Idiopathic gingival enlargement: A case report

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International Journal of Applied Dental Sciences 2018; 4(2): 14-18

ISSN Print: 2394-7489

ISSN Online: 2394-7497

IJADS 2018; 4(2): 14-18

www.oraljournal.com

Received: 04-02-2018

Accepted: 05-03-2018

Dr. Upendra Prasad

Post-Graduate Student,

Dept. of Periodontics,

Nair Hospital Dental College,

Mumbai, Maharashtra, India

Dr. Praneeta Kamble

Associate Professor,

Dept. of Periodontics,

Nair Hospital Dental College,

Mumbai, Maharashtra, India

Correspondence

Dr. Upendra Prasad

Post-Graduate Student,

Dept. of Periodontics,

Nair Hospital Dental College,

Mumbai, Maharashtra, India

Idiopathic gingival enlargement: A case report

Dr. Upendra Prasad

and

Dr. Praneeta Kamble

Abstract

Idiopathic gingival enlargement is a rare condition characterized by massive enlargement of the gingival

tissue that causes aesthetic and functional problems. Other forms of gingival enlargement also exist such

as genetic, drug induced etc. This case report addresses the diagnosis and treatment of a case of

idiopathic gingival enlargement in a 21-year-old male. The patient presented with generalized diffuse

gingival enlargement involving the maxillary and mandibular arches extending on buccal and

lingual/palatal surfaces and covering incisal/occlusal third of the teeth resulting in difficulty in speech

and mastication since last 10-12 years. Biopsy report confirmed the diagnosis of fibro-epithelial

hyperplasia. Gingivectomy was carried out in all four quadrants.

Keywords: Gingival enlargement, Idiopathic, Gingivectomy, Fibromatosis

Introduction

Idiopathic gingival enlargement (IGE) is a rare condition characterized by massive

enlargement of the gingiva. The enlargement of gingiva is slow and progressive in nature. It is

also known as elephantiasis, idiopathic fibromatosis, gingivomatosis, and hereditary gingival

fibromatosis

[1]

. It may occur as an isolated disorder or may be associated with conditions like

tuberous sclerosis

[2]

and hypertrichosis

[3]

. Various drugs such as calcium channel blockers

[4]

immunosuppressants

[5]

and anticonvulsants

[6]

can lead to massive gingival enlargement. It

may also occur as a part of syndromes like Zimmerman–Laband syndrome

[7]

Jones syndrome

[8]

, Murray‑ Peretic‑ Drescher syndrome

[9]

, Cross syndrome

[10]

, Ramon syndrome

[11]

and

Prune belly syndrome

[12]

Several ongoing investigations are ongoing to establish the exact genetic linkage and

heterogeneity associated with the disease, however the exact etiology is still not known. IGE is

now an established hereditary gingival enlargement (HGE) and the terms IGE and HGE are

used interchangeably

[13]

. Hereditary gingival enlargement displays both an autosomal

dominant mode of inheritance in some patients and an autosomal recessive in other cases.

Males and females are equally affected in this disease

[14]

Clinically IGE is characterized by gingival overgrowth, pink coloured gingiva which is firm in

consistency, and non‑ haemorrhagic

[15]

. IGE can affect both deciduous as well as permanent

dentition, however it has been shown to worsen during adolescence.

This anomaly is classified as two types according to its form. The localized nodular form is

characterized by the presence of multiple enlargements in the gingiva. The most common

symmetric form results in uniform enlargement of the gingiva. Hyperplastic gingival

enlargement may occur during or after the eruption of primary or permanent dentition and

rarely present at birth

[16]

. The most common effect related to gingival enlargement is mal-

positioning of teeth, diastemas, and prolonged retention of primary teeth. In cases of massive

enlargement the teeth are completely submerged, and the enlargement projects into the oral

vestibule resulting in facial disfigurement, difficulty in mastication, and speech.

Treatment of idiopathic gingival enlargement consists of surgical excision of the hyperplastic

tissue to restore gingival contours, but the recurrence rate is very high following surgical

excision

[17]

. Usually, these types of enlargements are associated with minimal local factors

and minimal alveolar bone loss; however, there have been few reports on this rare lesion where

it was associated with aggressive periodontitis.

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International Journal of Applied Dental Sciences

Case report

A 21-year-old male patient reported to the outpatient

department of Periodontics with a chief complaint of swollen

gums since 10-12 years involving all his teeth. The swelling

was aesthetically unpleasing and also causes problem during

speech, articulation, mastication, and causing inadequate lip

apposition. Patient did not undergo any kind of dental

treatment for the above problem. He did not give any history

of drugs intake, fever, anorexia, weight loss, seizures, hearing

loss, nor having any physical or mental disorder. Also familial

and postnatal history was non-contributory.

Clinical examination

Extra-oral examination showed that the patient had bilaterally

symmetrical facial profile and lymph nodes were not

palpable, TMJ movements were normal with incompetent lips

and a convex profile. An intraoral examination revealed

generalized, diffuse, nodular enlargement of the gingiva

involving the upper and lower arches, which were pale pink in

colour, and had a firm and fibrous consistency. The two-third

of the teeth surfaces were covered with enlarged gingiva, fig.

1, 2, 3.

Fig 1: Frontal view

Fig 2: Palatal view

Fig 3: Lingual view

Investigations

Panoramic radiograph showed no bone loss, fig. 4. Carious

lesion were present in 46, 47, 36 and 37. Over-retained

deciduous teeth 53, 71 and 81 were present. Routine blood

investigations were done which was within normal limits.

Excisional biopsy was carried out which was sent for

histopathological evaluation, fig. 5. The Histopathology

revealed the presence of dense connective tissue fibrils and

mild inflammatory cells infiltrates suggestive of fibro-

epithelial hyperplasia, fig. 6.

Fig 4: Panoramic radiograph

Fig 5: Excised

Fig 6: Histopathological slide

Differential diagnosis

Drug-induced enlargement, hereditary gingival enlargement

and idiopathic gingival enlargement.

Diagnosis

The family, medical, and drug histories were non-contributory

in this case; hence it was diagnosed as idiopathic gingival

enlargement.

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International Journal of Applied Dental Sciences

Treatment

After completion of Phase I treatment, a quadrant-wise

gingivectomy was performed under local anaesthesia using

Kirkland knives for incisions on the facial and lingual

surfaces and Orban periodontal knives were used for

interdental incisions. After achieving haemostasis periodontal

dressing was given in all four quadrants to reduce patient

discomfort, fig. 7-12. Post-operative follow-up was done for

the next 6 months which showed no sign of recurrence

Fig 7: Probing depth.

Fig 8: Gingivectomy with Kirkland knives.

Fig 9: Interdental incision with Orban knives.

Fig 10: Haemostasis achieved

Fig 11: Periodontal dressing

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International Journal of Applied Dental Sciences

Fig 12: Preoperative and postoperative comparison after six months

Discussion

Gingival fibromatosis may be congenital or hereditary, the

causes of which are not clearly understood. Hence, the terms

idiopathic gingival fibromatosis and hereditary gingival

fibromatosis are often used interchangeably

[14]

Fibrotic gingival enlargement can also occur after long

duration therapy with drugs like phenytoin

[6]

cyclosporine

[5]

nifedipine

[4]

. Hence use of these drugs should be ruled out.

Gingival fibromatosis may be associated with physical

development, retardation, and hypertrichosis

[3]

. Enlargement

usually begins with the eruption of the permanent dentition

but can develop with the eruption of the deciduous dentition;

rarely it may be present at birth or arise in adulthood

[16]

Maximal enlargement occurs either during loss of deciduous

teeth or in the early stages of eruption of permanent teeth and

progresses rapidly during "active" eruption and decreases

with the end of this stage

. It has been suggested that gingival

enlargement may be due to nutritional and hormonal factors;

however, these have not been completely substantiated. The

constant increase in the tissue mass can result in delayed

eruption and displacement of teeth, arch deformity, spacing,

and migration of teeth

[12]

. All these features may create

problem in normal mastication and in oral hygiene measures.

Maintaining good oral hygiene is important as the presence of

inflammation and infection can be associated with a risk of

recurrence of the gingival enlargement. However, gingival

fibromatosis recurrence is not only due to the presence of

local factors, but also due to genetic predisposition.

Therefore, it is not possible to predict the long-term results of

gingival fibromatosis treatment even when associated with

good oral hygiene.

Histologically, the gingival fibromatosis is mainly due to an

increase in numbers of fibroblast in the connective tissue

stroma. The nodular appearance can be attributed to the

hyperkeratinized epithelium. The treatment of choice in this

condition was gingivectomy as bony intervention was not

required. Since recurrence can occur within a few months

after surgery and may return to the original condition within

few years, the patient may have to undergo repeated

gingivectomy procedures. However, in this patient there was

no sign of recurrence for the six months follow up period.

Conclusion

Therefore, long-term follow-up is mandatory for maintenance

and to evaluate the predictability of the surgical treatment and

the recurrence of the gingival enlargement. IGE is an

enlargement of genetic predisposition and unknown etiology

and hence the rate of recurrence is very high impending the

normal functions and esthetics of the patient.

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