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MANAGEMENT OF IDIOPATHIC GINGIVAL FIBROMATOSIS

- A CASE REPORT

Presented by Dr.Nagesh Dolare Post graduate student

Guided by Dr. R.K. Yeltiwar Prof & Head

Department of periodontics Government Dental College & Hospital, Nagpur

Gingival enlargement is defined as an overgrowth or increase in the size of gingiva

Classification
Based on the etiological factors and pathological factors: I. Inflammatory enlargement II. Drug induced enlargement III. Enlargements associated with systemic disease or conditions IV. Neoplastic enlargement V. False enlargement

Degree of enlargement
Grade I: No signs of gingival enlargement Grade : confined to interdental papilla Grade : involve papilla and marginal gingiva Grade VI: enlargement covers three quarters or more of the crown

Idiopathic gingival enlargement is a rare (1:750000) condition of undermined cause The term Gingival fibromatosis is used for those cased which have an hereditary pattern, are part of a more extensive syndrome or idiopathic

It appears as an isolated disorder or may sometimes be associated with other conditions like epilepsy, hypettrichosis and mental retardation or associated with syndromes
Males and females are equally affected Idiopathic gingival fibromatosis primarily present in childhood

Clinical features
The facial and lingual surfaces of mandible and maxilla are generally affected or either jaws Pink, firm, leathery in consistency and pebbled surfaces In severe cases, the jaws appear bulbous.

Clinical features
The resultant effect may include speech difficulty and painful mastication as food deflects onto the enlarged tissue.

Other common side effects : diastema, malocclusion and prolonged retention of primary teeth.
The enlarged tissue creates retention for plaque

Management
Factors to consider in treatment planning : - esthetic -functional needs -onset of puberty because recurrence is predominately observed in children and teenagers rather than in adults.

Management
Controversy regarding when treatment should be performed. Minimal Gingival Enlargement:- Thorough scaling and home care. Severe Gingival Enlargement:- Surgical removal of enlarged gingiva and extraction of all teeth and reduction of the alveolar bone to prevent recurrence.

Management

Technique
Internal or external bevel gingivectomy Electrocautery Lasers

External bevel Gingivectomy


Advantages: Simplicity and quickness Disadvantages : Post-operative discomfort Increased chance post-operative bleeding Sacrifices keratinized tissue Does not allow for osseous recontouring

Laser
Advantages :
Ability to coagulate and seal blood vessels Vaporize the tissue Make accurate incisions and Improve healing because of its antimicrobial properties.

A 13 years girl came with complaint of generalized gingival overgrowth

Slowly increasing in size

Right side

Left side

Medical History

The patients medical history was normal. She did not exhibit any signs of hypettrichosis or mental retardation or syndrome and did not take any medication that could be associated with gingival hyperplasia.

Family history
There was no family history of similar types of gingival enlargement

Clinical Examination
The extra-oral examination did not reveal any abnormality. The intra-oral examination revealed generalized, severe gingival hyperplasia involving both buccal and lingual regions in the maxillary and mandibular arches except left side of mandibular arch.

The enlarged gingival tissues covered two-thirds or more of the clinical crowns of almost all teeth, and the palate was deformed by the excessive gingival tissue. Hence provisional diagnosis - idiopathic gingival enlargement was arrived at

Pre-operative cast

Investigations

1. Panoramic radiographic 2. Complete haemogram

Pre-operative view

Internal bevel incision

Interrupted figure-eight suture placed

1 month post-operative

Pre-operative

Post-operative: 6 months

Internal bevel gingivectomy


Objectives:
It removes the pocket lining
It conserves the relatively uninvolved outer surface of the gingiva It produces sharp, thin gingival margin for adaptation to the bone-tooth junction

Histological Features
Densely arranged collagen bundles numerous fibroblasts, and connective tissue that is relatively avascular.

Histological Features
Thickened and acanthotic epithelium also is present with elongated rete pegs Few chronic inflammatory cells

Discussion
Gingival enlargement can be caused by inflammation, systemic diseases such as leukemic infiltration and medication use such as cyclosporine, phenytoin, or nifedipine. In this case a diagnosis of idiopathic gingival enlargement was made because the patient was not under any medication that could lead to gingival enlargement, no significant family history was present and the patient did not exhibits any signs of syndrome

The suggested treatments of idiopathic gingival enlargement vary according to the complete eruption of permanent teeth and the severity of the enlargement Minimal gingival enlargement :Scaling and root planing of teeth and sufficient homecare suffices in cases of minimal gingival enlargement Surgical intervention is required when enlarged tissues impair function and appearance and act as a barrier to the eruption of teeth

Bozzo et al. and Bittencourt et al. suggested a conservative approach with their cases based on the patients condition and reports in the literature. However some authors recommend excision of the excess tissue combined with removal of all teeth in severe cases and suggest the condition does not recur if the teeth are extracted.

The most widely used surgical approach is the gingivectomy/ gingivoplasty

In this case quadrant-by-quadrant internal bevel gingivectomy and extraction of over retained teeth #53 and #74 done

Conclusion
Gingival enlargement is prevalent disease in child, conferring to the periodontist and pedodontist an important role in the correct diagnosis and treatment of affected patients. Gingival enlargement when present in child represent not only a pathologic situation but also functional and esthetic impediment hence prompt correction of this condition is a at most importance

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