontouring

Laser

Advantages : Ability to coagulate and seal blood vessels Vaporize the tissue Make accurate incisions and Improve healing because of its antimicrobial

properties.

• A 13 years girl came with complaint of generalized gingival overgrowth

• Slowly increasing in size

Right side Left side

Medical History

The patient’s medical history was normal.

She did not exhibit any signs of hypettrichosis or mental retardation or syndrome and did not take any medication that could be associated with gingival hyperplasia.

Family history

There was no family history of similar types of gingival enlargement

Clinical Examination

• The extra-oral examination did not reveal any abnormality.

• The intra-oral examination revealed generalized, severe gingival hyperplasia involving both buccal and lingual regions in the maxillary and mandibular arches except left side of mandibular arch.

• The enlarged gingival tissues covered two-thirds or more of the clinical crowns of almost all teeth, and the palate was deformed by the excessive gingival tissue.

• Hence provisional diagnosis - idiopathic gingival enlargement was arrived at

Pre-operative cast

Investigations

1. Panoramic radiographic

2. Complete haemogram

Internal bevel incision

Pre-operative view

Interrupted figure-eight suture placed

1 month post-operative

Pre-operative

Post-operative: 6 months

Internal bevel gingivectomy

Objectives:It removes the pocket lining

It conserves the relatively uninvolved outer surface of the gingiva

It produces sharp, thin gingival margin for adaptation to the bone-tooth junction

Histological Features

Densely arranged collagen bundles numerous fibroblasts, and connective tissue that is relatively avascular.

Histological Features

Thickened and acanthotic epithelium also is present with elongated rete pegs

Few chronic inflammatory cells

Discussion

• Gingival enlargement can be caused by inflammation, systemic diseases such as leukemic infiltration and medication use such as cyclosporine, phenytoin, or nifedipine.

• In this case a diagnosis of idiopathic gingival enlargement was made because the patient was not under any medication that could lead to gingival enlargement, no significant family history was present and the patient did not exhibits any signs of syndrome

• The suggested treatments of idiopathic gingival enlargement vary according to the complete eruption of permanent teeth and the severity of the enlargement

• Minimal gingival enlargement :Scaling and root planing of teeth and sufficient homecare suffices in cases of minimal gingival enlargement

• Surgical intervention is required when enlarged tissues impair function and appearance and act as a barrier to the eruption of teeth

• Bozzo et al. and Bittencourt et al. suggested a conservative approach with their cases based on the patient’s condition and reports in the literature.

• However some authors recommend excision of the excess tissue combined with removal of all teeth in severe cases and suggest the condition does not recur if the teeth are extracted.

The most widely used surgical approach is the gingivectomy/ gingivoplasty

• In this case quadrant-by-quadrant internal bevel gingivectomy and extraction of over retained teeth #53 and #74 done

Conclusion• Gingival enlargement is prevalent disease in

child, conferring to the periodontist and pedodontist an important role in the correct diagnosis and treatment of affected patients.

• Gingival enlargement when present in child represent not only a pathologic situation but also functional and esthetic impediment hence prompt correction of this condition is a at most importance