Gingival enlargements are quite common and may be either inflammatory, noninflammatory, or a combination of both. Gingival hyperplasia is a bizarre condition causing esthetic, functional, psychological, and masticatory disturbances of the oral cavity. Causes of gingival enlargement can be due to plaque accumulation, due to poor oral hygiene, inadequate nutrition, or systemic hormonal stimulation (Bakaeen and Scully, 1998). It can occur as an isolated disease or as part of a syndrome or chromosomal abnormality. A progressive fibrous enlargement of the gingiva is a facet of idiopathic fibrous hyperplasia of the gingiva (Carranza and Hogan, 2002; Gorlin et al., 1976). It is described variously as
Idiopathic gingival fibromatosis is characterized by a slowly progressive, benign enlargement, which affects the marginal gingiva, attached gingiva, and interdental papilla. The fibromatosis may potentially cover the exposed tooth surfaces, causing esthetic and functional problems, and in extreme cases may distort the jaws. Gingival tissues surrounding both the maxillary detention and the mandibular dentition may be affected. The hyperplasic gingiva usually presents a normal color and has a firm consistent with abundant stippling [
Syndromes associated with gingival fibromatosis [
Syndrome | Clinical features | Mode of inheritance |
---|---|---|
Laband syndrome | Syndactily, nose, and ear abnormalities, hyperplasia of the nails, and terminal phalanges | Dominant |
Rutherfurd syndrome | Corneal dystrophy | Dominant |
Cross syndrome | Microphthalmia, mental retardation, and pigmentary defects | Recessive |
Ramon syndrome | Hypertrichosis, mental retardation, delayed development epilepsy, and cherubism | Recessive |
A 30-year-old woman reported complaining of disfigurement of face due to swelling in gums since seven years, which was causing functional and masticatory difficulty. She presented with a generalized severe gingival overgrowth, involving the maxillary and mandibular arches and covering almost the whole dentition. The patient was also concerned about the progressively increasing space between her upper front teeth and their movement away from their original positions. Extra oral examination (Figure
Preoperative photograph with fullness of face.
Patient’s medical and family history was noncontributory
Intraoral examination revealed enlargement of the gingiva on both buccal and lingual/palatal sides with pinkish red, fibrous inconsistency and absence of stippling. Gingival enlargement enclosed the major surface of the teeth present except the incisal/occlusal surfaces. Severe diffuse enlargement involving the marginal, interdental, and attached gingiva of both arches, covering almost all the surfaces of the teeth, was found. There was generalized spacing in the dentition with proclined maxillary anteriors (Figure
Preoperative intraoral picture of generalized gingival fibromatosis.
Frontal view
Facial view
Mandibular arch fibromatosis
Maxillary arch fibromatosis
Clinical examination revealed mobility in all the teeth present and severe pathologic migration, especially of the upper anterior teeth. There were deep pockets present and there was an increase in the intermaxillary rest position. Physical examination of the whole body and blood investigations were advised to eliminate any medical abnormalities.
The radiographic findings corroborated those of the clinical examination and revealed severe generalized alveolar bone loss, which could be attributed to the local factors which must have exaggerated the hyperplastic condition. The peripheral blood results were normal and correlated with an absence of any history of systemic disease. Based on all these findings, a provisional diagnosis of idiopathic gingival enlargement was made.
Treatment decided was full mouth undisplaced flap surgery.
After routine phase one periodontal therapy a treatment plan was formulated which comprised of quadrant-wise undisplaced flap surgery (the only treatment of choice in this condition as we had to treat the patient’s underlying periodontal disease). The treatment procedure was explained to the patient and written consent was obtained. The surgery was planned under local anesthesia containing 2% lignocaine with 1 : 200000 epinephrine. Undisplaced flap surgery was performed to excise desired quantity of soft tissue. The wound was irrigated with betadine and a Coe-Pak (noneugenol, hard, and fast set) was given for seven days. Patient was advised to take analgesics and rinse twice daily with 0.2% chlorhexidine mouthwash. The excised tissue was sent for histopathological evaluation.
The sections revealed moderately dense collagenous connective tissue with collagen bundles arranged in a haphazard manner. Connective tissue was relatively avascular along with scanty inflammatory cell infiltrate showing dense wavy bundles of collagen fibers containing numerous fibrocytes and fibroblasts. The overlying epithelium was hyperplastic with elongated rete ridges. The histopathologic features led to the final diagnosis of idiopathic gingival fibromatosis.
The case was followed up for 6 weeks postoperatively and then every 3 months for 2 years. The mobility of the teeth was reduced to physiologic at the end of 3 months. No recurrence was observed within 2 years. Patient is still following the follow-up regime. Mild recurrence in the right maxillary posterior palatal segment was seen after 1 year (Figure
Postoperative intraoral picture of generalized gingival fibromatosis.
Frontal view
Facial view
Facial view
Maxillary view
Mandibular view
This paper reports a case of idiopathic gingival fibromatosis. It may be congenital or hereditary. Gingival overgrowth varies from mild enlargement of isolated interdental papillae to segmental or uniform and marked enlargement affecting one or both jaws [
The precise mechanism of idiopathic gingival fibromatosis is unknown, but it is seen often to confine to the fibroblasts which harbor in the gingivae. The hyperplastic response does not involve the periodontal ligament and occurs peripheral to the alveolar bone within attached gingivae [
There is inconsistency in the literature as to the cellular and molecular mechanisms that lead to gingival fibromatosis. Some authors report an increase in the proliferation of gingival fibroblasts [
The surgical treatment of choice is the gingivectomy, which was first advocated for drug-induced gingival enlargement in 1941. As there is, in nearly all circumstances, adequate attached gingiva, there is little fear of creating mucogingival problem with this technique. However, in this case we opted for undisplaced flap procedure to treat the patient’s periodontal disease as well as to improve esthetics. Since the literature reports high recurrence rate after surgery present case has been monitored closely for improvement in her periodontal condition for two years with a mild recurrence in the right maxillary posterior palatal segment. Patient was advised to maintain good oral hygiene to minimize the effect of inflammation on fibroblasts.
Our present case was of nonsyndromic idiopathic gingival enlargement, with its surgical management and followup for a period of two years. Treatment was undisplaced flap surgery, which appreciably improved the patient’s aesthetic and masticatory competence as well as her periodontal condition.
This study was self-funded by the authors and our institution and there is no conflict of interests.