Pandian R1, Pradeep KY1, Kalaivani V1

Affiliations:

1. Department of Periodontology, SRM Kattankulathur Dental College, SRM University, Chennai, India

Corresponding author:

Pradeep Kumar Yadalamyadalam1980@gmail.com

Laser versus conventional surgery in management of hereditary gingival fibromatosis - Case series

ABSTRACTPurpose: The goal of the presente article is to help the clinican to compare the clinical outcome of gingivectomy with laser versus conventional surgery.Case report: A 15 yrs old male patient reported with generalized hereditary gingival enlargement with clinical aspect of gingiva covering one third of den-tal crowns. No exposure to drugs like phenytoin, cyclosporine or calcium channel blockers such as nifedipine. There was no other medical history such as bone deformities or mentally retardation.Family history reveals hereditary gingival enlargement. On examination of pa-tient “A” siblings also showed similar characteristic gingival features. Based on these facts differential diagnosis was made between “drug induced gingival enlargement” and “hereditary gingival fibromatosis” and confirmed with his-topathological findings. Conclusions: Patients were subjected to 2 modalities of treatment in a split mouth; laser and conventional gingivectomy. Patient was more comfortable (was measured on a scale from 1 to 10 using visual analog scale) during and after treatment and healing was also faster and recurrence was delayed in la-ser techique.

KEYWORDSHereditary gingival fibromatosis, laser, gingivectomy.

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INTRODUCTIONHereditary Gingival Fibromatosis, also known as idio-pathic gingival hyperplasia, is a rare condition of gingival overgrowth. HGF is characterized as a benign, slowly pro-gressive, non-hemorrhagic, fibrous enlargement of kerati-nized gingiva. It is may be inherited as autosomal domi-nant trait and are usually non-syndromic.3, 4 According to many researchers it may due to mutation in son-of-sev-enless gene.1, 5, 6 The SOS1 is a guanine nucleotide-ex-change factor that functions in the transduction of signals that control cell growth and differentiation. A mutation in the SOS1 gene results in a single nucleotide insertion.6

Common clinical findings of HGF are nodular form or uni-form enlargement of the gingiva. The degree of gingiva overgrowth varies considerably, even among members of an affected family. There is variability in the number of teeth involved (extent) and the volume of excess gingi-va (severity). The gingival overgrowth can result in: halito-sis, mal alignment, diastemas, periodontal problems, pro-longed retention of deciduous teeth, delayed eruption of permanent teeth, aesthetic disfigurement, lip protrusion. The enlargement may project into the vestibule and floor of the mouth, interfere with normal mastication and even lip closure that make the speech difficult. The enlarging gingival tissue appears firm and pink with exaggerated stippling and it can involve the buccal and lingual tissues of both maxillary and mandibular arches.3,7 Local involve-ment mainly affects the maxillary tuberosities and lingual surfaces of lower molars,3, 7 and is typically characterized by the presence of multiple large masses. The symmet-ric form, which is the most common type of Hereditary Gingival enlargement results in uniform enlargement of the gingiva that is firm, dense, resilient, insensitive fibrous tissue that covers the alveolar ridges and extends over the teeth resulting in extensive pseudo pockets.8 The de-gree of enlargement may vary from mild to severe and may be the same between the individuals of the same family.3 HGF is seldom present at birth but may be noted at an early age. It usually begins at the time of eruption of permanent dentition but can develop with the eruption of primary dentition. If the enlargement is present before tooth eruption the dense fibrous tissue may interfere with or prevent the eruption.9 The most common effects re-lated to gingival overgrowth are diastemas, mal-position-ing of teeth, and prolonged retention of primary teeth8, increasing mobility of teeth1, abnormally shaped teeth and abnormal movement of teeth5, inflammation and/or

swelling of the gingiva.10, 11 Not necessarily any sign of pain but experiencing pain is possible.1 The histopathology of the excessive gingiva tissue shows dense fibrous connec-tive tissue (collagen, elastin and oxytalan fibres) with re-duced numbers of blood vessels. The overlying epithelium is often thickened with characteristic elongated rete pegs reaching deep into the connective tissue. Gingival hyper-plasia could be directly associated to three factors such as genetic susceptibility, dental plaque, and drugs and their metabolites.

CASE REPORTSThis article compares two different approaches name-ly conventional and laser gingivectomy in management of hereditary gingival fibromatosis in 3 patients in terms of healing, patient compliance, hemorrhage using split mouth design.

CASE REPORT: 1A 15-year-old male patient reported to the Department of Periodontics with a chief complaint of swollen gums involv-ing all his teeth since last three to four years preventing functions like proper speech, articulation, and mastication and also shows poor esthetics. Lips were incompetent. Patient gives familial history of enlargement involving all his siblings. He did not give any history of drugs intake, fe-ver, anorexia, weight loss, seizures, hearing loss, nor hav-ing any physical or mental disorder. Also familial and post-natal history was non-contributory.

CASE REPORT: 2 AND 3Siblings of patient “A” of same family reported to the Department of Periodontics with a chief complaint of swollen gums involving all their teeth with same features of patient one. Patient “B” was 12 years old female and patient “C” was 10 years old female with mixed dentition.

EXAMINATIONExtra-oral examination revealed that the patient has in-competent everted lips and a convex profile. An intraoral examination revealed generalized, diffused enlargement of the gingiva of upper and lower arches, involving at-tached gingiva, marginal gingiva and interdental papilla. Which were pale pink in color, and very firm and fibrous consistency (Figure 1). The teeth were barely visible as the enlarged gingiva covered till the incisal/occlusal third of the teeth.

Figure 1. Preoperative images of idiopathic gingival enlargement with frontal and lateral views

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The probing depth were measured using standardized pressure sensitive probe, the clinical attachment level (CAL) was assessed to determine the presence of a true or a pseudo pocket for all 3 patients.Panoramic radiograph revealed no bone loss (Figure 2). Hematological investigations were within normal limits. Incisional biopsy was carried out to confirm the diagnosis.

HISTOPATHOLOGICAL RESULTS It reveals bulbous increase in the connective tissue, which had densely arranged collagen fiber bundles, numerous elongated fibroblasts and less chronic inflammatory cells. The overlying epithelium exhibited hyperplasia and elon-gated rete pegs. Same histological features were exhibit-ed by all patients of this study.

TREATMENT PLANThorough examinations of extra and intraorally provision-al diagnosis were confirmed through investigations like Orthopantomogram (OPG), routine blood test, and inci-sional biopsy with an informed consent. After the inves-tigation the patients were informed about the diagno-sis and also about required treatment and its outcome. Patient and their parents were also aware of this study. After the consent from the patients and their parents, they underwent gingivectomy procedure using both Kirkland’s and Orban’s gingivectomy knife, and laser method.TREATMENT DONE: Ultrasonic scaling was done using top-ical anesthesia with 15% Lignocaíne spray and root plan-ning was done by infiltrating lignocaíne 2% +epinephrine 1:80000 which could increase the chromophore hemo-globin in fibrotic tissue sensitizing to laser. Personal oral hygiene was instructed. We followed conventional gingi-vectomy for one arch (Figure 3a) and diode laser (Picasso AMD LASERS, 810nm) with a 400-μm initiated tip and set on continuous mode at 0.6 to 1.2W for the anterior or 1.0 to 1.8W for the posterior (Figure 3b) for other arch.12 Patients were administered with local anesthesia (infiltra-tive and regional) for conventional gingivectomy. For laser gingivectomy only topical anesthesia was used. Though the tissue appeared to be pale and firm, the conventional gingivectomy showed more hemorrhage compared to la-sers site (Figure 3).Pain level was mesured on a scale from 1 to 10 using visual analog scale and it was found that pain experience in laser site was very much less when compared to con-ventional site.

RESULTSDuring conventional gingivectomy bleeding was more in-tense compared to lasers. The follow-up period was as-sessed at an interval of 1 week, 1month, 3 months, 6 month and 1 year and was showed faster healing in laser sites using healing index compared to conventional gingi-vectomy. Healing index (Huang et al. 2005) scored 1 in la-sers sites compared to conventional surgery.After 1 year follow up gingiva appears pink, firm, resilient in consistency with scalloped marginal gingival well adapt-ed to the tooth structure (Figure 4). Recurrence was higher in conventional gingivectomy site compared to laser sites.

DISCUSSIONThis article reports a family case of hereditary gingival fi-bromatosis. Those cases presented here can be consid-ered a severe variant of HGF with no signs or symptoms relating to any syndrome.The diagnosis was made on the basis of clinical presenta-tion, family history and histopathological features. In the present cases, the gingival enlargement was a hereditary condition, probably autosomal dominant, due to its ex-istence in siblings, although their parents were normal.

Figure 2. Orthopantomography showing mild horizontal bone loss with erupting third molars

Figure 3. Laser gingivectomy site shows less bleeding compared to scal-pel method (3a. conventional gingivectomy, 3b. laser gingivectomy)

b

a

Figure 4. Follow-up 1 month showing the sites interventioned

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Moreover, it was unrelated to endocrine problems or use of medications. The histopathological features of the present cases were classic of hereditary gingival fibroma-tosis. The tissue showed excess amount of collagen in an avascular connective tissue with overlying epithelium. The treatment need varies according to the degree of severi-ty, when the enlargement is minimum, good scaling of the teeth and home care may be essential to maintain good oral health. The relative increase in the gingival mass con-templates the need for surgical intervention owing to the functional and aesthetic compromise. We planned surgi-cal intervention with laser on one arch and conventional on another arch. The present study showed better results for laser gingivectomy compared to conventional sites. Less bleeding, less recurrence, better patient compliance, better and faster healing was noticed in laser sites com-pared to surgical method.

CONCLUSIONSRecurrence after HGF treatment is the important criteria to be taken into consideration. In this study laser gingi-vectomy show no or less recurrence, better healing com-pared to conventional method.

CONFLICT OF INTERESTThe authors declares that there is no conflict of interest regarding the publication of this article.

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