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Clinics and Practice 2016; volume 6:895

Diode laser versus scalpel in exfoliation thus resulting in the delayed eruption and crowding of the underlying teeth.2 The Correspondence: Samia Aboujaoude, Department the treatment of hereditary constant enlargement of the tissues can even- of Pediatric Dentistry, Faculty of Dentistry, gingival fibromatosis tually lead to arch deformity and can become Lebanese University. Hadath, Beirut, Lebanon. painful once the tissues cover the occlusal sur- Tel.: +961.3.230353. in a 6-year old boy faces of the molars.1 The affected gingiva E-mail: [email protected] appears as a pinkish non-hemorrhagic tissue Key words: Diode laser; gingivectomy; gingival 1 Samia Aboujaoude,1 with a firm consistency. A multitude of treat- hyperplasia; hereditary gingival fibromatosis. Antoine Cassia,2 Carla Moukarzel3 ment procedures have been described in the literature and can be summed into two main Acknowledgments: the authors would like to 1Department of Pediatric Dentistry; modalities: the surgical and the laser assisted thank Dr. Sami Eltoum, Department of Oral 2Department of Oral Pathology and resection of the hyperplastic gingiva.5,6 Pathology and Diagnosis, Faculty of Dentistry, Diagnosis; 3Department of Pediatric The purpose of the present case report is to Lebanese University. Dentistry, Lebanese University, Beirut, compare the outcomes of the classical surgical Lebanon Conflict of interest: the authors declare no poten- removal with scalpel of gingival hyperplasia tial conflict of interest. versus diode laser resection in a six-year-old patient with non-syndromic HGF. Received for publication: 11 September 2016. Abstract Accepted for publication: 11 October 2016.

Hereditary gingival fibromatosis (HGF) is a This work is licensed under a Creative Commons rare disease characterized by a benign Case Report Attribution NonCommercial 4.0 License (CC BY- NC 4.0). enlargement of the gingiva involving both the mandible and the maxilla. This case is about a A 6-year old male patient presented along ©Copyright S. Aboujaoude et al., 2016 6-year-old child with non syndromic HGF show- with his parents to our private dental clinic Licensee PAGEPress, Italy ing a severe gingival enlargement covering complaining of swelling gums causing unfa- Clinics and Practice 2016; 6:895 almost all surfaces of the teeth, in both arches, vorable aesthetic appearance as well as masti- doi:10.4081/cp.2016.895only hence causing major aesthetic, phonetic and catory and speech impairment. masticatory problems. The aim of the present Intraoral examination (Figure 1) revealed article is to compare the outcomes of two ther- severe diffuse enlargement of marginal, inter- tinuous wave mode, with a 400-diameter fiber. apeutical approaches: i) classical surgical dental, and attached gingiva covering almostuseThe incision and shaping were performed removal with scalpel; and ii) diode laser resec- all surfaces of the teeth in both arches. The around the cervical buccal and lingual or tion. Compared to the surgical approach, the gingival tissues were non-hemorragic with palatal regions of the maxillary and mandibu- clinical results show that the main advantages normal color and firm, fibrotic consistency. lar first and second primary molars. of the diode laser technique are a better visi- There was an upper anterior traumatic ulcer The patient was discharged home the same bility during the intervention, minimal post- resulting from atypical occlusion. day with a prescription of non-steroidal anti- operative discomfort combined to a better gin- Extra oral examination (Figure 2) revealed inflammatory (Ibuprofen Profinal® Paediatric gival recontouring. a convex profile with maxillary protrusion, Suspension, Julphar, 5 mL Suspension; 3 times However, the time consumption and the incompetent lips and bushy eyebrows. Occlusal per day) and asked to rinse twice daily with high cost of the laser equipment remain the radiographs showed the presence of all anteri- chlorhexidine gluconate USP 0.12% (GUM, main disadvantages of the systematic use of or permanent teeth with radiolucency on the Paroex®, Sunstar Americas, Inc.) for three this technique. left central primary maxillary root (Figure 3). consecutive days. Thecommercial patient has never received any medical Histopathology analysis of the specimen or surgical treatment for his condition. showed moderately dense collagenous connec- There is positive family history of a younger tive tissue with collagen bundles arranged in a Introduction brother affected by the same condition (Figure 4). haphazard manner. Connective tissue was rel- The treatment plan was to operate under gen- atively avascular along with scanty inflamma- Hereditary gingival fibromatosis (HGF)Non also eral anesthesia considering the invasive tory cell infiltrate showing dense wavy bundles known as hereditary gingival hyperplasia, idio- nature of the intervention and the patient’s pathic gingival fibromatosis, or hereditary gin- lack of cooperation. Both treatment modalities, of collagen fibers containing numerous fibro- gival overgrowth is a rare disease character- surgical resection and laser, were planned to cytes and fibroblasts. The overlying epithelium ized by a benign enlargement of the gingiva be used. The procedure was explained to the was hyperplastic with elongated rete ridges involving both the mandible and the maxilla.1,2 parents and informed consent was obtained. (Figure 5). The histopathologic features were It can be an isolated disease3 or part of many A surgical resection to expose the teeth of compatible with the diagnosis of idiopathic syndromes such as Zimmerman-Laband, the anterior upper and lower regions was per- gingival fibromatosis. Murray-Puretic-Drescher, Rutherfurd, and formed: using a number 15 blade, two horizon- At one week postoperatively, the patient Cowden.4 It equally affects both genders with tal buccally and palataly or lingually straight showed uneventful healing with functional an incidence of 1 in 750,000.5 HGF is usually incisions were made at the level of the middle and aesthetic improvement (Figure 6). transmitted through an autosomal dominant third of the upper and lower gingivae, extend- manner but autosomal recessive inheritance ing over the primary centrals, laterals and has also been reported.2 Patients suffering canines. The hypertrophied tissues were dis- from HGF present major aesthetic, phonetic sected using periosteal elevator and debulked. Discussion and masticatory problems.2 Since the enlarge- As for the posterior regions, diode laser of ment takes place simultaneously with the 810 nm wavelength (Lasersmile®, Biolase, Hereditary gingival fibromatosis is a rare eruption of deciduous teeth it can hinder their USA) was used at a power of 3.5 watts, in con- condition but the most common form of gingi-

[page 86] [Clinics and Practice 2016; 6:895] Case Report val hyperplasia. Gingival overgrowth varies from mild enlargement of isolated interdental papillae to segmental or uniform and marked enlargement affecting one or both jaws.1,7 The precise mechanism of HGF is unknown.7 Several authors described this clinical enlargement as the result of the prolifera- tion of fibroblasts and the increased produc- tion of their extracellular matrix molecules.2,3 Despite its benign aspect, this condition is quite disfiguring if left untreated. The hyperplastic process affects the gingivae peripheral Figure 3. Occlusal radiographs showed the presence of all anterior permanent teeth with to the alveolar bone and spares the periodontal radiolucency on the left central primary maxillary root. ligament.7 The enlargement begins with the emergence of deciduous dentition and gradu- ally increases to cover the teeth completely, delaying exfoliation of primary molars. The hypertrophied gingiva retains its normal color, texture and bleeding tendency.8,9 Hereditary gingival fibromatosis has been reported to cause severe crowding of underlying teeth, speech impairment, social isolation and difficulty in mastication.10 The optimal course of treatment for HGF is only use Figure 4. The patient’s brother presenting similar extra-oral features.

Figure 1. Intraoral view showing the severity of gingival hyperplasia in a 6-year old patient with hereditary gingival fibromatosis. commercial

Figure 5. A, B) Histopathology analysis showing avascular connective tissue relatively along with scanty inflammatory cell infiltrate presenting wavy bundles of collagen fibers contain- Non ing numerous fibrocytes and fibroblasts. The overlying epithelium is hyperplastic.

Figure 2. Extraoral view showing bushy eyebrows, maxillary protrusion and lips incompetence. Figure 6. Buccal, left and right intra-orally views one-week post-operative.

[Clinics and Practice 2016; 6:895] [page 87] Case Report still controversial.11,12 Depending on the sever- Arora N. Hereditary gingival fibromatosis- ity of the disease, gingivectomy, electrosurgery Conclusions a case report and management using a and laser resection have been described.6 In novel surgical technique. Rev Sul Bras 2006, Coletta and Graner suggested the use of The clinical results show that the main Odontol 2011;8:453-8. CO2 laser during gingivectomy for patients advantages of the diode laser technique 10. Ramakrishnan T, Kaur M. Multispeciality 13 with HGF. Compared to diode laser, the CO2 seem to be a better visibility during the approach in the management of patient laser has the same advantages and indication intervention, minimal post-operative dis- with hereditary gingival fibromatosis: 1- but however it has a larger console and there- comfort combined to a better gingival recon- year followup: a case report. Int J Dentistry fore it’s more difficult to transport.14 touring. However, the time consumption and 2010;2010:575979. A study conducted by Jin et al. comparing the high cost of the laser equipment remain 11. Ramnarayan BK, Sowmya K, Rma J. the use of scalpels, Er, Cr: YSGG and diode the main disadvantages of the systematic use Management of idiopathic gingival fibro- lasers for surgery on pig oral mucosa conclud- of this technique. Diode light equipment leads matosis: report of a case and literature ed that diode laser is a worthy alternative to to minimal post-operative pain and adverse review. Pediatr Dent 2011;33:431-6. the two different interventions.15 effects besides better aesthetic results in the 12. Reenesh MM, Rath CSK, Mukherjee LCM. Gingivectomy is one of the most convention- HGF peadiatric patients. Different surgical management modalities al treatment methods for HGF treatment due to Therefore, future investigations with larger 16 for a case of idiopathic generalized gingi- its low cost and easy access. samples and longer followup are mandatory. In the present case, the anterior upper and val enlargement with chronic periodonti- lower regions gingival resections were per- tis. J Oral Maxillofac Surg Med Pathol formed with conventional surgery using 2012;24:1-4. scalpel. As there is, in nearly all circum- References 13. Coletta RD, Graner E. Hereditary gingival stances, adequate attached gingiva, there is fibromatosis: a systematic review. J little fear of creating a mucogingival problem 1. Jayachandran M, Kapoor S, Mahesh R. Periodontol 2006;77:753-64. with the surgical removal technique.1 Idiopathic gingival fibromatosis rehabili- 14. Akbulut N, Kursen E, Tumer M, et al. Is the Posterior mandibular and maxillary gingival tation: a case report with two-year follow 810-nm diode laser the best choice in oral soft resections were achieved by diode laser, which only up. Case Rep Dent 2013;2013:513513. tissue therapy? Eur J Dent 2013;7:207-13. has a wavelength of 810 nm that is absorbed by 2. Mohan R, Verma S, Argarwal N, Singh U. 15. Jin JY, Lee SH, Yoon HJ. A comparative the gingival tissue with very little risk of dam- Non-syndromic hereditary gingival fibro- study of wound healing following incision age to the underlying bone. The diode laser matosis. BMJ Case Rep 2013;2013: with a scalpel, diode laser or Er, Cr: YSGG enhanced the visibility due to its hemostatic use laser in guinea pig oral mucosa: a histo- properties which facilitate the gingival re-con- bcr2012008542. logical and immunohistochemical analy- touring and re-designing.17 3. Zhou M, Xu L, Meng H. Diagnosis and The surgical technique used anteriorly was treatment of hereditary gingival fibro- sis. Acta Odontol Scand 2010;68:232-8. faster than laser and helped reducing the dura- matosis case. Chin J Dent Res 2011;14: 16. Camilotti RS, Jasper J, Ferreira TB, et al. tion of the procedure, whereas the laser has 155-8. Resection of gingival fibromatosis with the advantage of better hemostasis and hence 4. Tripathi A, Dete G, Saimbi C, Kumar V. high-power laser. J Dent Child (Chic) reduced the hemorrhagic complications in the Management of hereditary gingival fibro- 2015;82:47-52. posterior region which is in close proximity to matosis: a 2 years follow-up case report. J 17. Namour S. Atlas of current oral laser sur- the superior palatine artery located in the Indian Soc Periodontol 2015;19:342-4. gery. Boca Raton, FL: Universal- maxillary tuberosity region.18 5. Odessey E, Cohn A, Casper F, Schechter L. Publishers; 2011. p 149. The main objective of the laser treatment is Hereditary gingival fibromatosis: aggres- 18. Kanagotagi S, Sidana S, Rajguru S, Padhye to cut, decontaminate and regenerate the soft commercialsive 2-stage surgical resection in lieu of A. Gingival fibromatosis with distinctive traditional therapy. Ann Plast Surg 2006; tissue. It has been shown that a collagen secre- facies-a three generation case report. J 57:557-60. tion is initiated as early as 6 h after surgery Clin Diagn Res 2015;9:05-7. 17 6. Livada R, Shiloah J. Gummy smile: could it allowing a better healing of the gum. 19. Gontiya G, Bhatnagor S, Mohandas U, 19,20 be genetic: hereditary gingival fibromato- As described by several authors, laser Galgali SR. Laser assisted gingivectomy in Non sis. J Tenn Dent Assoc 2012;92:23-6. technology in the present case, enabled better pediatric patients: a novel alternative shaping, visibility and hemostasis during inci- 7. Tiwana PS, De Kok IJ, Stoker DS, Cooper treatment. J Indian Soc Pedod Prev Dent sion specially when used in the posterior LF. Facial distortion secondary to idiopath- 2011;29:264-9. palatal and lingual regions. This is in line with ic gingival hyperplasia: surgical manage- 20. Beer F, Körpert W, Passow H, et al. previous reports showing that hypertrophic ment and oral reconstruction with soft tissues treated with laser presented mini- endosseous implants. Oral Surg Oral Med Reduction of collateral thermal impact of mal tissue damage, little edema and less post- Oral Pathol Oral Radiol Endod 2005; diode laser irradiation on soft tissue due operative pain compared to the surgical treat- 100:153-7. to modified application parameters. Lasers ed regions.17,19-21 Moreover, diode laser gener- 8. Arabi SR, Ebrahimzad Z, Mahdi K, Med Sci 2012;27:917-21. ates superficial thermal wound reducing the Jourdehi SA. Hereditary gingival fibro- 21. Jasper J, Ferreira TB, Poli VD, Pagnoncelli inflammatory response and post- operative dis- matosis: a case report. Res J Biol Sci RM. Resection of gingival fibromatosis comfort compared to the surgical 2011;6:104-7. with high power laser. J Dent Child approach.17,19,20 9. Babu KB, Pavankumar K, Anuradha BR, 2015;82:47-52.

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