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182]

Case Report

Idiopathic gingival enlargement and its

management
Arvind K. Shetty, Hardik J. Shah, Mallika A. Patil, Komal N. Jhota

Department of Abstract:
Periodontics and Idiopathic gingival enlargement is a proliferative fibrous lesion of the gingival tissue that causes esthetic and
Oral Implantology, functional problems. Both genetically and pharmacologically induced forms of gingival enlargement exist. This
Padmashree case report addresses the diagnosis and treatment of a case of idiopathic gingival enlargement in a 13-year-
Dr. D. Y. Patil Dental old female. The patient presented with generalized diffuse gingival enlargement involving the maxillary and
College and Hospital, mandibular arches extending on buccal and lingual/palatal surfaces and covering incisal / occlusal third of
the tooth resulting in difficulty in speech and mastication since last three years. Patient also gave a history of
Nerul, Navi Mumbai, surgical treatment being carried out four years back in upper anterior region suggesting of recurrence. Biopsy
India report confirmed the diagnosis of gingival hyperplasia. Gingivectomy was carried out in all four quadrants by
using four different methods.
Key words:
Gingival enlargement, gingival fibromatosis, gingivectomy

INTRODUCTION with hypertrichosis [3] and associated with

mental retardation and epilepsy. Unlike in HGF

G ingival fibromatosis (GF) is a heterogeneous

group of disorders characterized by
progressive enlargement of the gingiva caused
Access this article online by an increase in submucosal connective tissue
Website: elements. Many cases are iatrogenic; some are
www.jisponline.com
inherited while others are idiopathic. [1] The
DOI: etiology and pathogenesis of gingival hyperplasia
10.4103/0972-124X.76935
are still not well established, however it could
Quick Response Code: be directly linked to three factors: individual
susceptibility, local factors (dental plaque,
caries, and iatrogenic factors) and the action
of chemical substances and their metabolites.
The condition is not painful until the tissue
enlarges to partially cover the occlusal surface
and becomes traumatized during mastication.
Due to massive gingival enlargement, an
affected child usually develops an abnormal
swallowing pattern and experiences difficulty
with speech and mastication. Along with these
features, there may be some interference with
maintenance of oral hygiene and mastication. All
these factors will favor accumulation of materia
alba and plaque, which further complicates
the existing hyperplastic tissue.[2] Acute pain
associated with gingival hyperplasia leads
Address for to loss of masticatory ability and difficulty in
correspondence: swallowing food. Therefore, these patients have
Dr. Arvind K. Shetty, a tendency to swallow partially crushed food
704, Florence, Opp. SBI, which eventually causes gastric disturbances.[2]
Vakola, Santacruz (E), The number of patients with this oral lesion
Mumbai - 55, India.
have greatly increased in the last three decades.
E-mail: drshettyarvind@
yahoo.co.in
Hereditary GF (HGF) is a rare disease, affecting
only one in 750,000 people [1] while it can
Submission: 19-11-2010 develop as an isolated disorder or a feature of
Accepted: 24-11-2010 a syndrome. HGF is most commonly associated
and iatrogenic GF, in idiopathic GF (IGF), no
causative agent can be identified and a family
history is always lacking. We report a non-
syndromic case of GF along with its management.
CASE REPORT
A 13-year-old female patient reported to
the Department of Periodontics with a chief
complaint of swollen gums involving all her teeth
since last three years preventing proper speech,
articulation, and mastication, causing inadequate
lip apposition and poor esthetics. Four years
earlier, she was operated for the enlargement
by a private practitioner. She did not give any
history of drugs intake, fever, anorexia, weight
loss, seizures, hearing loss, nor was having any
physical or mental disorder. Also familial and
postnatal history was non-contributory.
Examination
Extra-oral examination revealed that the patient
has incompetent everted lips and a convex
profile. An intraoral examination revealed
generalized, diffused, nodular enlargement of the
gingiva involving the upper and lower arches,
which were pink in color, and had a firm and
fibrous consistency [Figure 1]. The teeth were
barely visible as the enlarged gingiva covered
till the incisal/occlusal third of the teeth. Grade
I mobility was seen in lower incisors.
Investigations
Intraoral periapical and panoramic radiograph
revealed no bone loss [Figure 2]. Over-retained

Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010 263
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Shetty, et al.: Idiopathic gingival enlargement and its management

Figure 1: Pre-operative Figure 2: OPG

Figure 3: First quadrant – Ledge and Wedge technique Figure 4: Second quadrant – External bevel gingivectomy

Figure 6: Fourth quadrant – Diode laser

Figure 5: Third quadrant – Electrocautery

Diagnosis
On the basis of medical, family, drug history, clinical and
histological findings, it was diagnosed as idiopathic gingival
enlargement.

Figure 7: Postoperative
deciduous teeth 53 and 74 were present. Hematological
investigations were within normal limits. Punch biopsy was
carried out which revealed bulbous increase in the connective
tissue, which was relatively avascular and had densely
arranged collagen-fiber bundles, numerous fibroblasts, and
mild chronic inflammatory cells. The overlying epithelium
exhibited hyperplasia and had elongated rete ridges suggesting
histological diagnosis of fibroepithelial hyperplasia.
Treatment
After completion of Phase I treatment, a quadrant-wise
gingivectomy was performed under local anesthesia using
four different techniques. In first quadrant, ledge and wedge
technique was performed [Figure 3] followed by external bevel
gingivectomy in second quadrant after ten days [Figure 4].
Kirkland knives were used for incisions on the facial and lingual
surfaces. Orban periodontal knives were used for interdental
incisions. Ten days later, surgery using an electrocautery
device with a medium size, loop electrode was performed in
third quadrant [Figure 5]. A soft tissue diode laser was used
for gingivectomy in the fourth quadrant [Figure 6]. Co-pack
was given in all four quadrants to reduce patient discomfort.
Use of laser and electrocautery provided excellent hemostasis
and better immediate postoperative result. Also the patient
acceptance towards the treatment was better with these two
rather than the conventional approach [Figure 7].

264 Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010
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Shetty, et al.: Idiopathic gingival enlargement and its management
DISCUSSION
IGF may be congenital or hereditary. Though the genetic
mechanism is not well understood, the majority of the reported
cases have attributed the condition of fibrous enlargement
of gingiva to hereditary factors. The mode of transmission is
mainly autosomal dominant. The first polymorphic marker
for HGF phenotype is chromosome 2p21.[4,5] Many cases are
sporadic with no familial background.
Gingival hyperplasia can occur after therapy with drugs like
phenytoin,[6] cyclosporine, nifedipine, and nitrendipine. Long-
term use of these drugs has to be ruled out. The incidence of
gingival enlargement caused by phenytoin, an anticonvulsant
used in the treatment of epilepsy varies from 3−84.5%. Whereas,
cyclosporine a fairly potent immunosuppressive agent, used to
prevent organ transplant rejection and to treat several disease
of autoimmune origin, induced gingival enlargement in 30% of
the cases.[7] Nifedipine, which is a calcium channel blocker used
in the treatment of acute and chronic coronary insufficiency,
including angina pectoris and refractory hypertension and
nitrendipine an analog of nifedipine have also been reported
to induced gingival enlargement.[8,9]
Gingival hyperplasia may be associated with physical
development, retardation, and hypertrichosis.[10] Although
gingival tissue may appear normal at birth, hyperplastic GF
may become evident with the eruption of primary or permanent
dentition, suggesting a trauma-induced tissue reaction during
the eruption.[11] Sometimes gingival enlargement does not
occur until the eruption of the permanent dentition. Further
enlargement does not occur once the growth of jaw is completed.[12]
It has been suggested that gingival enlargement may be due
to nutritional and hormonal factors; however, these have not
been completely substantiated. The constant increase in the
tissue mass can result in delayed eruption and displacement
of teeth, arch deformity, spacing, and migration of teeth.[13] The
condition is not painful until the tissue enlarges to partially
cover the occlusal surface of the molars and become traumatized
during mastication, which was observed in the present case.
Due to massive gingival enlargement, an affected child usually
develops abnormal swallowing pattern and experiences
difficulty in speech and mastication. Along with these features,
there may be some interference with the oral hygiene measures
and normal mastication. All these will favor accumulation
of materia alba and plaque, which further complicates the
existing hyperplastic tissue. Maintenance of good oral hygiene
is very important. It is not known if plaque control measures
are effective in this condition; however, it is a good practice to
maintain the plaque control following gingivectomy procedure.
Histologically, the gingival hyperplasia is mainly due to an
increase and thickening of mature collagen bundles in the
connective tissue stroma. The nodular appearance can be
attributed to the thickened para hyperkeratinized epithelium.
Various modalities of treatment had been proposed including
radical treatment with extraction of the involved teeth, which
was reported not to favor a recurrence of the growth. The
only treatment of choice in this condition was gingivectomy
to satisfy the patient’s esthetics. Though the tissue appeared
to be pale and firm, the surgical procedure was complicated
Journal of Indian Society of Periodontology - Vol 14, Issue 4, Oct-Dec 2010 265
with excessive hemorrhage. Since recurrence could be expected
within a few months after surgery and may return to the
original condition within few years, the patient may have to
undergo repeated gingivectomy procedures. This often causes
further increase in the patients’ and parents’ psychological and
emotional stress. Hence, psychological counseling is a must for
patients and parents.
CONCLUSION
Even though recurrence cannot be predicted, the psychological
and functional benefits far outweigh the risk of recurrence. Oral
hygiene and the superimposition of plaque accumulation have
a crucial effect on the prognosis of GF. Long-term follow-up
will be required to evaluate the predictability of the different
surgical techniques.
ACKNOWLEDGMENT
The study was self-funded by the authors and their institution. No
conflicts of interest.
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Source of Support: Nil, Conflict of Interest: None.