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International Journal of Science and Healthcare Research Vol.4; Issue: 2; April-June 2019 Website: www.ijshr.com Case Report ISSN: 2455-7587

Idiopathic - A Case Report

Dr Rashidat Ul Khairat1, Dr Suhail Majid Jan2, Dr Roobal Behal3

1Department of Periodontics, Government Dental College and Hospital, Srinagar, Jammu and Kashmir, India 2Professor and Head, Department of Periodontics, Government Dental College and Hospital, Srinagar, Jammu and Kashmir, India. 3Assistant Professor, Department of Periodontics, Government Dental College and Hospital, Srinagar, Jammu and Kashmir, India.

Corresponding Author: Dr Rashidat Ul Khairat

ABSTRACT and Cross syndrome.[3] There are various synonyms for IGF that elephantiasis Idiopathic gingival enlargement is a rare gingivae, diffuse fibroma, familial proliferative fibrous lesion of the keratinized elephantiasis, idiopathic fibromatosis; gingival tissue of maxillary and mandibular hereditary gingival fibromatosis, congenital arches due to increase in submucosal connective familial fibromatosis.[4] tissue elements that cause esthetic and In gingival fibromatosis the gingival functional problems. This case report addresses tissue is usually firm, pale-pink with the overview of gingival fibromatosis in 17- yearoldfemale. The patient presented with leathery consistency and characteristic generalized diffuse gingival enlargement pebbled surface. Exaggerated may involving the maxillary and posterior teeth in be present. The gingival tissues may mandibular arches extending on buccal and partially or totally cover the teeth and delay lingual/palatal surfaces of the teeth resulting in or impede tooth eruption. There are pseudo- difficulty in speech and mastication since last 4- pocketing and diastema formation due to 5 years. Based on the history and clinical enlarged tissue.[1] There are mastication, examination, the diagnosis was made and the speech impediments or lip closure enlarged tissue was surgically removed. difficulties in severe cases. The tissue Keywords: Idiopathic gingival fibromatosis, growth is painless but may be painful when gingival hyperplasia tissues are traumatized during mastication.

The gingival hyperplasia may be INTRODUCTION generalised (symmetric) or localised Idiopathic gingival fibromatosis (nodular) involving the buccal and lingual (IGF) is an uncommon, benign, hereditary tissues of both maxillary and mandibular condition with no specific cause. IGF is arches.[5] The condition commences characterized by a slowly progressive, frequently when deciduous or permanent painless, non-hemorrhagic, fibrous teeth begin to erupt and is most commonly enlargement of maxillary and mandibular seen associated with the permanent teeth . keratinized gingiva.[1] It can lead to Females and males appear to be equally diastema, malocclusion, delayed eruption of affected. permanent dentition or prolonged retention Histologically, the affected tissues of primary dentition, causing esthetic and are generally composed of dense connective functional problems.[2] It occurs either as an tissue rich in coarse collagen fibers and are isolated disease or combined with some rare highly differentiated with young fibroblasts syndromes or chromosome disorders such and scarce blood vessels. The epithelium is as are Zimmerman-Laband syndrome, hyperkeratotic with elongated rete pegs. Murray-Puretic-Drescher syndrome, Unusual findings include the presence of Rutherford syndrome, Cowden syndrome, International Journal of Science and Healthcare Research (www.ijshr.com) 149 Vol.4; Issue: 2; April-June 2019

Rashidat Ul Khairat et al. Idiopathic Gingival Enlargement - A case Report small calcified particles, amyloid deposits, , Govt. Dental College islands of odontogenic epithelium and Srinagar with the chief complaint of osseous metaplasia in the connective tissue swelling in the of the upper and lower and ulcerations of the overlying mucosa.[6] jaw since four to five years. The patient first In IGF, no causative agent can be noticed the swelling 7 years back in the identified and a family history is lacking. If upper front region of the mouth that the inheritance is autosomal dominant, then gradually and slowly increased in size .The the phenotypic frequency is 1 in 750,000 patient had delayed tooth eruption of the people and the gene frequency is 1 in upper and lower teeth associated with 350,000.[7] This report presents the clinical gingival swelling. Swelling was painless, features and the management of a 17-year- but the patient complained that it interfered old female patient with idiopathic gingival with chewing. There was no history of fibromatosis. epilepsy or major illness. Developmental milestones and other systems of the patient CASE-REPORT were normal. Family and menstrual history A 17-year-old female patient was non contributory. reported to the Department of

Fig. 1: Maxillary Pre-Operative View Fig. 2: Frontal View Fig. 3: Lateral Pre-Operative View

Fig. 4: By Blade And Scalpel Fig. 5: Immediate Post-Orepative View Fig. 6: Immediatepost – Operative View -Palatal

Extraoral examination: General physical involved in the maxillary and posterior evaluation was done. The patient had mandibular quadrants covering almost the normal physical appearance and entire clinical . There was diffuse psychomotor skills. Patient had bilaterally involvement of marginal, papillary, and symmetrical face with incompetent lips and attached gingiva. The swelling was largely convex profile. pale pink, and firm, with stippling present in Intraoral findings: Gingival enlargement the anterior maxillary area and absent in was more predominant in the upper jaw and mandibular posterior region. There were in the posterior mandibular molar region. some deposits and generalized Both facial and palatal/lingual aspects were pseudo-pockets were observed with no

International Journal of Science and Healthcare Research (www.ijshr.com) 150 Vol.4; Issue: 2; April-June 2019 Rashidat Ul Khairat et al. Idiopathic Gingival Enlargement - A case Report . The enlargement had Gingival fibromatosis can occur as led to incompetent lips, poor esthetics and an isolated condition or be associated with also hindered in speech and mastication. other diseases or syndromes and can be She appeared apprehensive and lacked localized or generalized. The different forms confidence due to gummy smile. can be classified as following:[8] The dentition revealed the presence of all 1. Isolated HGF permanent teeth (except second and third 2. Isolated IGF molars) but the permanent 1st molars were 3. GF with hypertrichosis grossly carious. Due to the enlargement the 4. GF with hypertrichosis and mental teeth were malaligned with spacing between retardation and/or epilepsy them. Alginate impressions were made of 5. GF with mental retardation and/or both arches and then study models were epilepsy obtained for the record purpose. Routine 6. GF associated with other diseases as part blood investigations were done that were of a syndrome. within normal physiological range. Then written consent was obtained from the This article reports a case of Idiopathic patient after explaining the procedure to be Gingival Fibromatosis based on clinical done. appearance, non-contributory family history The treatment plan was formulated which and histopathological evaluation in the included phase 1 therapy, quadrant-wise present case. The cause of Idiopathic GF is gingivectomy, extraction of grossly decayed unknown, but may result from a variety of unrestorable 1st molars then followed genetic mutations, and therefore the clinical orthodontic treatment. Thorough scaling, presentation of the condition differs. It can root planing, and curettage were done and occur by either autosomal dominant or anti-microbial rinse gluconate autosomal recessive inheritance or a new 0.2% prescribed for 3 weeks. An incisional type of genetic mutations.[2] biopsy was done and tissue specimen was In the present case the patient reported sent for histopathological evaluation which gingival growth after the eruption of showed stratified squamous epithelium with permanent mandibular anteriors, gingival focal keratinization with dense collagen enlargement was more predominant in the stroma in the connective tissue. After phase upper jaw and in the posterior mandibular I therapy quadrant-wise gingivectomy was molar region. Both facial and palatal/lingual performed with blade and scalpel under aspects were involved in the maxillary and local anesthesia containing 2% lignocaine posterior mandibular quadrants covering with 1:200000 epinephrine. First, the almost the entire clinical crown. The maxillary surgery was performed. The tissue enlargement had influenced the alignment was excised till desired crown lengthening of her teeth resulting in diastema and was achieved along with thorough irrigation malpositioning. of the site was done. In some sites, There is inconsistency in the literature as to additional curettage was done. The patient the cellular and molecular mechanisms that was prescribed anti-biotic and analgesic lead to gingival fibromatosis. Some authors medication and rinse twice daily with 0.2% report an increase in the proliferation of Chlorhexidine for two weeks. gingival fibroblasts,[9] whereas others report Then mandibular surgery was performed slower-than normal growth.[10] Increased and the patient was then placed on a collagen synthesis rather than decreased schedule of periodic recall visits for levels of collagenase activity may be maintenance care. The involved.[9] The microscopic features of the maintenance was reinforced at every recall. present case were classic of gingival fibromatosis, that is, hyperplastic epithelium DISCUSSION

International Journal of Science and Healthcare Research (www.ijshr.com) 151 Vol.4; Issue: 2; April-June 2019 Rashidat Ul Khairat et al. Idiopathic Gingival Enlargement - A case Report with elongated rete ridges and dense fibrous management. J Indian Soc Periodontol. connective tissue stroma underneath.[11] 2016; 20(1):98–102. Treatment depends on the severity of the 3. Gorlin RJ, Pinborg JJ, Cohen MM, Jr. enlargement. Minimal enlargement is Syndromes of the head and neck. 2nd treated conservatively with routine edition. New York: McGraw Hill. 1976, p. 329-336. prophylaxis, irrigation, and . 4. Varma BR, Nayak RP. Clinical When there is an interference with chewing Periodontology. 2nd Ed. New Delhi: Arya or unsatisfactory appearance, treatment (Medi) Publishing House; 2009. p.177. includes gingivectomy with internal or 5. Bansal A, Narang S, Sowmya K, Sehgal N. external bevel incision or by using Treatment and two year follow up of a electrosurgery or lasers.[12] For the present patient with hereditary gingival case, gingivectomy with blade and scalpel fibromatosis. J Indian SocPeriodontol 2011; under local anesthesia and 0.2% 15:406-9. Chlorhexidine rinse twice a day for two 6. Gunhan O, Gardner DG, Bostanci H, weeks after each surgery was done with Gunhan M. Familial gingival fibromatosis regular follow up. with unusual histological findings. J Periodontol 1995 Nov; 66(11):1008-1011.

7. Breen GH, Addante R, Black CC. Early CONCLUSION onset of hereditary gingival fibromatosis in Idiopathic gingival fibromatosis is a a 28-month old. Pediatr Dent 2009 Jul-Aug; slowly growing progressive enlargement 31(4):286-288 which in severe cases affects the esthetics, 8. Pappachan B, Narayan JV, Nayak A. speech and mastication. Early diagnosis, Idiopathic gingival fibromatosis–a neglected emphasis on conservative management, and case. Indian J Radiologiol Imaging 2002; multidisciplinary treatment protocol are 12(3):335-338. important factors in the management of 9. Tipton DA, Howell KJ, Dabbous MK. patients with idiopathic GF. Surgical Increased proliferation, collagen and intervention depends on the severity of fibronectin production by hereditary gingival fibromatosis fibroblasts. J enlargement followed by regular recall Periodontol 1997; 68:524-30. visits evaluate oral hygiene, and the stability 10. Shirasuna K, Okura M, Watatani K, of the periodontal treatment. More genetic Hayashido Y, Saka M, Matsuya T. search is needed to identify their molecular Abnormal cellular property of fibroblasts basis to rule out mode of inheritance. from congenital gingival fibromatosis. J Oral Pathol 1988; 17:381-5. Conflict of interest statement and source of 11. Baptista IP. Hereditary gingival funding: non declared fibromatosis: A case report. J ClinPeriodontol 2002; 29:871-4. REFERENCES 12. Ramer M, Marrone J, Stahl B, Burakoff R. 1. AnandNayak P, Nayak UA, Khandelwal V, Hereditary gingival fibromatosis: Ninave N. Idiopathic Gingival Fibromato- Identification, treatment, control. J Am Dent sis. Int J ClinPediatr Dent. 2011; 4(1):77– Assoc 1996; 127:493-5 81. 2. Pol DG, Lobo TM, Pol SD. Idiopathic How to cite this article: Rashidat Ul Khairat, gingival fibromatosis with asymmetrical Suhail Majid Jan, Roobal Behal. Idiopathic presentation and electrosurgical gingival enlargement - a case report. International Journal of Science & Healthcare Research. 2019; 4(2): 149-152.

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International Journal of Science and Healthcare Research (www.ijshr.com) 152 Vol.4; Issue: 2; April-June 2019