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International Journal of Innovative Research in Dental Sciences

Vol. 4, Issue 3, May-June 2019

Epulis Fissuratum in Total Denture Wearers

Clinical Case Report
Dr. FZ.GHAZZAR, Dr. A.HATIM, Dr. K.MRHAR, Pr. S.BELLEMKHANNATE
(1)(2)(3): Prosthodontist in the Removable Prosthesis Service C.C.T.D Casablanca, Head of the Removable Prosthesis
Service C.C.T.D. Faculty of Dentistry, University Hassan II Casablanca, Morocco

ABSTRACT: Patients with a removable prosthesis may develop various mucosal pathologies, when
this prosthesis based on the depressible tissues of the fibromucosa overlying the maxillary and
mandibular jaw bone is poorly adapted.
Inflammatory fibrous hyperplasia, otherwise known as epulis fissuratum, is the most common
reactive mucosal disorder and is directly correlated to prosthesis wear. [5]
It is a reactive lesion of the oral mucosa caused by trauma to chronic trauma due to poorly fitting
prostheses [1, 2]

The size of the lesion varies from a few millimeters to a massive extension involving the entire
vestibule.
It is usually asymptomatic but sometimes severe inflammation and ulceration can occur, causing pain
and discomfort.
Surgical excision of the lesion and rehabilitation of the prosthesis are the treatment of choice.
This article presents, through clinical cases, the therapeutic approaches of different prosthetic
hyperplasias, secondary to the wearing of poorly adapted prostheses, for conventional prosthetic
rehabilitation.

KEYWORDS: Epulis fissuratum, ill fitting denture, inflammatory hyperplasia.

I. INTRODUCTION

The epulis fissuratum or fibrous prosthetic hyperplasia is a circumscribed pseudo-tumoral

hyperplastic lesion, sitting in the vestibule. It is a reaction lesion to poorly adapted prostheses
which appear in patients who have been fitted for a very long time. Chronic irritation is due to
prostheses whose edges are too sharp or too bulky. The lesions are presented as single or multiple
hyperplastic proliferations, of greater or lesser volume, elongated in the gingivo-labial or gingivo-
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International Journal of Innovative Research in Dental Sciences

Vol. 4, Issue 3, May-June 2019

jugal groove. The hyperplastic folds are floating, somehow firm and their proliferation may hinder
retention and prosthetic stability.
The chronic nature of the process means that the discomfort is often not an important feature, and
that the patient can continue to wear the defective prosthesis until the size of the hyperplasias
increases, and before the patient becomes report the lesion. In addition, the epulis fissuratum may be
associated with painful ulcerations at the base of the folds.
This pseudo-tumoral formation is frequent in the elderly with a female predominance, and develops
most often at the edges of the mandibular prostheses.
Treatment of the epulis includes surgical removal and pathological examination, followed by
relining of the patient's existing prosthesis with delayed-setting resin.
Case Report:
A 61-year-old female patient, consulting at the Casablanca Dental Consultation and Treatment
Center in the Prosthodontic Department, complaining of prosthetic instability and severe pain
exacerbated by the wearing of the prosthesis.
During the interrogation, the patient reports having been fitted with a total bimaxillary prosthesis
for 6 years, and the appearance of a small mass of soft tissue at the level of the lower arch which has
developed to the current size on a 12-month period with increased pain during chewing.
The endobuccal examination revealed the presence of multiple hyperplastic tissue folds at the
mandibular vestibule floor, the lesion is firm non-haemorrhagic floating with ulcerated appearance.
[Figure 1]
- The examination of the old prostheses reveals a medium prosthetic hygiene, an unstable
mandibular prosthesis and thin and sharp edges compared to the hyperplasia.
Following this examination, a surgical and prosthetic treatment plan was proposed to the patient.
The treatment consisted of the following steps:
- Motivation for prosthetic hygiene and mucosal hygiene,
- Plastic surgery followed by an anatomopathological examination of the operative specimen which
confirmed the epulidian nature of the tumor. [Figure 2]
-Realization of a tissue conditioning conventional bimaxillary prosthesis.
-After cicatrization realization of new prostheses respecting the norms. [Figure ¾]

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Figure 1: Presence of multiple hyperplastic

Figure 2: Ablation of mucous replies

Figure 3: Result after 15 days

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Figure 4: Result after 1 month

II. DISCUSSION

Epulis fissuratum is a common lesion in patients with old and inadequate removable prostheses
due to bone resorption associated with aging. This leads to repeated suction and suction motions
causing mucosal effusion, generating Fibrous hyperplasias in the form of bulges or leaflets.These
oral lesions related to the wearing of a removable prosthesis are most often observed in the carriers
of Complete Removable Prostheses (PAC) than Partial Movable Prostheses (PAP) [2], probably
because of the maximum mucosal recovery. [3] The prosthetic base acts as an insulator, a chemical,
mechanical and microbial irritant.
Ulcerations in areas with over-extension [1] are the most frequently found lesions. [4] They appear
after a point or chronic irritation of the mucosa caused by the wearing of a poorly adapted prosthesis.
In fact, the epulis fissuratum is more common in women, probably because they wear their
prostheses longer than men, for aesthetic reasons including [3,14] more postmenopausal mucosal
atrophy would generate a field favorable to the development of such lesions. [15]
The epulis fissuratum may assume the appearance of a sessile outgrowth with simple or multiple
benign proliferations. Most often, there are two layers, one extending below the prosthesis and the
other extending over the polished outer surface of the prosthesis. This lesion is most often covered
with an intact mucosa, soft or firm and not hemorrhagic, but it can sometimes be ulcerated. The
locations are most often located at the vestibule or anterior pelvic-lingual groove.
Hyperplasia is characterized by an absence of symptomatology often making consultation late; the
circumstances of consultation are due in general to the appearance of functional disorders.

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Histologically, epulis fissuratum is hyperplastic fibrous connective tissue. The epithelium above
the latter is often hyperkeratotic.
The management of this type of pathologies induced by the removable prosthesis comprises several
phases. The conditioning of the oral cavity appears as the preliminary sequence of a coherent
prosthetic treatment. The indication of pre-prosthetic surgery, with or without tissue conditioning and
rehabilitation of existing prostheses, can restore histological and physiological behavior to the oral
mucosa.
The treatment of hyperplasia can be non-surgical set in tissue condition or by surgical removal.
In the early stages of mucosal hyperplasia, when minimal and soft tissue conditioning is often
sufficient to reduce or eliminate this lesion.
Nevertheless, pre-prosthetic surgery is essential whenever these hyperplasias are important, fibrous
and old and when the conditioning in tissue condition brings no improvement.
Surgical excision should be systematically accompanied by a histopathological examination of the
operative specimen to confirm the diagnosis and eliminate any malignancy.
Rectification of defective prostheses; as well from the point of view of adaptation of the intrados
and edges, as at the occlusal level; allows to obtain a stable prosthesis whose limits are precise, if
these old prostheses are unusable, they will serve as transitional prostheses before making the final
prostheses, to carry out simultaneously the restoration of tissue condition and functional and aesthetic
rehabilitation.
Tissue conditioning is a prerequisite for the development of a complete prosthesis. It uses, among
other things, a delayed-setting resin filling the intrados of a prosthesis of use or transition. This step
of the prosthetic treatment is intended to place the patient favorable to the development of a new
prosthesis, improving the histological, anatomical and physiological structures of the tissues in
contact with the prosthesis.
The delayed-setting resins consist of [5]:
a powder consisting of micro-beads of polyethylmethacrylate and polyethylene methyl
methacrylate of different diameters;
a liquid mixture of ethyl alcohol and plasticizers comprising different types of phthalates.
These resins once applied at the intrados of the prosthesis after mixing, they spread slowly and
mold accurately to the tissue reliefs. The gel obtained acts in the viscoelastic phase as a cushion

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cushion between the prosthetic intrados and the mucosa reducing the trauma on the inflammatory
tissues.
The material loses its elastic properties, becomes granular. This transformation is caused by the
escape of the alcoholic esters to the salivary medium while the saliva enters the resin. The retard resin
becomes rough, aggressive towards the underlying tissues. This requires frequent renewal until the
tissues and surfaces of altered supports are improved.
New prostheses are made after healing, respecting a physiological distribution of the functional
pressures applied over the entire mucosal bearing surface in the realization of fingerprints and final
bases. The design of the prostheses must respect the different degrees of tissue resilience and other
factors of respect for the mucosal load capacity, by producing well-adapted, well-balanced and non-
traumatogenic prostheses, making it possible to restore all the physiological functions.

III. CONCLUSION

Although the wearing of a removable prosthesis provides an undeniable improvement in the quality
of life of the patient, the wearing of a poorly adapted prosthesis may be responsible for mucosal
lesions sometimes very debilitating.

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Vol. 4, Issue 3, May-June 2019

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