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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 159-162

Rare presentation of localized gingival overgrowth with osseous defect – Case report


1 Department of Periodontology, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Periodontology, Faculty of Dental Sciences, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission08-Jul-2022
Date of Acceptance27-Sep-2022
Date of Web Publication21-Jan-2023

Correspondence Address:
Dr. Anju Gautam
Department of Periodontology, Faculty of Dental Sciences, IMS, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_492_22

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  Abstract 


Gingival overgrowth is one of the most undesirable consequences that often lead to impaired esthetics and masticatory functions, compromised oral hygiene maintenance often requiring surgical excision of the excessive tissue. Gingival overgrowth belongs to a common group of lesions designated as focal reactive overgrowths. These growths are reactive in nature. A definitive diagnosis will then enable an appropriate management strategy. Peripheral giant-cell granuloma (PGCG) is a reactive focal overgrowth, ordinarily presents as an epulis-like growth. This is of a reactive rather than neoplastic nature and its pathogenesis is uncertain. It is widely considered to originate from the cells of the periodontal ligament, occurring as a response to irritants such as dental calculus, plaque, microorganisms, dental appliances, and restorations. The purpose of this article is to report the clinical, histopathological features and treatment of a case with PGCG arising from mandibular posterior alveolus in a 34-year-old female. The overgrowth was well defined along with the bone defect, involving the buccal aspect of the mandibular gingiva. The tooth was endodontically treated, the lesion was completely excised, and the osseous defect was filled with regenerative material. The 12-month follow-up radiograph revealed successful healing with no more recurrence.

Keywords: Bone graft, epulis, furcation, giant cell granuloma, gingival overgrowth


How to cite this article:
Srivastava R, Gautam A. Rare presentation of localized gingival overgrowth with osseous defect – Case report. Indian J Health Sci Biomed Res 2023;16:159-62

How to cite this URL:
Srivastava R, Gautam A. Rare presentation of localized gingival overgrowth with osseous defect – Case report. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:159-62. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/159/368328




  Introduction Top


Gingival overgrowth is one of the most undesirable consequences that often lead to impaired esthetics and masticatory functions, compromised oral hygiene maintenance often requiring surgical excision of the excessive tissue. Gingival enlargements are a common clinical finding and most represent reactive hyperplasia as a direct result of plaque-related inflammatory gingival disease.[1] They can be categorized based on their etiopathogenesis, location, size, extent, etc., They are commonly present as sessile or pedunculated lesions, bulbous interdental gingiva, diffuse swelling of the gingiva, etc., In the majority of cases, there is no apparent underlying bone involvement visible on the radiograph. However, on rare occasions, there might be superficial erosion of bone.[2] Based on the existing knowledge and clinical experience, a differential diagnosis can be formulated. Subsequently, after a detailed investigation, the clinician makes a final diagnosis or diagnosis of exclusion. The diagnosis of these lesions is essential for their successful management and of the patient as a whole. The purpose of this case report is to discuss the clinical, histopathological features and treatment of a case with peripheral giant-cell granuloma (PGCG) arising from mandibular posterior alveolus in a 34-year-old female.


  Case Report Top


A 34-year-old female patient presented to the faculty of dental sciences, with a chief complaint of swelling on gums at the lower back region for the past 2 months. On clinical examination, a well-circumscribed gingival swelling of 2.5 cm × 1.5 cm size was present in relation to 45.46 [Figure 1]. The lesion was soft in consistency, sessile, had a smooth shiny surface, and bled readily on probing. The patient's medical history was uneventful. After considering the dental history, the patient was referred for investigations.
Figure 1: Preoperative clinical view

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Investigations

Intraoral periapical radiograph revealed the presence of a bone loss in relation to tooth 46 [Figure 2]. Hematological investigations, such as complete blood count, bleeding time and clotting time, and blood sugar levels, were within normal limits. After the radiographic and hematological investigations, Phase-I therapy was conducted, followed by root canal treatment of the involved tooth 46. Based on clinical and radiologic findings, the differential diagnosis included fibrous hyperplasia, pyogenic granuloma, and PGCG and peripheral odontogenic fibroma.
Figure 2: Preoperative radiograph

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Management

After endodontic therapy in respect to 46, the surgical procedure was explained to the patient and informed consent was obtained. Under local anesthesia, the lesion was excised with 15-No. BP blade up to the base of the lesion. It was ensured that the lesion was completely excised by trimming the remnants of soft tissue adjacent to the tooth to prevent recurrence of the lesion and the sample was sent for histopathology. A mucoperiosteum flap was reflected, and the bone defect in the furcation was curetted [Figure 3]. Then, an alloplastic bone graft was placed (Periobone G™, India) [Figure 4], and the flap was sutured with 3-0 silk sutures. The periodontal dressing was applied to prevent the wound from trauma and to enhance healing for 1 week [Figure 5]. Antibiotics and analgesics were prescribed for 1 week. The patient was monitored on a weekly schedule postoperatively, to ensure good oral hygiene in the surgery performed area [Figure 6].
Figure 3: Osseous defect after flap reflection

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Figure 4: Bone graft and sutures placed

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Figure 5: Periodontal dressing placed

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Figure 6: Postoperative view after 15 days

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The histopathology of the specimen confirmed the diagnosis of PGCG. On histologic examination, the reddish-purple exophytic lesion showed an ulcerated overlying epithelium composed of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells (×100) [Figure 7]. Higher magnification (×400) demonstrated multinucleated giant cells dispersed within spindle-shaped mesenchymal stromal cells. The patient was recalled at 1-, 6-, and 12-month follow-ups. At 6-month recall, the tooth was asymptomatic with successful healing and no more recurrence [Figure 8]. Recall radiographs at 12 months revealed distinct evidence of bone fill [Figure 9].
Figure 7: Histopathological view under high magnification

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Figure 8: Six-month postoperative radiograph

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Figure 9: Twelve-month postoperative radiograph

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  Discussion Top


In the abovementioned case, the lesion presented as localized overgrowth on the gingiva. Giant cell granuloma is among the localized growths, considered to be reactive rather than neoplastic in nature. It is relatively a benign, nonodontogenic lesion of the oral cavity. It is a reactive response to local irritations and trauma that may be of central or peripheral type.[3] The lesion varies from a discrete spherical, tumor-like mass with a pedunculated attachment to a flattened, keloid-like enlargement with a broad base. It is bright red or purple and either friable or firm, depending on its duration; in the majority of cases, it presents with surface ulceration and purulent exudation.[4] Other terms used to describe this lesion include peripheral cementifying fibroma, peripheral fibroma with cementogenesis, peripheral fibroma with osteogenesis, peripheral fibroma with calcification, calcified or ossified fibrous epulis, and calcified fibroblastic granuloma.[5] Many of these lesions are difficult to be identified clinically and can be identified only on the basis of histopathology. It accounts for 7% of all benign tumors of the jaw.[6] PGCG is more common in the mandible than in the maxilla and common in the anterior region than in the posterior region.[7] Radiographs are important to determine if the lesion is of the gingival origin or of central origin with extension to the surface. The differential diagnosis of PGCG includes central giant cell granuloma, oral pyogenic granuloma, fibroma, Kaposi sarcoma, metastatic neoplasms of the oral cavity, oral malignant, and other nodular melanomas, metastatic tumors of the gingiva, nevi, and other inflammatory hyperplastic lesions.[8] The origin of multinucleated giant cells is unknown but some believe that they show immunohistochemical features of osteoclasts, while others suggest them to arise from mononuclear phagocyte system.[9] Other possible sources include osteoblasts, endothelial cells, and spindle cells. Treatment requires proper surgical intervention that ensures deep excision of the lesion including periosteum and affected periodontal ligament.[10] In the present case report, the lesion was completely excised to the periosteum level and the bony defect was packed with an alloplastic bone graft. After a follow-up period of 12 months, no residual or recurrent, swelling or bony defect was apparent, and the site showed successful healing of the lesion.


  Conclusion Top


Periodontal examinations, proper diagnosis and treatment planning, and maintenance of proper oral hygiene have a pivotal role in preventing recurrence. However, in the above case with multidisciplinary approaches such as endodontic therapy, appropriate surgical procedures, and incorporation of regenerative materials for osseous bone defect resulted in adequate bone fill.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drăghici EC, CrăiŢoiu Ş, MercuŢ V, Scrieciu M, Popescu SM, Diaconu OA, et al. Local cause of gingival overgrowth. Clinical and histological study. Rom J Morphol Embryol 2016;57:427-35.  Back to cited text no. 1
    
2.
Agrawal AA. Gingival enlargements: Differential diagnosis and review of literature. World J Clin Cases 2015;3:779-88.  Back to cited text no. 2
    
3.
Beaumont J, Chesterman J, Kellett M, Durey K. Gingival overgrowth: Part 1: Aetiology and clinical diagnosis. Br Dent J 2017;222:85-91.  Back to cited text no. 3
    
4.
Ballini A, Scattarella A, Crincoli V, Carlaio RG, Papa F, Perillo L, et al. Surgical treatment of gingival overgrowth with 10 years of follow-up. Head Face Med 2010;6:19.  Back to cited text no. 4
    
5.
Savage NW, Daly CG. Gingival enlargements and localized gingival overgrowths. Aust Dent J 2010;55 Suppl 1:55-60.  Back to cited text no. 5
    
6.
Verma PK, Srivastava R, Baranwal HC, Chaturvedi TP, Gautam A, Singh A. Pyogenic granuloma – Hyperplastic lesion of the gingiva: Case reports. Open Dent J 2012;6:153-6.  Back to cited text no. 6
    
7.
Ashok S, Gupta AA, Ashok KP, Mhaske SA. Peripheral ossifying fibroma: A rare case affecting maxillary region. Indian J Dent 2016;7:141-3.  Back to cited text no. 7
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8.
Rallan M, Pathivada L, Rallan NS, Grover N. Peripheral ossifying fibroma. BMJ Case Rep 2013;2013:bcr2013009010. doi: 10.1136/bcr-2013-009010.  Back to cited text no. 8
    
9.
Mishra AK, Maru R, Dhodapkar SV, Jaiswal G, Kumar R, Punjabi H. Peripheral cemento-ossifying fibroma: A case report with review of literature. World J Clin Cases 2013;1:128-33.  Back to cited text no. 9
    
10.
Harpenau LA, Kao RT, Sanz M, Lundergan WP. Treatment Planning and Treatment: Gingival Enlargement. Critical Decisions in Periodontology. 5th ed. USA: PMPH-USA; 2013.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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