Cell Biochem Biophys (2015) 71:1005–1010 DOI 10.1007/s12013-014-0301-1
ORIGINAL PAPER
Esthetic Management of Mucogingival Defects After Excision of Epulis Using Laterally Positioned Flaps Yu-feng Xie • Rong Shu • Jie-lei Qian Zhi-kai Lin • Georgios E. Romanos
•
Published online: 15 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Epulis is a benign hyperplasia of the oral soft tissues. Surgical excision always extends to the periosteum and includes scaling of adjacent teeth to remove any possible irritants. The esthetics of the soft tissues may be compromised, however. This article studies three cases in which an immediate laterally positioned flap (LRF) was used to repair mucogingival defects after epulis biopsies. After 24 months, the color and shape of the surgical areas were healthy and stable, nearly complete root coverage was evident, and no lesions reoccurred. For repairing gingival defects after biopsy, LRF appears to be minimally traumatic while promoting esthetic outcomes. Keywords Epulis Gingival defect Laterally positioned flaps Peripheral ossifying fibroma Pyogenic granuloma
Introduction Epulis is a non-specific term used for a tumor or tumor-like lesion of the gingiva. Localized and hyperplastic, epulides
Y. Xie R. Shu J. Qian Z. Lin Department of Periodontology, The Ninth People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China R. Shu (&) Department of Periodontology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 639 Zhi Zao Ju Road, Shanghai 200011, China e-mail: [email protected] G. E. Romanos Department of Periodontology, Stony Brook University, School of Dental Medicine, Stony Brook, NY, USA
are usually a consequence of chronic inflammation. On histologic examination, the vast majority are fibromas, peripheral ossifying fibromas (POFs), pyogenic granulomas (PGs), and peripheral giant-cell granulomas (PGCGs) [1]. The etiology is unclear. Trauma or local irritants such as plaque, calculus, microorganisms, excessive masticatory forces, and poor-quality restorations have been known to precipitate the development of disease [2]. Epulides can occur at all ages but are more prevalent in the third and fifth decades of life [3]. Research has shown that young adult females are affected more frequently than males [4], but an equal sex distribution is found among older patients [5]. Clinically, an epulis usually appears as a nodular mass, either pedunculated or sessile. The color ranges from lighter shades similar to the surrounding tissues to red (depending on the quantity of collagen and vascularized granulation tissue). Clinical development of the lesion is slow, asymptomatic, and painless. The clinical appearance of various epulides is similar; thus, differential diagnosis is always performed by histologic evaluation [6]. Protocols for treating epulides include many options, including excision with or without laser, cryosurgery, electrodessication and intra-lesion injection of ethanol or corticosteroid, and sodium tetradecyl sulfate sclerotherapy [7]. Surgical therapy predominates, however. The recurrence rate for PGs and POFs is said to range from 16 % to approximately 20 % after conservative excision [7–10]. To avoid recurrence, lesions should not only be excised together with a border of normal tissue, but the surgical wound bed should be curetted, and adjacent teeth should be scaled and root-planed. The disadvantage of extensive surgical excision is esthetic impairment of the soft-tissue morphology. In addition, postoperative soft-tissue recession can cause root sensitivity and caries. Repositioned
123
1006
Cell Biochem Biophys (2015) 71:1005–1010
Fig. 1 a Original soft-tissue lesion showing an almost 13-mm gingival mass covering most of the facial dental crown of the right maxillary canine. b Appearance after the gingival lesion was completely excised. c A laterally positioned partial-thickness graft was sutured with 5–0 polyglactin sutures. d Gingival connective tissue and keratinized epithelium started forming at the donor site 10 days post-surgery.
e Highly vascular proliferation and inflammatory cells in the lesion (hematoxylin–eosin, original magnification 940). f The entire surgical area had a sufficient blood supply and was covered by new epithelium at 1 month post-surgery. g Appearance of the surgical area 3 months post-surgery. h The color and shape of the surgical area were healthy and stable after 13 months of healing (Color figure online)
flaps or a connective tissue graft are sometimes necessary to repair the gingival defect in an esthetic manner. Several different surgical techniques have been recommended to manage mucogingival impairment at the time of excisional biopsy, which include lateral sliding flaps, subpedicle connective tissue grafts (SCTGs), and free gingiva grafts [11–16]. The SCTG, introduced in 1985 by Langer and Langer [17], has become the most common choice for covering denuded roots and correcting esthetic problems after epulis excision [12–15]. The SCTG is also considered to be the gold standard for treating recession-type defects [18]. The laterally positioned flap (LPF) was proposed in 1956 by Grupe and Warren [19]. No statistical difference has been found between SCTG and LPF regarding root coverage, but the increase in keratinized tissue with LPF is significantly greater than with SCTG [20]. Another advantage is that no palatal incision is needed for LPF, which minimizes patient discomfort and significantly decreases postoperative complications, such as bleeding and pain from the donor site. However, the LPF approach has limitations: it cannot be applied when there is
insufficient attached gingiva, a shallow vestibule, or fenestration/dehiscence at lateral donor site. The following reports describe 2 cases of PG and 1 case of POF, which were excisionally biopsied concomitant with esthetic treatment of the gingival defects using an immediate LPF technique at the time of biopsy.
123
Case 1 A 38-year-old Chinese male was referred to the Department of Periodontology, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, for evaluation of a localized gingival enlargement in the right maxillary canine area. The patient stated that gingival overgrowth had begun 6 months earlier, causing frequent discomfort when brushing his teeth. A non-smoker, he had no history of systemic diseases and no known allergies. The clinical examination revealed a red gingival overgrowth measuring almost 13 mm in diameter, which was raised, sessile, firm, and prone to bleeding. It covered most of the facial dental crown (Fig. 1a).
Cell Biochem Biophys (2015) 71:1005–1010
1007
Fig. 2 a A 9-mm red-colored overgrowth of the gingival papilla between # 28 and 29 was sessile, firm, and prone to bleeding and covered part of the facial dental crown. b The lesion was removed, after curettage of the bone defect and the subjacent periosteum. c Sutured adjacent graft with 4–0 polyglactin suture material. d The surgical area was covered by new epithelium at 1 week post-surgery.
e Histologic findings pathologically consisted of an ulcer forming on the surface, involving a loss of part of the epithelium. The lesion showed highly vascular proliferation, with many inflammatory cells and fibroblasts (hematoxylin–eosin, original magnification 940). f Appearance of the surgical area 6 months post-surgery. G Appearance of the surgical area 1 year post-surgery (Color figure online)
The patient provided informed consent, and on the day of surgery, intraoral antisepsis was performed with a 0.12 % chlorhexidine rinse. Following local anesthesia using 2 % articaine with epinephrine 1:100,000, the gingival lesion was completely excised with a #15c knife. After curettage of the bone defect and root planing, the subjacent periosteum was also removed (Fig. 1b). A partial-thickness mucogingival graft was elevated with a vertical releasing incision located at the distal part of the right maxillary central incisor and then fitted into the recipient site, and sutured to the gingival margin 1 mm coronal to the cementoenamel junction using 5–0 polyglactin suture material to obtain complete root coverage (Fig. 1c). A periodontal dressing (VocopacÒ, Voco, Cuxhaven, Germany) was applied to protect the wound. The patient was prescribed ibuprofen (1 tablet two times per day when necessary) for pain management, along with amoxicillin 500 mg and metronidazole 200 mg 3 times per day for 1 week to suppress inflammation. The periodontal dressing was removed after 1 week (Fig. 1d), and the sutures were removed at 2 weeks. The patient was instructed to brush with a very soft toothbrush in the surgical area and rinse twice daily with 0.12 % chlorhexidine mouth rinse for at least 2 weeks. Microscopic examination
of the lesion showed highly vascular proliferation that resembled granulation tissue. Numerous small and large endothelium-lined channels were formed, which were engorged with red blood cells, and inflammatory cells were evident. A PG was diagnosed (Fig. 1e). After 1 month, the entire surgical area had a sufficient blood supply and was covered by new epithelium (Fig. 1f). After 3 months, no recurrence of the lesion was observed, and the gingival contour had recovered a scalloped appearance (Fig. 1g). By 13 months, the color and shape of the surgical area were healthy and stable, and the papillae were completely filled in the interdental area (Fig. 1h). The patient was very satisfied with the results.
Case 2 A 47-year-old Chinese female presented with a painless gingival overgrowth in the right mandibular posterior area. Her medical history was non-significant. She was healthy, a non-smoker, and free from allergies. During the examination, a red soft-tissue lesion almost 9 mm in diameter was noted between teeth #28 and #29. Being sessile, firm, and
123
1008
Cell Biochem Biophys (2015) 71:1005–1010
Fig. 3 a An approximately 8 9 4 mm soft-tissue overgrowth in the gingival margin, which was sessile and firm and did not bleed easily. b The overgrowth was excised, with gingiva default exposure. c, c-1 Photograph and schematic diagram of the vertical partial-thickness graft prepared from a lateral incisor. d, d-1 Photograph and schematic diagram of the rotated partial-thickness graft at the recipient site. e, e1 Photograph and schematic diagram of the graft after suturing with 5–0 polyglactin sutures. f Histologic findings: local ulcer and loss of
the epithelium; the fibrous connective tissue was rich in fibroblasts, collagen fibers, expanded small blood vessels, local trabecular calcification, and inflammatory cell infiltration (hematoxylin–eosin, original magnification 940). g Photograph and schematic diagram of the surgical area 1 week post-surgery. h Appearance of the surgical area 3 months post-surgery. i Appearance of the surgical area 12 months post-surgery. j, j-1 Appearance of the surgical area 24 months post-surgery
prone to bleeding, it covered part of the facial dental crown (Fig. 2a). The patient could not recall any trauma to the area or foreign body lodged in it. Tooth #28 was discolored from a root canal treatment, and # 29 responded positively to an electric pulp test. The surgical procedure was similar to that in Case 1. After intraoral antisepsis, local infiltration anesthesia was obtained using 2 % articaine with epinephrine 1:100,000. An incision surrounding the lesion was made with a 1- to 2-mm margin, and the lesion was removed. After curettage of the bone defect and subjacent periosteum (Fig. 2b), a partial-thickness graft of the second premolar and the mesial part of the first molar was prepared and rotated to the recipient site, where it was sutured with 4–0 polyglactin suture material (Fig. 2c). Periodontal dressing was used to protect the wound. The patient was prescribed the same medications as in Case 1. At the 1-week follow-up, the surgical area was covered by new epithelium (Fig. 2d). The patient did not complain of any post-surgical discomfort.
The histologic findings showed a lesion with an ulcerous surface, with highly vascular proliferation and many inflammatory cells and fibroblasts (Fig. 2e). The diagnosis was a PG in the right mandibular first molar area. At 6 months and 1 year after surgery, the lesion had not recurred, the gingival contour and color were very good, and the graft matched the surrounding gingiva (Fig. 2f, g)
123
Case 3 A 33-year-old Chinese male presented with a slow-growing, painless, localized gingival enlargement in the left maxillary central incisor area. He had no history of any systemic diseases and no allergies to any medicines or metals. He was a smoker of an average of 10–20 cigarettes per day. Clinical examination revealed an approximately 8 9 4 mm2 soft-tissue overgrowth in the gingival margin, which was sessile and firm and did not bleed easily
Cell Biochem Biophys (2015) 71:1005–1010
(Fig. 3a). Pulp testing of tooth # 9 indicated that it was vital. The patient had no endodontic signs or symptoms. Six weeks after scaling and root planing, a reevaluation and excisional biopsy were performed. Under local anesthesia, the lesion was removed along with the adjacent marginal gingiva, including a generous V-shaped margin of safety. All soft tissues at this site (including the periosteum) were removed from the bone (Fig. 3b). A vertical partial-thickness graft was prepared from the lateral incisor (Fig. 3c, c-1) and inserted into the recipient site (Fig. 3d, d-1), where it was sutured with 5–0 polyglactin suture material. The gingival margin of the flap was positioned and sutured 1 mm coronal to the cementoenamel junction. The exposed periosteum of the lateral incisor was completely covered by suturing the adjacent mucosa to avoid post-surgical pain (Fig. 3e, e-1). Periodontal dressing was used to protect the wound, and the patient was prescribed the same medications as in case 1. Hematoxylin–eosin-stained sections showed that the epulis pathologically consisted of stratified squamous epithelium with a local ulceration. The fibrous connective tissue was rich in fibroblasts, collagen fiber, expanded small blood vessels, local trabecular calcification, and inflammatory cell infiltration (Fig. 3f). The diagnosis was a POF accompanied by inflammation. The patient was seen at 1 week (Fig. 3g), 6 weeks, 3 months (Fig. 3h), 6 months, 12 months (Fig. 3i), and 24 months (Fig. 3j, j-1) after surgery. At the 1-week follow-up, both the dressing and the sutures were removed. The probing depth of the maxillary left central incisor with the laterally positioned graft was 1 mm after 3 months. No recurrence of the lesion was observed in the surgical area. By the 24-month follow-up, the color and shape of surgical area were healthy and stable (Fig. 3h). Nearly complete root coverage was evident. The patient was very satisfied with the results.
Discussion In the cases described here, the patients had good potential donor sites for harvest of a lateral sliding graft. In the first case, the right maxillary lateral incisor was a palatally displaced tooth near the PG lesion, so the gingival biotype at the donor site was thick. Hwang [21] reported a positive association between flap thickness and complete root coverage. With such a biotype, the prognosis is excellent. In all 3 cases, a split-thickness flap was used to reduce the potential risk of alveolar bone dehiscence or resorption at the donor area. In 2005, Pini Prato et al. reported that the post-surgical positioning in the gingival margin of coronally advanced flaps is an important factor in obtaining complete root coverage [22]. In the anterior esthetic zone,
1009
the authors typically place the flap 1–2 mm coronal to the CEJ to compensate for postoperative recession of wound contraction [23]. Because research has shown a correlation between higher flap tension and recession induction [24], the authors reduce flap tension before suturing to maximize complete root coverage. To minimize postoperative pain caused by tissue exposure in Case 3, the exposed periosteum of the lateral incisor was completely covered by suturing the adjacent mucosa without increasing flap tension. Reduced postoperative bleeding and pain was identified, based on patient feedback. After 1 year, donor sites were covered with adjacent mucosa, and sufficient keratinized gingiva had formed on the margin of the alveolar bone. The use of split-thickness flaps preserved the periosteum, which was helpful for the migration of epithelial cells from the adjacent gingiva, resulting in the formation of keratinized gingiva.
Conclusion For certain indications, the LPF can yield similar esthetic outcomes for repairing gingival defects after biopsy as the SCTG. Additionally, the LPF has the advantage of avoiding the need for a palatal incision, which significantly decreases postoperative complications such as bleeding and pain.
Disclosure The authors have no financial interests in any of the products that are mentioned in this paper.
References 1. Daley, T. D., Wysocki, G. P., Wysocki, P. D., & Wysocki, D. M. (1990). The major epulides: Clinicopathological correlations. Journal/Canadian Dental Association. Journal de l’Association Dentaire Canadienne, 56, 627–630. 2. Kumar, S. K., Ram, S., Jorgensen, M. G., Shuler, C. F., & Sedghizadeh, P. P. (2006). Multicentric peripheral ossifying fibroma. Journal of Oral Science, 48, 239–243. 3. Kfir, Y., Buchner, A., & Hansen, L. S. (1980). Reactive lesions of the gingiva. A clinicopathological study of 741 cases. Journal of Periodontology, 51, 655–661. 4. Al-Khateeb, T., & Ababneh, K. (2003). Oral pyogenic granuloma in Jordanians: A retrospective analysis of 108 cases. Journal of Oral and Maxillofacial Surgery, 61, 1285–1288. 5. Pilch, B. Z. (2001). Head and neck surgical pathology (pp. 389–390). Philadelphia: Lippincott Williams & Wilkins. 6. Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2009). Oral and maxillofacial pathology (2nd ed., pp. 783–791). Philadelphia: WB Saunders. 7. Jafarzadeh, H., Sanatkhani, M., & Mohtasham, N. (2006). Oral pyogenic granuloma: A review. Journal of Oral Science, 48, 167–175.
123
1010 8. Bhaskar, S. N., & Jacoway, J. R. (1966). Pyogenic granuloma: Clinical features, incidence, histology, and result of treatment: Report of 242 cases. Journal of Oral Surgery, 24, 391–398. 9. Eversole, L. R., & Rovin, S. (1972). Reactive lesions of the gingiva. Journal of Oral Pathology, 1, 30–38. 10. Buchner, A., & Hansen, L. S. (1987). The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surgery, Oral Medicine, Oral Pathology, 63, 452–461. 11. Anderegg, C. R., & Metzler, D. G. (1996). Free gingival graft following biopsy: A case report of tissue management. Journal of Periodontology, 67, 532–535. 12. Walters, J. D., Will, J. K., Hatfield, R. D., Cacchillo, D. A., & Raabe, D. A. (2001). Excision and repair of the peripheral ossifying fibroma: A report of 3 cases. Journal of Periodontology, 72, 939–944. 13. Joda, T. (2012). Esthetic management of mucogingival defects after total excision in a case of pyogenic granuloma. European Journal of Esthetic Dentistry, 7, 110–119. 14. Sahingur, S. E., Cohen, R. E., & Aguirre, A. (2004). Esthetic management of peripheral giant cell granuloma. Journal of Periodontology, 75, 487–492. 15. Lev, R., Moses, O., Holtzclaw, D., & Tal, H. (2010). Esthetic treatment of peripheral giant cell granuloma using a subepithelial connective tissue graft and a split-thickness pouch technique. Journal of Periodontology, 81, 1092–1098. 16. Bosco, A. F., Bonfante, S., Luize, D. S., Bosco, J. M., & Garcia, V. G. (2006). Periodontal plastic surgery associated with treatment for the removal of gingival overgrowth. Journal of Periodontology, 77, 922–928.
123
Cell Biochem Biophys (2015) 71:1005–1010 17. Langer, B., & Langer, L. (1985). Subepithelial connective tissue graft technique for root coverage. Journal of Periodontology, 56, 715–720. 18. Chambrone, L., Chambrone, D., Pustiglioni, F. E., Chambrone, L. A., & Lima, L. A. (2008). Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? Journal of Dentistry, 36, 659–671. 19. Grupe, H. E., & Warren, R. (1956). Repair of gingival defects by a sliding flap operation. Journal of Periodontology, 27, 92–95. 20. Ricci, G., Silvestri, M., Rasperini, G., & Cattaneo, V. (1996). Root coverage: A clinical/statistical comparison between subpedicle connective tissue graft and laterally positioned full thickness flaps. Journal of Esthetic Dentistry, 8, 66–73. 21. Hwang, D., & Wang, H. L. (2006). Flap thickness as a predictor of root coverage: A systematic review. Journal of Periodontology, 77, 1625–1634. 22. Pini Prato, G. P., Baldi, C., Nieri, M., et al. (2005). Coronally advanced flap: The post-surgical position of the gingival margin is an important factor for achieving complete root coverage. Journal of Periodontology, 76, 713–722. 23. Bouchard, P., Malet, J., & Borghetti, A. (2000). Decision-making in aesthetics: Root coverage revisited. Periodontology, 2001(27), 97–120. 24. Pini Prato, G. P., Pagliaro, U., Baldi, C., et al. (2000). Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: A randomized controlled clinical study. J Periodontol, 71, 188–201.
ORIGINAL PAPER
Esthetic Management of Mucogingival Defects After Excision of Epulis Using Laterally Positioned Flaps Yu-feng Xie • Rong Shu • Jie-lei Qian Zhi-kai Lin • Georgios E. Romanos
•
Published online: 15 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Epulis is a benign hyperplasia of the oral soft tissues. Surgical excision always extends to the periosteum and includes scaling of adjacent teeth to remove any possible irritants. The esthetics of the soft tissues may be compromised, however. This article studies three cases in which an immediate laterally positioned flap (LRF) was used to repair mucogingival defects after epulis biopsies. After 24 months, the color and shape of the surgical areas were healthy and stable, nearly complete root coverage was evident, and no lesions reoccurred. For repairing gingival defects after biopsy, LRF appears to be minimally traumatic while promoting esthetic outcomes. Keywords Epulis Gingival defect Laterally positioned flaps Peripheral ossifying fibroma Pyogenic granuloma
Introduction Epulis is a non-specific term used for a tumor or tumor-like lesion of the gingiva. Localized and hyperplastic, epulides
Y. Xie R. Shu J. Qian Z. Lin Department of Periodontology, The Ninth People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China R. Shu (&) Department of Periodontology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 639 Zhi Zao Ju Road, Shanghai 200011, China e-mail: [email protected] G. E. Romanos Department of Periodontology, Stony Brook University, School of Dental Medicine, Stony Brook, NY, USA
are usually a consequence of chronic inflammation. On histologic examination, the vast majority are fibromas, peripheral ossifying fibromas (POFs), pyogenic granulomas (PGs), and peripheral giant-cell granulomas (PGCGs) [1]. The etiology is unclear. Trauma or local irritants such as plaque, calculus, microorganisms, excessive masticatory forces, and poor-quality restorations have been known to precipitate the development of disease [2]. Epulides can occur at all ages but are more prevalent in the third and fifth decades of life [3]. Research has shown that young adult females are affected more frequently than males [4], but an equal sex distribution is found among older patients [5]. Clinically, an epulis usually appears as a nodular mass, either pedunculated or sessile. The color ranges from lighter shades similar to the surrounding tissues to red (depending on the quantity of collagen and vascularized granulation tissue). Clinical development of the lesion is slow, asymptomatic, and painless. The clinical appearance of various epulides is similar; thus, differential diagnosis is always performed by histologic evaluation [6]. Protocols for treating epulides include many options, including excision with or without laser, cryosurgery, electrodessication and intra-lesion injection of ethanol or corticosteroid, and sodium tetradecyl sulfate sclerotherapy [7]. Surgical therapy predominates, however. The recurrence rate for PGs and POFs is said to range from 16 % to approximately 20 % after conservative excision [7–10]. To avoid recurrence, lesions should not only be excised together with a border of normal tissue, but the surgical wound bed should be curetted, and adjacent teeth should be scaled and root-planed. The disadvantage of extensive surgical excision is esthetic impairment of the soft-tissue morphology. In addition, postoperative soft-tissue recession can cause root sensitivity and caries. Repositioned
123
1006
Cell Biochem Biophys (2015) 71:1005–1010
Fig. 1 a Original soft-tissue lesion showing an almost 13-mm gingival mass covering most of the facial dental crown of the right maxillary canine. b Appearance after the gingival lesion was completely excised. c A laterally positioned partial-thickness graft was sutured with 5–0 polyglactin sutures. d Gingival connective tissue and keratinized epithelium started forming at the donor site 10 days post-surgery.
e Highly vascular proliferation and inflammatory cells in the lesion (hematoxylin–eosin, original magnification 940). f The entire surgical area had a sufficient blood supply and was covered by new epithelium at 1 month post-surgery. g Appearance of the surgical area 3 months post-surgery. h The color and shape of the surgical area were healthy and stable after 13 months of healing (Color figure online)
flaps or a connective tissue graft are sometimes necessary to repair the gingival defect in an esthetic manner. Several different surgical techniques have been recommended to manage mucogingival impairment at the time of excisional biopsy, which include lateral sliding flaps, subpedicle connective tissue grafts (SCTGs), and free gingiva grafts [11–16]. The SCTG, introduced in 1985 by Langer and Langer [17], has become the most common choice for covering denuded roots and correcting esthetic problems after epulis excision [12–15]. The SCTG is also considered to be the gold standard for treating recession-type defects [18]. The laterally positioned flap (LPF) was proposed in 1956 by Grupe and Warren [19]. No statistical difference has been found between SCTG and LPF regarding root coverage, but the increase in keratinized tissue with LPF is significantly greater than with SCTG [20]. Another advantage is that no palatal incision is needed for LPF, which minimizes patient discomfort and significantly decreases postoperative complications, such as bleeding and pain from the donor site. However, the LPF approach has limitations: it cannot be applied when there is
insufficient attached gingiva, a shallow vestibule, or fenestration/dehiscence at lateral donor site. The following reports describe 2 cases of PG and 1 case of POF, which were excisionally biopsied concomitant with esthetic treatment of the gingival defects using an immediate LPF technique at the time of biopsy.
123
Case 1 A 38-year-old Chinese male was referred to the Department of Periodontology, Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, for evaluation of a localized gingival enlargement in the right maxillary canine area. The patient stated that gingival overgrowth had begun 6 months earlier, causing frequent discomfort when brushing his teeth. A non-smoker, he had no history of systemic diseases and no known allergies. The clinical examination revealed a red gingival overgrowth measuring almost 13 mm in diameter, which was raised, sessile, firm, and prone to bleeding. It covered most of the facial dental crown (Fig. 1a).
Cell Biochem Biophys (2015) 71:1005–1010
1007
Fig. 2 a A 9-mm red-colored overgrowth of the gingival papilla between # 28 and 29 was sessile, firm, and prone to bleeding and covered part of the facial dental crown. b The lesion was removed, after curettage of the bone defect and the subjacent periosteum. c Sutured adjacent graft with 4–0 polyglactin suture material. d The surgical area was covered by new epithelium at 1 week post-surgery.
e Histologic findings pathologically consisted of an ulcer forming on the surface, involving a loss of part of the epithelium. The lesion showed highly vascular proliferation, with many inflammatory cells and fibroblasts (hematoxylin–eosin, original magnification 940). f Appearance of the surgical area 6 months post-surgery. G Appearance of the surgical area 1 year post-surgery (Color figure online)
The patient provided informed consent, and on the day of surgery, intraoral antisepsis was performed with a 0.12 % chlorhexidine rinse. Following local anesthesia using 2 % articaine with epinephrine 1:100,000, the gingival lesion was completely excised with a #15c knife. After curettage of the bone defect and root planing, the subjacent periosteum was also removed (Fig. 1b). A partial-thickness mucogingival graft was elevated with a vertical releasing incision located at the distal part of the right maxillary central incisor and then fitted into the recipient site, and sutured to the gingival margin 1 mm coronal to the cementoenamel junction using 5–0 polyglactin suture material to obtain complete root coverage (Fig. 1c). A periodontal dressing (VocopacÒ, Voco, Cuxhaven, Germany) was applied to protect the wound. The patient was prescribed ibuprofen (1 tablet two times per day when necessary) for pain management, along with amoxicillin 500 mg and metronidazole 200 mg 3 times per day for 1 week to suppress inflammation. The periodontal dressing was removed after 1 week (Fig. 1d), and the sutures were removed at 2 weeks. The patient was instructed to brush with a very soft toothbrush in the surgical area and rinse twice daily with 0.12 % chlorhexidine mouth rinse for at least 2 weeks. Microscopic examination
of the lesion showed highly vascular proliferation that resembled granulation tissue. Numerous small and large endothelium-lined channels were formed, which were engorged with red blood cells, and inflammatory cells were evident. A PG was diagnosed (Fig. 1e). After 1 month, the entire surgical area had a sufficient blood supply and was covered by new epithelium (Fig. 1f). After 3 months, no recurrence of the lesion was observed, and the gingival contour had recovered a scalloped appearance (Fig. 1g). By 13 months, the color and shape of the surgical area were healthy and stable, and the papillae were completely filled in the interdental area (Fig. 1h). The patient was very satisfied with the results.
Case 2 A 47-year-old Chinese female presented with a painless gingival overgrowth in the right mandibular posterior area. Her medical history was non-significant. She was healthy, a non-smoker, and free from allergies. During the examination, a red soft-tissue lesion almost 9 mm in diameter was noted between teeth #28 and #29. Being sessile, firm, and
123
1008
Cell Biochem Biophys (2015) 71:1005–1010
Fig. 3 a An approximately 8 9 4 mm soft-tissue overgrowth in the gingival margin, which was sessile and firm and did not bleed easily. b The overgrowth was excised, with gingiva default exposure. c, c-1 Photograph and schematic diagram of the vertical partial-thickness graft prepared from a lateral incisor. d, d-1 Photograph and schematic diagram of the rotated partial-thickness graft at the recipient site. e, e1 Photograph and schematic diagram of the graft after suturing with 5–0 polyglactin sutures. f Histologic findings: local ulcer and loss of
the epithelium; the fibrous connective tissue was rich in fibroblasts, collagen fibers, expanded small blood vessels, local trabecular calcification, and inflammatory cell infiltration (hematoxylin–eosin, original magnification 940). g Photograph and schematic diagram of the surgical area 1 week post-surgery. h Appearance of the surgical area 3 months post-surgery. i Appearance of the surgical area 12 months post-surgery. j, j-1 Appearance of the surgical area 24 months post-surgery
prone to bleeding, it covered part of the facial dental crown (Fig. 2a). The patient could not recall any trauma to the area or foreign body lodged in it. Tooth #28 was discolored from a root canal treatment, and # 29 responded positively to an electric pulp test. The surgical procedure was similar to that in Case 1. After intraoral antisepsis, local infiltration anesthesia was obtained using 2 % articaine with epinephrine 1:100,000. An incision surrounding the lesion was made with a 1- to 2-mm margin, and the lesion was removed. After curettage of the bone defect and subjacent periosteum (Fig. 2b), a partial-thickness graft of the second premolar and the mesial part of the first molar was prepared and rotated to the recipient site, where it was sutured with 4–0 polyglactin suture material (Fig. 2c). Periodontal dressing was used to protect the wound. The patient was prescribed the same medications as in Case 1. At the 1-week follow-up, the surgical area was covered by new epithelium (Fig. 2d). The patient did not complain of any post-surgical discomfort.
The histologic findings showed a lesion with an ulcerous surface, with highly vascular proliferation and many inflammatory cells and fibroblasts (Fig. 2e). The diagnosis was a PG in the right mandibular first molar area. At 6 months and 1 year after surgery, the lesion had not recurred, the gingival contour and color were very good, and the graft matched the surrounding gingiva (Fig. 2f, g)
123
Case 3 A 33-year-old Chinese male presented with a slow-growing, painless, localized gingival enlargement in the left maxillary central incisor area. He had no history of any systemic diseases and no allergies to any medicines or metals. He was a smoker of an average of 10–20 cigarettes per day. Clinical examination revealed an approximately 8 9 4 mm2 soft-tissue overgrowth in the gingival margin, which was sessile and firm and did not bleed easily
Cell Biochem Biophys (2015) 71:1005–1010
(Fig. 3a). Pulp testing of tooth # 9 indicated that it was vital. The patient had no endodontic signs or symptoms. Six weeks after scaling and root planing, a reevaluation and excisional biopsy were performed. Under local anesthesia, the lesion was removed along with the adjacent marginal gingiva, including a generous V-shaped margin of safety. All soft tissues at this site (including the periosteum) were removed from the bone (Fig. 3b). A vertical partial-thickness graft was prepared from the lateral incisor (Fig. 3c, c-1) and inserted into the recipient site (Fig. 3d, d-1), where it was sutured with 5–0 polyglactin suture material. The gingival margin of the flap was positioned and sutured 1 mm coronal to the cementoenamel junction. The exposed periosteum of the lateral incisor was completely covered by suturing the adjacent mucosa to avoid post-surgical pain (Fig. 3e, e-1). Periodontal dressing was used to protect the wound, and the patient was prescribed the same medications as in case 1. Hematoxylin–eosin-stained sections showed that the epulis pathologically consisted of stratified squamous epithelium with a local ulceration. The fibrous connective tissue was rich in fibroblasts, collagen fiber, expanded small blood vessels, local trabecular calcification, and inflammatory cell infiltration (Fig. 3f). The diagnosis was a POF accompanied by inflammation. The patient was seen at 1 week (Fig. 3g), 6 weeks, 3 months (Fig. 3h), 6 months, 12 months (Fig. 3i), and 24 months (Fig. 3j, j-1) after surgery. At the 1-week follow-up, both the dressing and the sutures were removed. The probing depth of the maxillary left central incisor with the laterally positioned graft was 1 mm after 3 months. No recurrence of the lesion was observed in the surgical area. By the 24-month follow-up, the color and shape of surgical area were healthy and stable (Fig. 3h). Nearly complete root coverage was evident. The patient was very satisfied with the results.
Discussion In the cases described here, the patients had good potential donor sites for harvest of a lateral sliding graft. In the first case, the right maxillary lateral incisor was a palatally displaced tooth near the PG lesion, so the gingival biotype at the donor site was thick. Hwang [21] reported a positive association between flap thickness and complete root coverage. With such a biotype, the prognosis is excellent. In all 3 cases, a split-thickness flap was used to reduce the potential risk of alveolar bone dehiscence or resorption at the donor area. In 2005, Pini Prato et al. reported that the post-surgical positioning in the gingival margin of coronally advanced flaps is an important factor in obtaining complete root coverage [22]. In the anterior esthetic zone,
1009
the authors typically place the flap 1–2 mm coronal to the CEJ to compensate for postoperative recession of wound contraction [23]. Because research has shown a correlation between higher flap tension and recession induction [24], the authors reduce flap tension before suturing to maximize complete root coverage. To minimize postoperative pain caused by tissue exposure in Case 3, the exposed periosteum of the lateral incisor was completely covered by suturing the adjacent mucosa without increasing flap tension. Reduced postoperative bleeding and pain was identified, based on patient feedback. After 1 year, donor sites were covered with adjacent mucosa, and sufficient keratinized gingiva had formed on the margin of the alveolar bone. The use of split-thickness flaps preserved the periosteum, which was helpful for the migration of epithelial cells from the adjacent gingiva, resulting in the formation of keratinized gingiva.
Conclusion For certain indications, the LPF can yield similar esthetic outcomes for repairing gingival defects after biopsy as the SCTG. Additionally, the LPF has the advantage of avoiding the need for a palatal incision, which significantly decreases postoperative complications such as bleeding and pain.
Disclosure The authors have no financial interests in any of the products that are mentioned in this paper.
References 1. Daley, T. D., Wysocki, G. P., Wysocki, P. D., & Wysocki, D. M. (1990). The major epulides: Clinicopathological correlations. Journal/Canadian Dental Association. Journal de l’Association Dentaire Canadienne, 56, 627–630. 2. Kumar, S. K., Ram, S., Jorgensen, M. G., Shuler, C. F., & Sedghizadeh, P. P. (2006). Multicentric peripheral ossifying fibroma. Journal of Oral Science, 48, 239–243. 3. Kfir, Y., Buchner, A., & Hansen, L. S. (1980). Reactive lesions of the gingiva. A clinicopathological study of 741 cases. Journal of Periodontology, 51, 655–661. 4. Al-Khateeb, T., & Ababneh, K. (2003). Oral pyogenic granuloma in Jordanians: A retrospective analysis of 108 cases. Journal of Oral and Maxillofacial Surgery, 61, 1285–1288. 5. Pilch, B. Z. (2001). Head and neck surgical pathology (pp. 389–390). Philadelphia: Lippincott Williams & Wilkins. 6. Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2009). Oral and maxillofacial pathology (2nd ed., pp. 783–791). Philadelphia: WB Saunders. 7. Jafarzadeh, H., Sanatkhani, M., & Mohtasham, N. (2006). Oral pyogenic granuloma: A review. Journal of Oral Science, 48, 167–175.
123
1010 8. Bhaskar, S. N., & Jacoway, J. R. (1966). Pyogenic granuloma: Clinical features, incidence, histology, and result of treatment: Report of 242 cases. Journal of Oral Surgery, 24, 391–398. 9. Eversole, L. R., & Rovin, S. (1972). Reactive lesions of the gingiva. Journal of Oral Pathology, 1, 30–38. 10. Buchner, A., & Hansen, L. S. (1987). The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surgery, Oral Medicine, Oral Pathology, 63, 452–461. 11. Anderegg, C. R., & Metzler, D. G. (1996). Free gingival graft following biopsy: A case report of tissue management. Journal of Periodontology, 67, 532–535. 12. Walters, J. D., Will, J. K., Hatfield, R. D., Cacchillo, D. A., & Raabe, D. A. (2001). Excision and repair of the peripheral ossifying fibroma: A report of 3 cases. Journal of Periodontology, 72, 939–944. 13. Joda, T. (2012). Esthetic management of mucogingival defects after total excision in a case of pyogenic granuloma. European Journal of Esthetic Dentistry, 7, 110–119. 14. Sahingur, S. E., Cohen, R. E., & Aguirre, A. (2004). Esthetic management of peripheral giant cell granuloma. Journal of Periodontology, 75, 487–492. 15. Lev, R., Moses, O., Holtzclaw, D., & Tal, H. (2010). Esthetic treatment of peripheral giant cell granuloma using a subepithelial connective tissue graft and a split-thickness pouch technique. Journal of Periodontology, 81, 1092–1098. 16. Bosco, A. F., Bonfante, S., Luize, D. S., Bosco, J. M., & Garcia, V. G. (2006). Periodontal plastic surgery associated with treatment for the removal of gingival overgrowth. Journal of Periodontology, 77, 922–928.
123
Cell Biochem Biophys (2015) 71:1005–1010 17. Langer, B., & Langer, L. (1985). Subepithelial connective tissue graft technique for root coverage. Journal of Periodontology, 56, 715–720. 18. Chambrone, L., Chambrone, D., Pustiglioni, F. E., Chambrone, L. A., & Lima, L. A. (2008). Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? Journal of Dentistry, 36, 659–671. 19. Grupe, H. E., & Warren, R. (1956). Repair of gingival defects by a sliding flap operation. Journal of Periodontology, 27, 92–95. 20. Ricci, G., Silvestri, M., Rasperini, G., & Cattaneo, V. (1996). Root coverage: A clinical/statistical comparison between subpedicle connective tissue graft and laterally positioned full thickness flaps. Journal of Esthetic Dentistry, 8, 66–73. 21. Hwang, D., & Wang, H. L. (2006). Flap thickness as a predictor of root coverage: A systematic review. Journal of Periodontology, 77, 1625–1634. 22. Pini Prato, G. P., Baldi, C., Nieri, M., et al. (2005). Coronally advanced flap: The post-surgical position of the gingival margin is an important factor for achieving complete root coverage. Journal of Periodontology, 76, 713–722. 23. Bouchard, P., Malet, J., & Borghetti, A. (2000). Decision-making in aesthetics: Root coverage revisited. Periodontology, 2001(27), 97–120. 24. Pini Prato, G. P., Pagliaro, U., Baldi, C., et al. (2000). Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: A randomized controlled clinical study. J Periodontol, 71, 188–201.
