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 Table of Contents  
CASE REPORTS
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 11-14

The management of mucogingival defect after excision of a pyogenic granuloma: 3-year follow-up


1 Department of Periodontology, Faculty of Dental Medicine of Monastir, Monastir, Tunisia
2 Department of Dentistry, Military Hospital of Tunis, Tunis, Tunisia

Date of Web Publication21-Mar-2018

Correspondence Address:
Dr. Safa Ben Tanfous
Service de Parodontologie, Clinique Dentaire de Monastir, Rue Avicenne, Monastir 5000
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dmr.dmr_12_17

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  Abstract 


The pyogenic granuloma (PG) is an exuberant tissue response to local irritation or trauma. The young lesions are highly vascular, red or reddish purple, often elevated and ulcerated, and bleed easily. Older lesions tend to be more collagenized and pink in appearance. Despite the name, no pyogenic material or pus is found in the lesion. Treatment protocol of PG includes many options. However, surgical excision is the treatment of choice. Several others highlighted the extremely varied recurrence rates. This case report aims to present 3-year follow-up management of mucogingival defect following surgical excision of PG.

Keywords: Coronally advanced flap, mucogingival defects, pyogenic granuloma, surgical excision


How to cite this article:
Tanfous SB, Masmoudi R, Soudani W, Guezguez L. The management of mucogingival defect after excision of a pyogenic granuloma: 3-year follow-up. Dent Med Res 2018;6:11-4

How to cite this URL:
Tanfous SB, Masmoudi R, Soudani W, Guezguez L. The management of mucogingival defect after excision of a pyogenic granuloma: 3-year follow-up. Dent Med Res [serial online] 2018 [cited 2018 Apr 19];6:11-4. Available from: http://www.dmrjournal.org/text.asp?2018/6/1/11/228116




  Introduction Top


The pyogenic granuloma (PG) is one of the reactive lesions of the gingiva.[1] This term was introduced for the first time by Hartzell in 1904.[2] Nowadays, it is considered as a misnomer because the lesion is unrelated to infection, does not contain pus, and is not strictly speaking a granuloma.[3] Indeed, this common tumor-like benign lesion of the oral tissues is, actually, considered to be reactive and traumatic rather than neoplastic in nature.[4],[5] Moreover, trauma or local irritants have been known to be predisposing factors.[6] PG is the most prevalent gingival overgrowth lesion.[3] It can occur at all ages. In addition, females are twice more frequently affected than males.[4]

Clinically, PG usually appears as a nodular mass, either pedunculated or sessile. The marginal gingiva is its predilection site with 75% and only 15% of the lesions on the alveolar mucosa.[7],[8]

Treatment protocol of PG includes many options. However, surgical excision is the treatment of choice.[9] Several others highlighted the extremely varied recurrence rates.[10] This explains the need of a wide excision whose margins should reach healthy tissue. Such approach can lead to anesthetic root exposure.[1],[11],[12] Several surgical techniques have been proposed to manage such mucogingival defects at the time of excisional biopsy.[13]

The aim of this paper is to present 3-year follow-up management of mucogingival defect following surgical excision of PG.


  Case Report Top


A 26-year-old systemically healthy female was referred to the Department of Periodontology of the Faculty of Dental Medicine of Monastir (Tunisia), with a painless gingival enlargement at the papilla between teeth 21 and 22 causing discomfort. The patient stated that gingival overgrowth had begun 4 months ago with an increasing separation of the contact between the teeth. The clinical examination revealed a firm pedunculated gingival lesion which presenting an ulcerated surface [Figure 1]a and [Figure 1]b.
Figure 1: (a) Clinical appearance of the whole mouth and lesion, (b) note the pedunculated implantation of the lesion

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First of all, treatment protocol includes a conventional nonsurgical therapy with full mouth scaling. In addition, the patient was advised to perform and maintain her oral hygiene by brushing 3 times a day and to use a chlorhexidine mouth rinse of 0.2% twice daily. At the second appointment, 2 weeks later, we observed that there was a slight reduction in the overgrowth [Figure 2].
Figure 2: Clinical photograph showing the regression of the lesion after initial therapy

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Despite the fact that the lesion regressed, nonsurgical therapy was insufficient to lead to the complete regression of this reactive gingival lesion. Regarding these conditions, we decided to perform surgical management with a wide excision of the gingival enlargement to remove the lesion, the entire papilla, and underlying attachment to the crestal bone. However, the excision of the lesion resulted in a partially root exposure of teeth 21 and 22 associated with the loss of the papilla between the two teeth. Therefore, a coronally advanced flap (CAF) without realizing incision was performed to recreate an interproximal papilla of normal tissue. The flap was raised in a full-thickness manner to provide that portion of the flap critical for root coverage and papilla reconstruction with more thickness. A sharp and wide dissection beyond the vestibular lining mucosa was, then, carried out to eliminate muscle tensions and to provide an adequate coronal displacement of the gingival tissue. The flap was, finally, maintained in a coronal position with suspended sutures around the contact point; and a periodontal dressing was applied to prevent the wound from trauma [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d. Following surgical operation, amoxicillin 1 × 2 for 7 days, paracetamol 2 × 3 for 5 days, and chlorhexidine oral rinse 1 × 2 for 10 days were prescribed.
Figure 3: (a) Mucogingival defect after the lesion excision, (b) a mucoperiosteal flap was elevated, (c) the flap was coronally advanced and maintained in a coronal position with suspended sutures around the contact point, (d) the wound surface was covered by a periodontal dressing

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The tissue specimen was fixed in formalin and sent for pathological investigation. Histopathological examination revealed a squamous mucosa whose epithelium was per place ulcerated. The chorion assumed the appearance of a granulation tissue rich in capillary type vessels and spindle-shaped cells such as fibroblast like, which were consistent with PG [Figure 4].
Figure 4: Histopathological examination: the epithelium is per place ulcerated. The chorion is rich in capillary type vessels and spindle-shaped cells fibroblast like

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By the end of 8-month follow-up, complete root coverage was achieved, papilla was completely filled in the interdental area, and gingival contour was harmonious [Figure 5]a. It must be stressed that no sign of a relapse was noted, even 3 years postoperatively [Figure 5]b.
Figure 5: (a) Postoperative 8th months clinical appearance of the surgical site, (b) 3rd years clinical appearance of the surgical site

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  Discussion Top


The etiology of PG is unclear. It is not a neoplasm but rather seems to be a reactive lesion caused by trauma or mechanical irritations.[5] In this case, calculus and dental plaque should probably explain the development of such lesion.

Clinical features of PG allow to confusion with many other soft tissue reactive lesions [3] [Table 1]. Thus, only histological examinations are definitive in establishing the right diagnosis.[2] Indeed, in our case, histopathological findings were consistent with the diagnosis of PG.
Table 1: Differential diagnosis of pyogenic granuloma

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Treatment protocol of PG includes many options, and clinicians must take into account the lesion dimensions.[3] Indeed, if the lesion is small, initial periodontal therapy by scaling and root planning is the sufficient treatment.[14] While most important lesions require a surgical excision following nonsurgical therapy. The latter approach steal the treatment of choice for PG.[3],[9],[14]

However, periodontist should keep in mind that an inadequate surgical resection is one of the most important predisposing factors for relapse; especially that the recurrence rates of this gingival lesion are extremely varied in the related literature. This explains the need of a wide excision whose margins should be completely located in healthy tissue.[10] In our case, no recurrence occurred through 3-year follow-up.

However, such radical approach has disadvantages. Indeed, it can lead to gingival defects with anesthetic root exposure, especially when the lesion is in the anterior zone.[1],[11],[12] From this point of view, several surgical techniques have been proposed to correct mucogingival defects.[13] Overall, all treatments were effective in reducing gingival recessions with a concomitant improvement in attachment levels.[4]

In this case study, as expected, the excision of the lesion resulted in mucogingival defect with loss of the papilla between teeth 21 and 22. To manage this defect, a CAF without realizing incision was performed. In fact, the CAF is the first choice when there is adequate keratinized tissue apically to the defect.[15] Moreover, this technique leads to better results in terms of root coverage than laterally positioned flap and free gingival graft (FGG). In addition, esthetic outcomes are better with CAF than with FGG.[16] Furthermore, the postoperative course is less troublesome since donor sites far from the mucogingival defect are not involved, and healing will occur by first intention.[17] Besides, we avoided vertical releasing incisions because they might damage the blood supply to the flap and result in unesthetic visible white scars.[15] The gingival margin (GM) was placed coronal to the cementoenamel junction to enhance root coverage and interdental papilla recreation. In fact, the greater postoperative coronal displacement of the GM may cause greater root coverage.[18] Indeed, in our case, 3 year, postoperatively, complete root coverage was achieved, papilla was completely filled, and gingival contour was harmonious.


  Conclusion Top


PG needs to be diagnosed early. Adequate excision is essential for minimizing the risk of a relapse. Moreover, histological evaluation is obligatory to confirm the diagnosis.

This case demonstrated that the immediate esthetic rehabilitation with a CAF without realizing incision is an effective procedure in the management of mucogingival defects after total excision of PG.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rossmann JA. Reactive lesions of the gingiva: Diagnosis and treatment options. Open Pathol J 2011;5:23-32.  Back to cited text no. 1
    
2.
Regezi JA, Sciubba JJ, Jordan RC. Oral Pathology: Clinical Considerations. 4th ed. Philadelphia: WB Saunders; 2003.  Back to cited text no. 2
    
3.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci 2006;48:167-75.  Back to cited text no. 3
    
4.
Joda T. Esthetic management of mucogingival defects after total excision in a case of pyogenic granuloma. Eur J Esthet Dent 2012;7:110-9.  Back to cited text no. 4
    
5.
Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol 1980;51:655-61.  Back to cited text no. 5
    
6.
Xie YF, Shu R, Qian JL, Lin ZK, Romanos GE. Esthetic management of mucogingival defects after excision of epulis using laterally positioned flaps. Cell Biochem Biophys 2015;71:1005-10.  Back to cited text no. 6
    
7.
Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: Evaluation of oral conditions. Br J Oral Maxillofac Surg 1986;24:376-82.  Back to cited text no. 7
    
8.
Neville BW, Damm DD, Chi AC, Allen CM. Oral and Maxillofacial Pathology. Philadelphia: Elsevier Health Sciences; 2015.  Back to cited text no. 8
    
9.
Bataineh A, Al-Dwairi ZN. A survey of localized lesions of oral tissues: a clinicopathological study. J Contemp Dent Pract 2005;6:30-9.  Back to cited text no. 9
    
10.
Angelopoulos AP. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surg 1971;29:840-7.  Back to cited text no. 10
    
11.
Schneider LC, Weisinger E. The true gingival fibroma. An analysis of 129 fibrous gingival lesions. J Periodontol 1978;49:423-4.  Back to cited text no. 11
    
12.
Buchner A, Ficarra G, Hansen LS. Peripheral odontogenic fibroma. Oral Surg Oral Med Oral Pathol 1987;64:432-8.  Back to cited text no. 12
    
13.
Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: root coverage revisited. Periodontol 2000 2001;27:97-120.  Back to cited text no. 13
    
14.
Bouchard P. Plaque induced gingivitis. In: Parodontologie and Dentisterie Implantaire: Médecine Parodontale. Vol. 1. France: Lavoisier Médecine; 2015. p. 82-91.  Back to cited text no. 14
    
15.
Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions: A comparative controlled randomized clinical trial. J Periodontol 2009;80:1083-94.  Back to cited text no. 15
    
16.
Borghetti A, Monnet-Corti V. Chirurgie Plastique Parodontale. 2nd ed. France: CDP; 2008.  Back to cited text no. 16
    
17.
Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved, coronally advanced flap: A modified surgical approach for isolated recession-type defects. J Periodontol 2004;75:1734-41.  Back to cited text no. 17
    
18.
Zucchelli G, Amore C, Sforza NM, Montebugnoli L, De Sanctis M. Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study. J Clin Periodontol 2003;30:862-70.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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