Jou

rnal o

f ICD

RO

• Volu

me 8 • Issu

e 2 • July - D

ecemb

er 2016 • Pag

es ?-?

??

Website:www.jicdro.org

Perio - Endo - ImplantJUL-DEC 2016 / VOL-8 / ISSUE NO-2

Print ISSN: 2231-0754, E-ISSN: 2231-5357

124 © 2016 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow

INTRODUCTION

Hullihen’s description in 1844 was most likely the first pyogenic granuloma reported in English literature.[1] Pyogenic granuloma was first originally described in 1897 by two French surgeons, Poncet and Dor, who named this lesion otyomycosis hominis.[2] The term “pyogenic granuloma” or “granuloma pyogenicum” was coined in 1904 by Hartzell.[3] The name pyogenic granuloma is a misnomer since it neither contains pus nor represents a granuloma histologically. In actually, it is a capillary hemangioma of lobular subtype as suggested by Mills et al., which is the reason, they are often quite prone to bleeding.[4] Pyogenic granuloma is also known as pregnancy granuloma or granuloma gravidarum or pregnancy tumor or tumor of pregnancy when occurring in a pregnant woman. Cawson et al. in dermatological literature have described it as “granuloma telangiectacticum” due to the presence of numerous blood vessels seen in histologic sections.[5]

Address for correspondence: Prof. Awadhesh Kumar Singh, 2/108, Vibhav Khand, Gomati Nagar, Lucknow - 226 010, Uttar Pradesh, India. E-mail: draksinghlko@gmail.com

Pyogenic granuloma is a common tumor‑like growth of oral cavity or skin that is considered to be non‑neoplastic.[6,7] Jafarzadeh et al. defined pyogenic granuloma as an inflammatory overgrowth of the oral mucosa caused by minor trauma or irritation.[2] According to Neville et al., these injuries might be caused in the mouth by gingival inflammation due to poor hygiene, trauma, or local infection.[6]

Pyogenic granuloma is manifested as a sessile or pedunculated, resilient, erythematous, exophytic, and papule or nodule with a smooth or lobulated surface that bleeds easily.[2] The gingiva is the most commonly affected site by pyogenic granuloma, accounting for 75% of all cases.[8] Although occurrence of

Access this article onlineWebsite: www.jicdro.orgDOI: 10.4103/2231-0754.186426Quick Response Code:

Lateral pedicle graft for repair of residual gingival defect following complete surgical excision of a pyogenic granulomaAwadhesh Kumar Singh, Abhisek GautamDepartment of Periodontology, Chandra Dental College and Hospital, Barabanki, Uttar Pradesh, India

ABSTRACT

The pyogenic granuloma, one of the gingival lesions, has recurrence rate of 16%. To minimize the recurrence rate, it must be completely excised. Complete surgical excision can result in residual gingival defect. McCrea repaired residual gingival defect by subepithelial connective tissue graft with lateral mucogingival pedicle flap,andChoudharyet al. managed residual gingival defect by subepithelial connective tissue graft only. The aim of this case report was to use lateral pedicle graft for repair of residual gingival defect following complete surgical excision of a pyogenic granuloma. A patient with pyogenic granuloma on labial surface of maxillary central incisors was treated by complete surgical excision, and residual gingival defect was repaired by lateral pedicle graft. A lateral pedicle graft was raised as full-thickness up to mucogingival line and partial-thickness apical to mucogingival line from the left side of residual gingival defect. After 6 months, no recurrence was noticed. Thus, lateral pedicle graft can be potentially used for repair of residual gingival defect following complete surgical excision of a pyogenic granuloma.

Key words: Lateral pedicle graft, pyogenic granuloma, residual gingival defect

Cite this article as: Singh AK, Gautam A. Lateral pedicle graft for repair of residual gingival defect following complete surgical excision of a pyogenic granuloma. J Int Clin Dent Res Organ 2016;8:124-8.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

For reprints contact: reprints@medknow.com

CasE rEport

Singh and Gautam: Lateral pedicle graft for residual gingival defect repair

125Journal of the International Clinical Dental Research Organization | July-December 2016 | Vol 8 | Issue 2

these lesions on the lips, tongue, oral mucosa, and palate has also been reported.[6] Lesions are slightly more common on the maxillary gingiva than the mandibular gingiva, anterior areas are more frequently affected than posterior areas. Furthermore, these lesions are much more common on the facial aspect of the gingiva than the lingual aspect, some extent between the teeth and involve both the facial and lingual gingiva.[2] According to Vilmann et al., the majority of pyogenic granuloma are found on the marginal gingiva with only 15% of the tumors on the alveolar part.[7]

Conservative surgical excision and removal of causative irritants (plaque, calculus, foreign material, and source of trauma) are the usual treatments for gingival lesions. Recurrence of pyogenic granuloma after excision is known complication which is said to be 16% of the treated lesions.[2] Complete surgical excision is associated with a low risk of recurrence.[9] To minimize the possibility of recurrence, soft tissue lesions should be excised down to bone. In the maxillary anterior area, complete surgical excision of an epulis can create a mucogingival defect and leave the patient with a significant cosmetic problem unless appropriate efforts are taken to repair the residual gingival defect. A subepithelial connective tissue graft together with a lateral mucogingival pedicle flap was used by McCrea to repair the extensive defect after simply removing an epulis.[10] Subepithelial connective tissue grafting was done by Choudhary et al. after excision of an epulis for the management of residual gingival defect.[11] To harvest connective tissue graft, a second surgical site, usually in the palatal premolar area is needed, therefore increasing patient morbidity. The aim of this case report was to use lateral pedicle grafting for repair of residual gingival defect following complete surgical excision of a pyogenic granuloma.

CASE REPORT

A 60‑year‑old female patient had a chief complaint of gum enlargement in her upper front teeth region since 1 year which caused difficulty during chewing. It started from a small pea size painless growth from gingival margin and gradually increased to the present size. On intraoral examination, a sessile, erythematous, underlying surface ulcerated, tender, nonlobulated nodular growth measuring about 19.5 mm × 19.0 mm × 14.5 mm which covered more than two‑thirds of crown was present on labial surface of maxillary central incisors [Figure 1]. Intraoral periapical radiograph showed interdental bone loss [Figure 2].

Patient underwent basic periodontal treatment of Phase I therapy including scaling, root planing, and instructions for proper oral hygiene measures. After 3 weeks of Phase I therapy, surgery was planned. At the time of surgery, informed

written consent was taken from the patient. This case report was approved by the Institutional Ethical Committee for human subjects and was also conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000.

The patient was instructed to do presurgical rinse by 0.2% chlorhexidine gluconate solution. The facial skin around the mouth was cleaned with spirit and scrubbed by 5.0% povidone iodine solution. After proper part preparation, 2% lignocaine hydrochloride with 1:80,000 adrenaline was administered to anesthetize infraorbital nerves. After local anesthesia, a complete surgical excision of the pyogenic granuloma was performed with approximately 1 mm beyond its borders. All soft tissues at the site including periosteum were removed down to bone to prevent recurrence; as a result, there was a residual gingival defect [Figure 3]. Excised tissue was sent for biopsy [Figure 4]. After excision, exposed root was scaled, planed, and washed with saline water. A lateral pedicle graft was raised as full‑thickness up to mucogingival line and partial‑thickness apical to mucogingival line from the left side of residual gingival defect, using a submarginal incision, a vertical incision from distal end of submarginal incision and a cutback incision from apical end of vertical incision [Figure 5]. Lateral pedicle graft was prepared in such a manner that it should exceed the width of the residual gingival defect of approximately 3 mm. Lateral pedicle graft was mesially and coronally positioned overlying the residual gingival defect and sutured to cover it with minimal tension [Figure 6].

Histopathological examination showed tissue lined by partly ulcerated stratified squamous epithelium with rete pegs deepened into papillary connective tissue [Figure 7]. Underlying connective tissue consisted of lobulated aggregates of proliferating capillaries with intervening fibrous stroma showing mild inflammatory infiltrates comprised lymphocytes and histiocytes. No neoplastic pathology was

Figure 1: pyogenic granuloma on labial surface of maxillary central incisors

Singh and Gautam: Lateral pedicle graft for residual gingival defect repair

126 Journal of the International Clinical Dental Research Organization | July-December 2016 | Vol 8 | Issue 2

identified [Figure 8]. Histopathological findings confirmed that it was a capillary hemangioma of lobular subtype [Figure 9].

Antibiotics and analgesic were prescribed. Patient was instructed not to masticate meals from anterior teeth and

not to brush the teeth in the treated area for 2 weeks but to rinse 0.2% chlorhexidine gluconate mouthwash twice daily for 1 min. After 2 weeks, sutures were removed [Figure 10]. Patient was advised to clean teeth by extra soft toothbrush

Figure 2: intraoral periapical radiograph showed interdental bone loss Figure 3: after complete excision of pyogenic granuloma

Figure 4: excised pyogenic granuloma Figure 5: lateral pedicle graft

Figure 6: lateral pedicle graft sutured over the residual gingival defect Figure 7: stratified squamousepitheliumwith elongatedand interconnectedrete pegs

Singh and Gautam: Lateral pedicle graft for residual gingival defect repair

127Journal of the International Clinical Dental Research Organization | July-December 2016 | Vol 8 | Issue 2

and continue mouthwash for another 2 weeks. After this period, routine oral hygiene procedures could be reintroduced.

Patient was recalled at every week in the 1st month and then every month up to 6 months. At each recall visits, oral prophylaxis and motivation for routine oral hygiene procedures were done. After 6 months, no reappearance of pyogenic granuloma was noted, and residual gingival defect was completely disappeared [Figure 11].

DISCUSSION

Standard treatment therapy for pyogenic granuloma remains that of complete surgical excision plus root planing of the affected tooth though the injection of penicillin into the infected site[12] or the use of CO2 laser[13,14] has been proposed. The recurrence of the pyogenic granuloma is often seen.[10]

Natural history of pyogenic granuloma follows three distinct phases. In the cellular phase, lobules are compact and cellular with little lumen formation. In the capillary phase, lobules become frankly vascular with abundant intraluminal red blood

cells. One or more central vessels develop a large lumen with a thick muscular layer resembling a vein. In the involutionary phase, there is a tendency of intra‑ and peri‑lobular fibrosis with increased venular differentiation.[2]

As periodontal patients become more aware of their periodontal conditions, periodontists must face the challenges raised by the demanding patients. Periodontal defects such as residual gingival defect/cosmetic gingival defect are becoming a greater concern for patients. Loss of gingival tissue following surgical techniques can be construed as mismanagement and contribute to a breakdown in the patient/surgeon professional relationship. Although the surgeon selects the technique to be used, it is the patient who judges surgery results. Therefore, it seems reasonable to reconstruct tissue to produce an esthetic result to the satisfaction of the patient wherever possible.[10]

McCrea reported a case of microsurgical repair of labial gingival tissues following excision of an epulis by subepithelial connective tissue graft together with a lateral mucogingival pedicle flap.

Figure 8: lobules of capillaries

Figure 9: lobular capillaries hemangioma type of pyogenic granuloma

Figure 10: two weeks postoperative, after sutures removal Figure 11: six months postoperative, no recurrence of pyogenic granuloma

Singh and Gautam: Lateral pedicle graft for residual gingival defect repair

128 Journal of the International Clinical Dental Research Organization | July-December 2016 | Vol 8 | Issue 2

He followed 18 months and found that the methodology was to both preserve and improve the mucogingival complex.[10] Choudhary et al. described periodontal plastic procedure for the management of the residual gingival defect after excision of an epulis. They found that simultaneous placement of subepithelial connective tissue grafting after excision of the lesion seems to be a viable surgical option in such cases because this will avoid second surgical procedure for the management of the residual gingival defect.[11]

Grupe and Warren described sliding flap operation for repair of gingival defect comprising the use of a full‑thickness pedicle flap moved horizontally to cover the denuded root; this may consequently lead to the exposure of the donor area’s root and bone tissue.[15] To reduce the risk of gingival recession and bone dehiscence at the donor site, original procedure has been modified by Grupe in such a way that the coronal half of gingiva is undisturbed. For this, he used a submarginal incision to preserve the marginal gingiva at the donor site.[16] This modified technique of the sliding flap operation was employed in this case report to repair the residual gingival defect resulting from complete surgical excision of a pyogenic granuloma. This 1‑stage procedure allows predictable repair of residual gingival defect in the attached gingiva and yields an excellent color blend with the adjacent tissues. However, this approach cannot be used if the lateral donor site lacks an adequate band of attached gingiva, or if a shallow vestibule is present. In addition, precautions must be taken if the facial bone at the donor site could potentially have a fenestration or dehiscence. A split‑thickness flap or another surgical approach should be used in this cases.[17]

Like other studies, this case report of the lateral pedicle graft for repair of residual gingival defect following complete surgical excision of a pyogenic granuloma has certain limitations. The technique, although simple, needs surgical dexterity for the operator, especially during the reflection of lateral pedicle graft as full‑thickness up to mucogingival line, which is firmly attached to the underlying bone and in making partial‑thickness graft apical to mucogingival line.

CONCLUSION

It is customary to manage pyogenic granuloma by aggressive complete surgical excision. Lateral pedicle graft may potentially be one approach used to repair the resultant residual gingival defect following complete surgical excision of a pyogenic granuloma and minimize patient esthetic considerations. Furthermore, this technique will avoid the second surgical site for the management of the residual gingival defect. Long‑term follow‑up is extremely important following complete surgical excision of a pyogenic granuloma because of the risk of recurrence.

Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

REFERENCES

1. HullihenSP.Caseof aneurismbyanastomosisof the superiormaxillae.AmJDentSci1844;4:160‑2.

2. JafarzadehH, SanatkhaniM,MohtashamN.Oral pyogenicgranuloma:Areview.JOralSci2006;48:167‑75.

3. Hartzel l MB. Granuloma pyogenicum. J Cutan DisSyph1904;22:520‑5.

4. MillsSE,CooperPH,FechnerRE.Lobularcapillarieshemangioma:Theunderlyinglesionofpyogenicgranuloma.Astudyof73casesfromtheoralandnasalmucousmembranes.AmJSurgPathol1980;4:470‑9.

5. CawsonRA,BinnieWH,SpeightPM,BarrettAW,Wright JM.LucasPathology ofTumors ofOral Tissues. 5th ed.Missouri:Mosby;1998.p.252‑4.

6. NevilleBW,DammDD,AllenCM,BouquetJE.Softtissuetumors.In:OralandMaxillofacialPathology.3rded.Netherlands:ElsevierPublication;2004.p.176‑7.

7. VilmannA, Vilmann P, VilmannH. Pyogenic granuloma:Evaluation of oral conditions. Br J OralMaxillofac Surg1986;24:376‑82.

8. LinRL,JannigerCK.Pyogenicgranuloma.Cutis2004;74:229‑33.9. MatsumotoK,NakanishiH, Seike T,KoizumiY,MiharaK,

KuboY.Treatmentofpyogenicgranulomawithasclerosingagent.DermatolSurg2001;27:521‑3.

10. McCreaSJ.Microsurgicalrepairoflabialgingivaltissuesfollowingexcisionofanepulis:Acasereportwith18‑monthfollowup.OralSurg2009;2:126‑35.

11. ChoudharyV,WarrierS,KaurA,SahooNK.Periodontalplasticprocedureforthemanagementoftheresidualgingivaldefectafterexcisionofanepulis.JIndianSocPeriodontol2015;19:345‑7.

12. elWadyW,LazrakH,CantaloubeD. In situ penicillintherapyinthetreatmentofepulis.MedTrop(Mars)1998;58:149‑54.

13. KomoriT,YokoyamaK,TakatoT,MatsumotoK.CasereportsofepulistreatedbyCO2laserwithoutanesthesia.JClinLaserMedSurg1996;14:189‑91.

14. HallettKB,BankierA,ChowCW,BatemanJ,HallRK.Gingivalfibromatosis andKlippel‑Trénaunay‑Weber syndrome.Casereport.Oral SurgOralMedOral PatholOral Radiol Endod1995;79:578‑82.

15. GrupeHE,WarrenRF.Repairofgingivaldefectsbyaslidingflapoperation.JPeriodontol1956;27:92‑5.

16. GrupeHE.Modified technique for the slidingflapoperation.JPeriodontol1966;37:491‑5.

17. WaltersJD,WillJK,HatfieldRD,CacchilloDA,RaabeDA.Excisionandrepairoftheperipheralossifyingfibroma:Areportof3cases.JPeriodontol2001;72:939‑44.