Zimmermann-Laband-1 Syndrome: Clinical, Histological, and Proteomic Findings of a 3-Year-Old Patient with Hereditary Gingival Fibromatosis

biomedicines

Case Report Zimmermann-Laband-1 Syndrome: Clinical, Histological, and Proteomic Findings of a 3-Year-Old Patient with Hereditary Gingival Fibromatosis

Federica Guglielmi 1 , Edoardo Staderini 1,* , Federica Iavarone 2 , Laura Di Tonno 1 and Patrizia Gallenzi 1

1 Istituto di Odontoiatria, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy 2 Istituto di Biochimica e Biochimica Clinica, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy * Correspondence: [email protected]; Tel.: +39-0630154286

Received: 29 May 2019; Accepted: 27 June 2019; Published: 29 June 2019

Abstract: Background: Zimmermann-Laband-1 syndrome (ZLS-1; OMIM# 135500) is a rare genetic disorder whose oral pathognomonic sign is the development of progressive, diffuse, and severe gingival hypertrophy. Most children with abnormally gingival hyperplasia may also present multiple unerupted teeth and skeletal deformities of maxillary arches (i.e., skeletal anterior open bite). Despite phenotypic variability of the clinical spectrum, gingival fibromatosis is the hallmark of ZLS-1. Method: In this study, we report a 3-year-old male patient with a ZLS-1-related gingival overgrowth and failure of eruption of the deciduous teeth in the molar area. Surgical excision was performed under general anesthesia. Results: At three weeks follow-up, esthetics was significantly improved in terms of gingival appearance, and teeth eruption allowed an adequate masticatory function. Conclusion: In severe cases, surgical removal of the hyperplasic fibrous tissue may be required to expose unerupted teeth and establish a proper gingival contour. Surgical excision under general anesthesia is an elective procedure for patients with special needs, mental disability, as well as young and adult patients with dental anxiety type II and IV associated with poor oral health.

Keywords: gingival ﬁbromatosis; Zimmermann-Laband syndrome; periodontal disease; oral microbiome

1. Introduction The term “Laband syndrome”, also known as Zimmerman-Laband syndrome (ZLS), indicates an extremely rare genetic disorder characterized by abnormalities of the facial area and the extremities (hands and feet). Most children with ZLS-1 report generalized gingival hyperplasia, thus involving functional and aesthetic issues. Furthermore, affected infants may exhibit abnormally long and thin fingers and toes and/or deformed or absent nails at birth. In some cases, cataract, hepatosplenomegaly, hypertrichosis, hearing loss, and mental retardation may be present. [1] ZLS-1 is part of a rare and heterogeneous group of disorders called “hereditary gingival fibromatosis”, it affects around 1/1,000,000 patients with both autosomal dominant and recessive inheritance [2]. Clinically, it is associated with local or diffuse non-hemorrhagic gingival enlargement. The underlying alveolar bone is not directly influenced by gingival hyperplasia, but the gingival excess can allow plaque accumulation, causing biofilm-induced gingivitis, pseudopockets, caries, and halitosis. Failure of deciduous and permanent tooth eruption often occurs [3].

Biomedicines 2019, 7, 48; doi:10.3390/biomedicines7030048 www.mdpi.com/journal/biomedicines Biomedicines 2019, 7, 48 2 of 6

We report a case of multidisciplinary management of a hereditary gingival fibromatosis in a Biomedicines3-year-old 2019 male, 7, patientx FOR PEER who REVIEW had cutaneous, phenotypic, and molecular features of ZLS-1. The present2 of 6 Biomedicinesstudy is reported 2019, 7, x accordingFOR PEER REVIEW to the CARE (CAse REport) guidelines [4]. 2 of 6 2. Experimental Section 2. Experimental Section 2.1. Patient Information 2.1. Patient Information 2.1. Patient Information A 3-year-old child was referred for clinical examination to the Pediatric Dentistry Unit of the A 3-year-old child was referred for clinical examination to the Pediatric Dentistry Unit of the DepartmentA 3-year-old of Surgical child Scienceswas referred for Head for clinical and Neck examination Diseases, Agostinoto the Pediatric Gemelli Dentistry University Unit Hospital of the Department of Surgical Sciences for Head and Neck Diseases, Agostino Gemelli University Hospital of Departmentof Rome: during of Surgical the early Sciences diagnostic for Head screening and Neckfor suspected Diseases, genetic Agostino abnorma Gemellilities, University the pediatricians Hospital Rome: during the early diagnostic screening for suspected genetic abnormalities, the pediatricians of of Rome:the Rare during Diseases the earlyUnit noticeddiagnostic generalized screening gingival for suspected fibromatosis genetic with abnorma poorlities, periodontal the pediatricians health. the Rare Diseases Unit noticed generalized gingival fibromatosis with poor periodontal health. of the Rare Diseases Unit noticed generalized gingival fibromatosis with poor periodontal health. 2.2. Medical, Family, and Psychosocial History 2.2. Medical, Family, and Psychosocial History 2.2. Medical, Family, and Psychosocial History The child presented clinically the salient dysmorphogenetic features of ZLS-1: middle-degree The child presented clinically the salient dysmorphogenetic features of ZLS-1: middle-degree intellectualThe child disability presented with clinically autistic thetraits, salient motor dysm impairmentorphogenetic with features ataxic gait of ZLS-1:notes, middle-degreeand structural intellectual disability with autistic traits, motor impairment with ataxic gait notes, and structural intellectualepilepsy. The disability genetic analysiswith autistic showed traits, a pathogenet motor imicpairment mutation with in the ataxic KCNH1 gait genenotes, on and chromosome structural epilepsy. The genetic analysis showed a pathogenetic mutation in the KCNH1 gene on chromosome epilepsy.1q32.2 (OMIM# The genetic 135500) analysis with a showed heterozygous a pathogenet de novoic mutationtransmission. in the The KCNH1 child wasgene born on chromosome at 42 weeks 1q32.2 (OMIM# 135500) with a heterozygous de novo transmission. The child was born at 42 weeks of 1q32.2of gestation (OMIM# regularly 135500) from with non-consanguineous a heterozygous de novo parents tran insmission. apparent The good child health; was born his motherat 42 weeks was gestation regularly from non-consanguineous parents in apparent good health; his mother was born in ofborn gestation in Italy, regularly but she has from Cape non-consanguineous Verdean origin. parents in apparent good health; his mother was Italy, but she has Cape Verdean origin. born Duringin Italy, the but firstshe hasobservation, Cape Verdean we noticed origin. a delay in dental eruption and a severe generalized During the first observation, we noticed a delay in dental eruption and a severe generalized hypertrophyDuring theof the first buccal observation, and lingual we aspectsnoticed of a thedela attachedy in dental and marginaleruption gingiva;and a severe no decays generalized and/or hypertrophy of the buccal and lingual aspects of the attached and marginal gingiva; no decays hypertrophylesions involving of the oral buccal mucosa and werelingual detected. aspects Atof thethis attached time, intraoral and marginal photographs gingiva; were no takendecays (Figures and/or and/or lesions involving oral mucosa were detected. At this time, intraoral photographs were taken lesions1 and 2). involving It was therefore oral mucosa decided, were in detected. agreement At withthis time, the parents, intraoral to photographs keep the situation were takenunder (Figures control (Figures1 and2 ). It was therefore decided, in agreement with the parents, to keep the situation under 1with and re-evaluation 2). It was therefore every 6decided, months. in agreement with the parents, to keep the situation under control control with re-evaluation every 6 months. with re-evaluation every 6 months.

Figure 1. Facial phenotype of the child with Zimmermann-Laband-1 syndrome. Figure 1. Facial phenotype of the child with Zimmermann-Laband-1 syndrome. Figure 1. Facial phenotype of the child with Zimmermann-Laband-1 syndrome.

Figure 2. Pre-treatment intraoral photo. Figure 2. Pre-treatment intraoral photo. 2.3. Therapeutic Intervention 2.3. Therapeutic Intervention Two years after the first observation, the child came for a check-up appointment. The parents revealedTwo that years the after child the was first diagnosed observation, with Zimmermthe child cameann-Laband-1 for a check-up syndrome, appointment. associated The with parents a true revealedgingival hythatperplasia. the child was diagnosed with Zimmermann-Laband-1 syndrome, associated with a true gingivalThe hyprogressiveperplasia. gingival enlargement, particularly in the molar area, was associated with failure of eruptionThe progressive of the deciduous gingival teeth. enlargem Therefore,ent, particularly it was proposed in the molar to the area, parents was toassociated remove thewith gingival failure of eruption of the deciduous teeth. Therefore, it was proposed to the parents to remove the gingival Biomedicines 2019, 7, 48 3 of 6

2.3. Therapeutic Intervention Two years after the first observation, the child came for a check-up appointment. The parents revealed that the child was diagnosed with Zimmermann-Laband-1 syndrome, associated with a true gingivalBiomedicines hyperplasia. 2019, 7, x FOR PEER REVIEW 3 of 6 BiomedicinesThe progressive 2019, 7, x FOR gingival PEER REVIEW enlargement, particularly in the molar area, was associated with failure3 of 6 ofovergrowth eruption ofin the order deciduous to improve teeth. the Therefore, clinical itdi wassplay proposed of the crowns. to the parents Owing to to remove his uncooperative the gingival overgrowth in order to improve the clinical display of the crowns. Owing to his uncooperative overgrowthattitude and in his order medical to improve history, the gingival clinical excision display ofwas the performed crowns. Owing under to general his uncooperative anesthesia in attitude a day attitude and his medical history, gingival excision was performed under general anesthesia in a day andsurgery his medicalservice designed history, gingival for patients excision with was special performed needs. under The case general study anesthesia was conducted in a day with surgery the surgery service designed for patients with special needs. The case study was conducted with the serviceparents’ designed understanding for patients and written with specialconsent needs. to the intervention The case study and was research conducted participation. with the parents’ parents’ understanding and written consent to the intervention and research participation. understandingUsing a periodontal and written probe, consent the probing to the intervention pocket depth and (PPD) research was participation.preoperatively measured on the Using a periodontal probe, the probing pocket depth (PPD) was preoperatively measured on the circumferenceUsing a periodontal of the teeth. probe, In order the probingto evaluate pocket the depththickness (PPD) of the was connect preoperativelyive tissue, measured a small punch on the circumference of the teeth. In order to evaluate the thickness of the connective tissue, a small punch circumferencewas made on the of thebuccal teeth. and In palatal order to aspect evaluate of each the thickness tooth for ofwhich the connective gingivectomy tissue, was a smallcarried punch out. was made on the buccal and palatal aspect of each tooth for which gingivectomy was carried out. wasUsing made a 15c on blade, the buccal a perpendicular and palatal aspect paramarginal of each tooth non-beveled for which incision gingivectomy was made was carriedon the out.vestibular Using Using a 15c blade, a perpendicular paramarginal non-beveled incision was made on the vestibular aand 15c palatal blade, aaspect. perpendicular Then, an paramarginal external intrasulcula non-beveledr incision incision was was carried made on out the to vestibular reach the and previous palatal and palatal aspect. Then, an external intrasulcular incision was carried out to reach the previous aspect.horizontal Then, incision, an external thus intrasulculardelimitating incisiona marginal was flap carried that out was to reachsculpted, the previouslifted, and horizontal removed. incision, Since horizontal incision, thus delimitating a marginal flap that was sculpted, lifted, and removed. Since thusthe hyperplastic delimitating gingiva a marginal had flap a thick that keratinized was sculpted, den lifted,se fibrous and removed. tissue, large-grain Since the and hyperplastic fine-grain gingiva olive- the hyperplastic gingiva had a thick keratinized dense fibrous tissue, large-grain and fine-grain olive- hadshaped a thick diamond keratinized burs were dense used fibrous to create tissue, a large-grain sloping plane and fine-grainprojected externally olive-shaped on diamondthe vestibular burs shaped diamond burs were used to create a sloping plane projected externally on the vestibular wereaspect. used The to external create abevel sloping was plane performed projected to preserve externally a proper on the gum vestibular architecture aspect. after The surgery external as bevel well aspect. The external bevel was performed to preserve a proper gum architecture after surgery as well wasas to performedallow the apical to preserve placement a proper of surgical gum architecture flap (Figures after 3 and surgery 4). An as ultrasound well as to allowtip was the used apical to as to allow the apical placement of surgical flap (Figures 3 and 4). An ultrasound tip was used to placementremove any of surgicallittle fibrous flap (Figures fragment3 and between4). An ultrasound teeth. The tip excised was used gingival to remove tissue any was little sent fibrous for remove any little fibrous fragment between teeth. The excised gingival tissue was sent for fragmenthistopathological between analysis. teeth. The excised gingival tissue was sent for histopathological analysis. histopathological analysis.

Figure 3. Intra-operativeIntra-operative photo: orotrach orotrachealeal intubation intubation in general anesthesia; gingival fibromatosis. ﬁbromatosis. Figure 3. Intra-operative photo: orotracheal intubation in general anesthesia; gingival fibromatosis.

Figure 4. Intra-operativeIntra-operative photo: photo: gingivec gingivectomytomy and and gingivoplasty gingivoplasty surgery surgery.. Figure 4. Intra-operative photo: gingivectomy and gingivoplasty surgery. 3. Results 3. Results After three weeks, the patient showed completecomplete healing; then, follow-up appointments were After three weeks, the patient showed complete healing; then, follow-up appointments were scheduled every three months (Figure 55).). EstheticsEsthetics waswas signiﬁcantlysignificantly improvedimproved inin termsterms ofof gingivalgingival scheduled every three months (Figure 5). Esthetics was significantly improved in terms of gingival appearance, and teeth eruption allowed an adequate masticatory function.function. appearance, and teeth eruption allowed an adequate masticatory function. Biomedicines 2019, 7, 48 4 of 6 Biomedicines 2019, 7, x FOR PEER REVIEW 4 of 6 Biomedicines 2019, 7, x FOR PEER REVIEW 4 of 6

Figure 5. Post-operative photo: soft soft ti tissuessue healing 3 months later. Figure 5. Post-operative photo: soft tissue healing 3 months later. 3.1. Histological Characteristics 3.1. Histological Characteristics 3.1. Histological Characteristics Histological features of the biopsied sample revealed the presence of squamous-lining oral mucosa Histological features of the biopsied sample revealed the presence of squamous-lining oral withHistological parakeratosis features and pseudoepitheliomatous of the biopsied sample hyperplasia revealed along the withpresence the subepithelial of squamous-lining deposition oral of mucosa with parakeratosis and pseudoepitheliomatous hyperplasia along with the subepithelial mucosadense hypocellular with parakeratosis connective and tissue pseudoepithelioma collagenized withtous focal hyperplasia mixoidal along changes. with No the obvious subepithelial atypia deposition of dense hypocellular connective tissue collagenized with focal mixoidal changes. No depositionwas observed of (Figuresdense hypocellular6 and7). connective tissue collagenized with focal mixoidal changes. No obvious atypia was observed (Figures 6 and 7). obvious atypia was observed (Figures 6 and 7).

Figure 6. Histological findings of the biopsied sample: the squamous-lining oral mucosa with Figure 6. HistologicalHistological findings ﬁndings of of the biopsied sample: the the squamous-lining squamous-lining oral oral mucosa with parakeratosis and pseudoepitheliomatous hyperplasia. parakeratosis and pseudoepitheliomatous hyperplasia.

Figure 7.7.Histological Histological ﬁndings findings of the of biopsied the biopsied sample: sample: the subepithelial the subepithelial deposition deposition of dense hypocellular of dense Figure 7. Histological findings of the biopsied sample: the subepithelial deposition of dense connectivehypocellular tissue connective collagenized tissue withcollagenized focal mixoidal with focal changes. mixoidal changes. hypocellular connective tissue collagenized with focal mixoidal changes. 3.2. Analysis of Salivary Biomarkers 3.2. Analysis of Salivary Biomarkers 3.2. Analysis of Salivary Biomarkers The unstimulated saliva was collected following a standardized protocol [5]. The patient had The unstimulated saliva was collected following a standardized protocol [5]. The patient had fastedThe for unstimulated at least two hourssaliva beforewas collec the appointment.ted following Salivaa standardized was collected protocol in the [5]. morning The patient between had fasted for at least two hours before the appointment. Saliva was collected in the morning between 10:00fasted A.M. for at and least 12:00 two P.M. hours before the appointment. Saliva was collected in the morning between 10:00 A.M. and 12:00 P.M. 10:00 A.M. and 12:00 P.M. Saliva was subsequently moved to a plastic container in an ice bath. Afterwards, it was combined Saliva was subsequently moved to a plastic container in an ice bath. Afterwards, it was combined with an acidic solution (0.2% 2,2,2-trifluoroacetic acid (TFA)) in 1:1 v/v ratio. The sample was with an acidic solution (0.2% 2,2,2-trifluoroacetic acid (TFA)) in 1:1 v/v ratio. The sample was Biomedicines 2019, 7, 48 5 of 6

Saliva was subsequently moved to a plastic container in an ice bath. Afterwards, it was combined with an acidic solution (0.2% 2,2,2-triﬂuoroacetic acid (TFA)) in 1:1 v/v ratio. The sample was subjected to a centrifugation at 8000 g for 10 min at 4 ◦C. Finally, the acidic supernatant was separated from the precipitate and stored at 80 C until the analysis was carried out by HPLC-ESI-MS (100 /l, corresponding − ◦ to 50/ l of saliva). The whole salivary sample of the child was analyzed through a top-down proteomic approach: intact protein ions or large protein fragments were subjected to gas-phase fragmentation for MS analysis [6,7]. A preliminary analysis showed an increase in inﬂammatory state proteins compared to healthy subjects of the same sex and age; moreover, the defensins alpha 1 and alpha 3 were doubled compared to the controls, and the presence of the S100A7 was also highlighted.

4. Discussion Clinical follow-ups were scheduled every 6 months because the recurrence risk of the gingival fibromatosis is reported to be high for 6-year follow-up. Based on the histopathological, clinical, and molecular findings, a differential diagnosis of ZLS-1 was made excluding the other types of hereditary gingival fibromatosis (HGF). (Figure7, Table1)

Table 1. Classiﬁcation of hereditary gingival ﬁbromatosis.

Classification of Hereditary Gingival Fibromatosis 1. Hereditary gingival fibromatosis 2. Gingival fibromatosis with craniofacial dysmorphism 3. Gingival fibromatosis with progressive deafness 4. Gingival fibromatosis/ hypertrichosis syndrome 5. Ramon syndrome 6. Zimmermann-Laband syndrome 7. Infantile systemic hyalinosis 8. Juvenile hyaline fibromatosis 9. Oculodental syndrome, Rutherfurd type 10. Amelogenesis imperfecta/nephrocalcinosis syndrome 11. Amelogenesis imperfecta/gingival fibromatosis syndrome

The analysis of salivary biomarkers suggests that the salivary concentration of inflammatory markers in patients with gingival fibromatosis is upregulated in comparison to that found in healthy patients. Several articles have recently outlined the potential use of saliva as a diagnostic fluid. Saliva is a non-invasive and indispensable source of information for diagnosis of rare diseases. Recent proteomic platforms have analyzed the human salivary proteome and characterized about 3000 differentially expressed proteins and peptides. Future investigations are needed to identify chronic inflammatory proteins and molecular markers for genotype-dental phenotype correlation of ZLS.

5. Conclusions The aim of this study was to present the multidisciplinary management of a syndromic child with hereditary gingival ﬁbromatosis, showing that a team of geneticists, dentists, pathologists, and biochemists can work together to achieve a comprehensive diagnosis and treatment of rare diseases [8]. In severe cases, surgical removal of the hyperplasic ﬁbrous tissue may be required to expose unerupted teeth and establish a proper gingival contour. Surgical excision under general anesthesia is an elective procedure for patients with special needs, mental disability, as well as young and adult patients with dental anxiety type II and IV associated with poor oral health [9,10].

Author Contributions: Conceptualization: E.S. and F.G.; methodology: E.S.; validation: F.G., E.S., and P.G.; formal analysis: F.I.; investigation: F.G. and F.I.; data curation: L.D.T.; writing—original draft preparation: F.G.; writing—review and editing: E.S.; visualization: L.D.T.; supervision: P.G.; project administration: P.G. Funding: This research received no external funding. Biomedicines 2019, 7, 48 6 of 6

Conﬂicts of Interest: The authors declare no conﬂict of interest.

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