Periodontal plastic procedure for the management of the residual gingival defect after excision of an epulis.

Dentinal hypersensitivity and unesthetic appearance are common findings after excision of an epulis due to exposure of root and underlying bone. The simultaneous placement of subepithelial connective tissue grafting after excision of the lesion seems to be viable surgical option in such cases. Furthermore, this will avoid second surgical procedure for the management of the residual gingival defect.

INTRODUCTION

Gingival recession is a matter of concern for both patients and dental professionals, especially when exposure of the root surface is linked to deterioration in esthetic appearance and increase in dental hypersensitivity.[1] Traditionally, periodontal therapy was predominantly focused on establishing biologically and functionally stable periodontium. The presence of gingival recession exemplifies a situation in which a treatment modality that addresses not only biologic and functional, but also esthetic demands. Effectiveness of various periodontal plastic surgery (PPS) techniques such as free gingival grafting, subepithelial connective tissue grafting (SCTG), coronally advanced flap and guided tissue regeneration in the treatment of recession-type defects has been reported in several trials.[23] Walters et al.[4] stated that total excision of the lesion in the maxillary anterior region can result in an unsightly gingival defect unless appropriate efforts are taken to repair the mucogongival defects. Recently, McCrea described an alternative surgical approach to simply removing an epulis.[5] A subepithelial connective tissue graft together with a lateral mucogingival pedicle flap was used to repair the extensive defect after excision of the lesion to preserve and improve the mucogingival complex. Various different PPS techniques may be used to manage this defect and minimize patient esthetic concerns. In the literature, there are very few reports for the management of the residual gingival defect after excision of localized gingival growth. Therefore, the purpose of the present case report is to discuss the management of epulis by simultaneous excision and a PPS procedure for obtaining optimum esthetics and function.

CASE REPORT

A 28-year-old female patient reported to the Department of Periodontics, Armed Forces Medical College, Pune with a chief complaint of swelling in relation to her lower front teeth since 1-year which was unaesthetic and hindered the chewing from lower front teeth. The swelling started as a small painless growth 1-year back gradually increasing to the present size. An intraoral examination revealed generalized pink gingiva with a well-demarcated, nontender, firm, focal, sessile nodular growth measuring about 1.5 cm × 2 cm and covering the crown up to incisal third [Figure 1]. Medical history was noncontributory. An intraoral periapical radiograph of the mandibular central incisors showed no bone involvement [Figure 2]. On the first visit, oral hygiene instructions were given, and complete oral prophylaxis was done. Furthermore, incisional biopsy was carried out under local anesthesia which revealed hyperplastic, acanthotic parakeratinized, stratified squamous epithelium with elongated and interconnected rete ridges. Underlying connective tissue consisted of dense collagen bundles, fibroblasts, blood vessels and inflammatory cells mainly lymphocytes – suggestive of chronic inflammatory fibrous hyperplasia [Figure 3]. On the next visit under local anesthesia, intrasulcular incision was performed to raise the split thickness envelope flap [Figure 4] and localized growth was excised [Figure 5]. Followed by removal of residual calculus and root planning before placement of a connective tissue graft [Figure 6] harvested utilizing Bruno's technique.[6] Graft and flap were sutured with 3-0 resorbable sutures internally and externally to eliminate any movement [Figure 7]. The patient was motivated to maintain oral hygiene and was asked to rinse her mouth with 0.2% chlorehexidene mouthwash twice daily for 1-week. The patient was kept under observation through recall checkups. At 6 months recall, there was no recurrence of the growth and complete root coverage was achieved [Figure 8].

Figure 1

Preoperative photograph

Figure 2

Intraoral periapical radiograph

Figure 3

Photomicrograph of the specimen

Figure 4

Intrasulcular incision

Figure 5

Excision of an epulis

Figure 6

Connective tissue graft positioning

Figure 7

Final suturing

Figure 8

Healing after 6 months

DISCUSSION

Periodontal plastic surgery forms an important part of periodontal therapy for the management of mucogingival deformities. Obtaining root coverage has become more predictable with advances in the understanding of soft tissue healing, and the search for the best technique has led to a lot of improvement in surgical procedures aimed in this direction. The use of connective tissue graft for gingival recession was first reported by Langer and Langer in 1985.[7] Since then, a lot of modifications in the technique for retrieving and use of SCTG have been reported with improved and more predictable root coverage.[89] The SCTGs have been highly predictable in gingival recession therapy with respect to high percentage of root coverage, better healing and less postoperative discomfort at the donor site when compared with free gingival grafts The success of which can be attributed to the double blood supply at the recipient site from the underlying periosteum and overlying flap.[7] In anterior region, complete excision of an epulis will create a mucogingival defect, this may be esthetically and functionally unacceptable to the patients. Therefore, appropriate efforts are required to repair the residual gingival defect. Walters et al.[4] reported 3 cases of peripheral ossifying fibroma in maxillary incisor region and after excision repaired with different PPS techniques. In the case, 1 lateral sliding flap resulted in predictable repair of defects in the attached gingiva and yielded excellent color blend with adjacent tissues. However, this approach cannot be used if lateral donor site lacks an adequate band of attached gingiva, or if vestibule is shallow. In case 2 SCTG also resulted in good tissue color match and can be used in cases where there is inadequate donor tissue at adjacent site or if there is a shallow vestibule. In case 3 coronally positioned flap allowed excellent access to underlying periosteum and root surface with minimal postsurgical discomfort. However, this approach can only be used if there is relatively wide band of keratinized tissue apical to biopsy defect. McCrea reported a case where microsurgical repair of labial gingival tissues was done following excision of epulis and results were maintained at 18 month follow-up.[5] In our case, because lesion was in the anterior region, so it was decided to do incisional biopsy first to confirm the nature of the growth and subsequent planning for simultaneous removal of the lesion and connective tissue grafting. Complete root coverage was seen at 6 months follow-up.

CONCLUSION

Dentinal hypersensitivity and unesthetic appearance are common findings after excision of an epulis due to exposure of root and underlying bone. The simultaneous placement of SCTG after excision of the lesion seems to be viable surgical option in such cases. Also, this will avoid second surgical procedure for the management of the residual gingival defect. It is to be noted that care must be taken to diagnose the nature of the growth prior to performing such procedure.