Inflammatory fibrous hyperplasia between surgery and tissue conditioning: A case report

Abstract

Introduction and importance

Inflammatory fibrous hyperplasia also called epulis fissuratum, often caused by an ill-fitting prosthesis and typically treated surgically, can be managed entirely conservatively with proper prosthetic adjustments.

Case presentation

A female edentulous patient with an epulis fissuratum brought on by a too lengthy and ill-fitting removable full denture is described in this case study. Soft-conditioner material was used to treat the oral lesion, with the modified existing prosthesis serving as support.

Clinical discussion

Early conditioning tissue care of the epulis fissuratum, in conjunction with proper prosthesis rehabilitation and appropriate oral hygiene, produces positive clinical outcomes and prevents the need for surgery.

Conclusion

The effectiveness of this conservative therapy highlights how different surgical and prosthetic specialties can complement each other, advocating for a systematic tissue conditioning step before proceeding with a surgical approach.

Highlights

• •Epulis fissuratum from an ill-fitting denture can be managed conservatively with adjustments and tissue conditioning.
• •Early tissue conditioning and hygiene help avoid surgery and improve outcomes in prosthetic rehabilitation.
• •This case supports tissue conditioning before surgery as part of a systematic, multidisciplinary approach.

1. Introduction

A pedunculated hyperplastic swelling of the gingiva has historically been referred to as a “epulis”. This can be either generalized (symmetric) or localized (nodular). Gingival overgrowth can be classified as localized fibrous hyperplasia, peripheral ossifying fibroma, pyogenic granuloma, or peripheral giant cell granuloma (PGCG), according to a histological analysis. Peripheral fibroma (PF)/epulis is the most commonly reported gingival enlargement, followed by pyogenic granuloma, PF with calcification, and PGCG [1].

Inflammatory fibrous hyperplasia (IFH), improperly called epulis fissuratum (EP), is described as a sessile growth with one or more laminae. It is the result of trauma and chronic inflammation caused by the edges of an overextended or unbalanced occlusion of removable prosthesis. There are often two laminae, one extending under the denture and the other extending over the polished outer surface of the denture. If left untreated, it will be an obstacle to the fabrication of a new, well-fitting prosthesis [2,3]. EF has no malignant potential, and recurrences after excision are almost always due to persistent irritation from sharp or overextended prosthetic edges that were not properly addressed [3].

The anterior region of both maxillae and mandible is the most common site for EF. The condition predominantly affects women in their sixth and seventh decades of life, which is the typical age range at the time of detection or surgical removal [4].

The most common techniques used for removing this hyperplastic lesion are surgical scalpels, electrical scalpels, or different types of lasers [5]. Surgical therapy involves excision of the lesion, biopsy to rule out potential malignancy, and relining or fabrication of a prosthetic device that may have triggered the condition [3]. Surgically excising the EF can result in edema, post-operative discomfort, and bleeding. Additionally, the traditional surgical approach often leads to a loss of vestibular depth, delayed wound healing and re-epithelialization, and the need for sutures or, in some cases, tissue grafts [6]. Recurrence may occur if a poorly fitted denture is not corrected or replaced after excision [3].

Alongside surgery, tissue conditioning is a non-invasive therapeutic option for treating the tissues covering the bearing surface and peripheral areas. This technique is essential for restoring compressed or displaced tissues to a position closer to their physiological state. The process helps tissues regain their normal thickness, vascularization, and overall health [7], thereby preventing errors in vertical dimension and centric relation registration, and other aspects of prosthetic function, all with the use of tissue conditioners [8].

We reported on a patient with an EF caused by an excessively long and poorly fitted removable full denture. The oral lesion was treated using the soft-conditioned tissue procedure. This case report aims to demonstrate the effectiveness of this conservative therapy and to illustrate how different surgical and prosthetic specialties can complement each other. This case report has been reported in line with the SCARE Criteria [9].

2. Patient information

A 60-year-old female patient was referred from the department of oral surgery for a duplication of the upper anterior ridge. Uncontrolled type 2 diabetes was discovered in medical history.

She reported wearing a poorly designed maxillary and mandibular complete removable prosthesis, experiencing denture instability during oral functions. She acknowledged using any oral or prosthetic hygiene techniques.

3. Clinical findings

Extraoral examination: a slightly reduced height of the lower face compared to the other facial levels, due to a decrease in the vertical dimension of the occlusion. A flat profile: manipulation of the patient in centric relation showed that this profile was due to mandibular protrusion and not to skeletal class 3.

Intraoral examination: bimaxillary complete edentulous supporting complete dentures. The upper arch revealed an inflamed, hyperplastic tissue extending from the right premolar region to the contralateral one filling the maxillary vestibular sulcus (Fig. 1).

Fig. 1.

The maxillary ill-fitting prosthesis induced lesion.

Prosthesis examination: The patient wore a poorly designed, ill-fitting, unstable bimaxillary complete removable prosthesis with abraded occlusal surfaces of the prosthetic teeth and sharp overextended edges, with an anteroposterior offset between the anterior vestibular sulcus and the edge of the maxillary prosthesis (Fig. 2).

Fig. 2.

Current ill-fitting prostheses of the patient; A. Maxillary prosthesis; B. Mandibular prosthesis.

Radiological examination: No abnormalities were observed in panoramic radiograph except for moderate resorption of the bimaxillary edentulous ridges, which is clinically classified as Atwood class 2 resorption.

4. Timeline

After the initial visit to the Department of Oral Surgery, the patient was referred to the Department of Removable Prosthetics, where the treatment plan was established. This included referring the patient to their physician for dietary advice and anti-diabetic treatments to achieve diabetes management, followed by the tissue conditioning approach. Once this is completed, the fabrication of new prostheses could begin.

5. Diagnostic assessment

Based on clinical and radiological findings, the diagnosis was an ill-fitting denture induced IFH/EF in the maxillary.

6. Therapeutic intervention

6.1. Adaptation of current denture

The overextended edges of the maxillary denture were identified using light silicone impression material and reduced using a pear-shaped carbide trimmer on a lathe, especially the edge part related to the Hyperplasia area (Fig. 3).

Fig. 3.

Light silicone impression identifying overextended edges.

6.2. Tissue conditioning

Tissue conditioning was made using adjusted old prostheses filled with Soft-liner® type delayed-setting resin. During the resin curing process, the patient was instructed to perform the movements of the secondary impression to register the peripheral seal (Fig. 4). The first two follow-ups were conducted at seven-day intervals to replace the tissue conditioning material. Subsequently, follow-ups were scheduled every 15 days until full recovery was achieved after two and a half months, with a total of six sessions.

Fig. 4.

Old maxillary prosthesis filled with Soft-liner®.

The tissue conditioning procedure was combined with local application of a sodium hyaluronate-based gel (Hyalugel®).

6.3. Refection of new removable complete dentures

Following initial and secondary impressions, the rims of the stent were used to take the patient's maxillomandibular relationship. Denture teeth have been arranged following the choosing of resin fake teeth. Fitting is done both aesthetically and functionally with the patient's consent. Following the polymerization process of the heat-cure acrylic resin, complete prosthesis was inserted. For optimal prosthesis integration, occlusal equilibration has been established (Fig. 5).

Fig. 5.

New elaborated prostheses.

7. Follow up and outcomes

A week later, a first control was planned to evaluate the wound's cleanliness and healing, replace the tissue conditioning material, and manually round the prosthetic edge outside the patient's mouth by adding tissue conditioning material facing the EF. The conditioner was renewed in a span of seven to fifteen days until the complete regression of the lesion (Fig. 6). When the healing process was finished two and a half months following the procedure, the final full denture was created using the standard procedures. There were no indications of inflammation or recurrence a one and half years following the patient's return.

Fig. 6.

Healing process. A: The control session at 4 weeks. B: The control session at 8 weeks. C: The last control session.

8. Discussion

Depending on the kind of lesion and its cause, several approaches are taken to treat mucosal diseases of prosthetic origin in situations involving full dentures. One of the lesions that is most commonly seen is the EF [10]. The patient may be at risk for carcinoma if the trauma at the site of this lesion persists, which is why care is important [11]. So the differential diagnosis must be made with a true papilloma or a squamous cell carcinoma that has proliferated around a prosthesis [3].

A tissue conditioning procedure was suggested for our patient. We began by correcting her previous prosthesis, which prevented the several phases of creating an interim prosthesis and enabled quick patient care. Then we filled them with a tissue conditioner type delayed-setting resin (Soft-liner®), combined with local application of a sodium hyaluronate-based gel (Hyalugel®), resulting in regression of inflammation within 6 control seances.

The physicochemical properties of the tissue conditioner promote the formation of a vestibular depth with a physiological appearance, ensure a harmonious distribution of occlusal loads, and improve the stability and retention of the current prosthesis by maximizing the use of the support surfaces. After healing, it facilitates the integration of the new prosthesis [11]. These new prostheses help establish the vertical occlusal dimension allowing neuro-musculoarticular conditioning [8].

In conjunction with proper oral and prosthetic hygiene, the tissue conditioner material was replaced periodically according to the manufacturer's instructions. The lesion regressed over a follow-up period of ten weeks, after which the primary impression for the new prosthesis was made. A follow-up one and a half years after the insertion of the new prosthesis revealed no recurrence of the lesion.

While non-removable prosthetic solutions could be considered, our patient explicitly preferred a rehabilitation approach that did not involve surgical procedures. She insisted on a solution that would allow her to wear prosthetic teeth continuously, ensuring uninterrupted function and facilitating effortless feeding.

For a completely edentulous maxilla, the main non-removable options include Implant-Supported Fixed Prostheses (All-on-4/All-on-6) and Hybrid Prostheses (Implant-Retained Fixed-Removable Prostheses) [12,13]. Both of these approaches involve surgical intervention and additional costs, which the patient was unwilling to undergo. Additionally, opting for a non-surgical rehabilitation allowed her to avoid post-surgical medical treatments, such as analgesics and antibiotics, which are typically required after implant procedures.

The use of absorbable mesh or graft augmentation can enhance bone volume, optimizing the implantation phase in cases of hybrid prostheses or implant-supported fixed prostheses [14]. Additionally, in removable prosthetic rehabilitation, such augmentation can improve retention and sustentation surfaces. However, in this case, it was not necessary, as the existing surface already provided sufficient retention. This was confirmed by the stability of the current prosthesis during the tissue conditioning procedure. Moreover, the success of bone augmentation procedures depends on multiple factors, including the primary stability of the graft [15], which may interfere with the tissue conditioning procedure. The removable prosthesis used as support for the tissue conditioner can compromise this stability.

Given these considerations, removable prosthetic rehabilitation after a tissue conditioning was the most appropriate solution, balancing functional needs, patient preferences, and clinical feasibility.

9. Conclusion

Surgical intervention has been extensively described in the literature and has demonstrated its effectiveness in treating ill-fitting denture-induced IFH. These interventions may or may not be accompanied by tissue conditioning, which optimizes healing and provides the patient with a functional prosthesis during the recovery process. Additionally, in cases of limited lesions, tissue conditioning alone is a recognized approach.

However, for patients with extensive lesions, it is preferable to first implement tissue conditioning rather than immediately resorting to surgery. Surgical intervention may still be indicated as a complementary treatment for residual hyperplasia in select cases.

While non-removable prosthetic options, with or without graft or absorbable mesh augmentation, can provide superior outcomes in terms of retention, aesthetics, and function, a removable solution allows lower cost and to avoid surgical intervention and associated medical treatments.

10. Patient perspective

The patient reported increased prosthesis stability and oral function, especially during mastication, and expressed great pleasure with the results of the tissue conditioning approach to conservatively manage her EF.

Author contribution

Tahiri Alaoui Mohamed El Arbi: Writing the paper.

Rokhssi Hasnaa: Correction of the paper.

Bentahar Oussama: Correction of the paper.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Our case report is exempt from ethical approval. This case report includes intraoral images that do not reveal the patient's identity.

The treatment provided follows a conventional and widely accepted protocol at the Faculty of Dental Medicine of Rabat. The patient provided written informed consent after being shown the images and fully informed of their intended use in this report.

Prior to submission, we consulted the Ethics Committee of Faculty of Dental Medicine, Mohammed V University in Rabat, and we were informed that formal ethical approval was not required for this case report, given the anonymized nature of the images and the standard nature of the procedure. However, if formal approval is deemed necessary, we are prepared to take the required steps accordingly.

Guarantor

Tahiri Alaoui Mohamed El Arbi.

Research registration number

This is not a “First in Man” study.

Funding

No funding resources.

Conflict of interest statement

The authors declare no conflicts of interest.