Modified gingivoplasty for hereditary gingival fibromatosis: two case reports

A 20-year-old woman was referred to the periodontics department, Hospital of Stomatology for the management of her periodontal enlargement. The patient's chief complaint was painless swollen gums, difficulty in mastication, phonetics, and unpleasing appearance. Her medical history was non-contributory and she was taking no therapeutic drug regularly. In the course of taking family history, she reported another case of gingival enlargement in her biological sister.

Physical examination allowed to exclude major dysmorphic features of the face, hands, and nails as well as hypertrichosis. No deafness or intellectual disability was evidenced. On extra-oral examination, the patient presented with an open lip posture and convex profile (Fig. 3a). The intraoral examination revealed a calculus index (CI) [22] of 1–2, and plaque index of 1–2. The enlarged gingiva was diffused, pink in color and dense in consistency covering most part of teeth on buccal and lingual/palatal aspects in both maxillary and mandibular arches. There were diastemas between the teeth and over-bite was also present (Fig. 3b). The maxillary and mandibular anterior teeth showed migration with diastemas. Few carious teeth were noted. Panoramic radiograph revealed no significant changes in alveolar bone (Fig. 3c).

On the basis of these findings, a diagnosis of non-syndromic hereditary gingival fibromatosis (HGF) was given. With the consent of the patient and her family, non-surgical periodontal treatment which comprised sub-gingival scaling and root planning and oral hygiene instruction was initially taken. Next, a bilateral posterior superior alveolar nerve block was administered with a supplemental local anesthesia obtained through labial and palatal infiltration. After strict disinfection, gingivoplasty surgery in both labial/buccal and palatal/lingual sides in the maxilla was performed. Crevicular incision was made along to the sulcus the using a cconventional scalpel (11/12/15c) and down to the alveolus and then, full thickness flap was raised above the mucogingival junction (Fig. 4a). The fibrotic connective tissue and alveolar bone were exposed. It’s not difficult to distinguish the pathological tissue from the outside soft tissue, for the pathological part is very hard in texture and pale in colour. Therefore, depending on the texture and color, the fibrotic connective tissue was resected and the gingiva was scalloped in shape, with slightly thinner margins (Fig. 4b). The handpiece and bur were used to remove the outside fibrotic alveolar bone and reshape normal physiological alveolar anatomy (Fig. 4c). The split thickness gingival flap was raised below the mucogingival junction. After debridement, the flap was repositioned apically and sutured with absorbable suture (polyglycolic acid braid with short term resorption) (Fig. 4d). With a bilateral inferior alveolar nerve block anesthesia and labial and palatal infiltration anesthesia, the operation in the mandible was utilized 4 weeks after the one in the maxilla (Fig. 4e–h). The patient was advised to continue taking the antibiotic (amoxicillin, 500 mg tds) and fluid intake after operation for 3 days. Intense exercise and brushing teeth within 24 h after operation should be avoided. A 0.12% chlorhexidine gluconate rinse was prescribed for administration twice a day for one week. The patient could eat without pain 7 days after the operation. Comfortably eating was achieved 14 days after the suture were removed. Complete healing occurred 3 months after the operation.

Postoperatively, the removed gingival tissue was examined pathologically (Fig. 5a). After haematoxylin and eosin (H&E) staining, histopathology analysis of the specimen showed that mature collagenous connective tissue with collagen bundles arranged in a parallel manner. Connective tissue was relatively avascular along with scanty inflammatory cell infiltration, mainly lymphocytes and plasma cells infiltration. These finding corresponded with the characteristics of HGF.

12 months after the first surgery (Fig. 5b), no pain or discomfort was complained and no inflammation was found throughout the observation period. The crowns adequately exposed without any tendency of recurrence. The oral hygiene was reinforced. After the surgery, the patient underwent a regular periodontal assessment and basic maintenance therapy every 3 to 6 months and lost after one year follow up. Imperfectly, the patient gave up the orthodontic treatment for the financial problem though it was strongly advised.

The patient was a 22-year-old female when she first visited the periodontics department, Hospital of Stomatology with a chief complaint of progressive gingival enlargement to cover the entire permanent dentition. In the past 2 years, the enlargement led to difficulty in mastication, pronunciation, and poor esthetics. She had not reported gingival pain and spontaneous bleeding. Her father also had a history of similar gingival enlargement. There was no history of taking medicine, systemic disorder or drug allergy. No signs of mental disorder, hormonal changes, or deformities of nail development were observed. Extraoral examination showed an open-lip posture (Fig. 6a). Intraoral examination revealed poor oral hygiene, with a large amount of debris at the gingival margin. Both the free and attached gingiva showed hyperplasia and hypertrophy in the maxillary and mandibular region. In the severe area, the pathological gingival tissue which had a firm and fibrous consistency covers three-quarters to the entire of the crowns. No noticeable mobility of teeth was detected. The displacement of anterior teeth and premolars could be seen and the dental caries in posterior teeth as well the residual roots of tooth #37&#46 were detected (Fig. 6b). The panoramic radiograph showed no obvious horizontal and vertical bone loss. Carious teeth in the posterior region and residual roots of tooth #37&#46 were noted (Fig. 6c).

The patient was diagnosed with non-syndromic HGF, multiple dental caries and residual root of tooth #37&#46. With the consent of the patient and her family, sub-gingival scaling/root planning and oral hygiene education were performed in the first month with no significant improvement in the gingival enlargement. Surgical treatment was performed in the maxillary and mandibular region in sequence using a modified gingivoplasty combined with a crevicular incision and apically positioned flap as mentioned. During surgery, the fibrotic connective tissue was removed to the maximum, and the keratinized gingiva was retained. Besides, the residual roots were extracted. The patient was given the same postoperative guidelines as in case 1.

The removed hyperplastic gingival tissues were measure by a routine pathological examination. The connective tissue was presented as fibrous and avascular, and has densely-arranged collagen-fiber bundles arranging in all directions, numerous fibroblasts, and mild chronic inflammatory cells infiltration (Fig. 7a).

Three months after the gingivoplasty, the patient was able to maintain good oral hygiene, and the crowns were adequately exposed. Moreover, the gingival morphology in the upper and lower dentition significantly was improved (Fig. 7b). During the period, the restoration for caries and occlusal therapy had been finished. Twelve months after the treatment, the patient still maintained good oral hygiene without periodontal inflammation (Fig. 7c). There was no significant evidence on the recurrence of gingival hypertrophy. It is important to conduct basic periodontal therapy, plaque and calculus control, and oral hygiene maintenance either before, during, or after surgery. Hence, the patient kept undergoing a regular periodontal assessment and basic maintenance therapy every 3 to 6 months and lost after one year follow up. The patient also gave up the orthodontic treatment for the financial problem.