Treatment of Epulis Fissuratum Using an In Situ Harvested Free Gingival Graft: A Case Series and Literature Review

ABSTRACT

Epulis fissuratum (EF) is a reactive fibrous overgrowth in the oral vestibule caused by chronic denture irritation. We describe two patients (aged 58 and 42 years) in whom EF was excised and vestibuloplasty performed using a free gingival graft (FGG) harvested from the excised lesion itself. In Case 1, a hyperplastic fold of the maxillary anterior alveolar mucosa was removed, the incision apically repositioned, and the thinned, deepithelialized graft immobilized over the periosteum. In Case 2, peri‐implant hyperplastic tissue was excised and the graft, prepared using the accordion technique, was positioned around the healing abutments. Case 1 was followed up at 2 and 10 months and Case 2 at 2 months; healing was uneventful in both, with a clinically adequate band of keratinized mucosa and stable vestibular depth at each visit. Within the limitations of this short‐follow‐up two‐case report, using the lesion itself as the graft source provided acceptable keratinized mucosa and vestibular depth. Larger prospective studies with 12–24‐month follow‐up are warranted.

Key Clinical Message

Epulis fissuratum (EF) is a reactive fibrous overgrowth from ill‐fitting dentures that compromises denture retention, and its excision may shallow the vestibule. These two cases show EF excised with vestibuloplasty using free gingival grafts (FGGs) harvested from the lesion itself, avoiding a palatal donor site, with a review of management options.

1. Introduction

Epulis fissuratum (EF), also known as denture‐induced inflammatory fibrous hyperplasia, is a reactive overgrowth of fibrous connective tissue in the oral vestibule caused by chronic irritation from an ill‐fitting denture [1, 2]. EF occurs more frequently in the anterior region of the jaws, with a slight predilection for the maxilla [3]. Clinically, the lesion usually presents as one or more folds of hyperplastic tissue that are firm and fibrous on palpation, although erythematous or ulcerated variants have also been reported. Although EF is generally asymptomatic in its early stages, it may enlarge over time, impairing denture retention and stability and occasionally causing pain or ulceration.

Treatment options are selected according to the size of the lesion and the general condition of the patient. Management usually begins with elimination of the source of irritation, most often by adjusting or replacing the prosthesis. When conservative measures fail, surgical removal of the excess tissue is indicated [2, 3]. Because surgical excision alone may reduce vestibular depth and thereby compromise denture stability, excision combined with vestibuloplasty and a free gingival graft (FGG) is generally preferred [4]. FGG is the most widely used mucogingival procedure for augmenting the width of keratinized tissue; however, it requires a second surgical (donor) site, which may increase patient discomfort, operating time, and the risk of complications [5].

Previous case reports of EF managed by excision and vestibuloplasty with FGG have described favorable outcomes in terms of vestibular depth and prosthetic rehabilitation, but in all of them the graft was harvested from the palatal mucosa, which is a recognized source of postoperative discomfort [3, 4]. The present report describes two cases in which EF was excised and vestibuloplasty was performed using an FGG harvested from the excised EF tissue itself, thereby avoiding a second donor site. A concise review of the currently available techniques for the management of EF is also provided.

2. Case History and Examination

2.1. Case 1

2.1.1. Case History and Examination

A 58‐year‐old male, non‐smoker with no relevant medical history, was referred to the Department of Periodontology for the removal of maxillary fibrous hyperplasia caused by an ill‐fitting complete prosthesis. He had been wearing the same set of dentures for 4 years.

Intraoral examination revealed a hyperplastic lesion on the maxillary anterior alveolar mucosa, extending into the vestibular sulcus (Figure 1A). The lesion was covered by non‐inflamed mucosa and was firm on palpation. The alveolar ridge showed insufficient keratinized mucosa, and no erythema or oral candidiasis was observed on the palate. Because the removable prosthesis was poorly adapted and the lesion was neither ulcerated nor indurated, a clinical diagnosis of denture‐induced hyperplasia was made. Surgical excision combined with an FGG was therefore planned. The procedure was explained to the patient and written informed consent was obtained.

FIGURE 1.

Surgical management of epulis fissuratum (EF) in Case 1 (maxillary anterior region). (A) Preoperative view showing the hyperplastic fold of the maxillary anterior alveolar mucosa extending into the vestibular sulcus. (B) Two partial‐thickness incisions outlining the lesion, from the right maxillary second premolar to the contralateral side, and elevation of the partial‐thickness flap. (C) Free gingival graft (FGG) harvested directly from the surface of the excised EF. (D) The upper incision edge repositioned apically and secured with periosteal sutures to deepen the vestibule. (E) The FGG placed over the exposed periosteum and immobilized with sutures. (F, G) Clinical views at the 2‐month (F) and 10‐month (G) follow‐up visits, showing favorable healing, an adequate band of keratinized mucosa, and an increased depth of the vestibular sulcus.

2.1.2. Investigation and Treatment

Local anesthesia was achieved with 2% lidocaine and epinephrine (1:80,000). Two partial‐thickness incisions were made with a #15c surgical blade (Swann‐Morton, England), outlining the fibrous hyperplasia from the right maxillary second premolar to the contralateral side (Figure 1B). The FGG was harvested directly from the surface of the EF (Figure 1C) and included both the epithelium and the underlying connective tissue. The graft was carefully thinned, and any residual inflammatory tissue was meticulously removed from its inner surface with the #15c blade. Further inflammatory remnants were excised with tissue scissors and moist gauze in order to prepare a clean periosteal recipient bed.

The upper edge of the incision was sutured apically with simple periosteal sutures using Vicryl 5‐0 (Supalon, SUPA, Iran) (Figure 1D). The graft was then secured to the periosteal bed with Vicryl 5‐0 sutures and stabilized with cross‐sutures of Nylon 5‐0 (Supalon, SUPA, Iran) (Figure 1E). No periodontal dressing was applied. The patient was instructed to follow a soft diet and to limit facial movements for 14 days, to avoid brushing around the surgical site for the first 3 days, and to apply an ice pack to the upper lip. Chlorhexidine 0.2% mouthrinse was prescribed twice daily for 2 weeks, together with a non‐steroidal anti‐inflammatory drug (Novafen). The first postoperative follow‐up visit was scheduled 2 weeks after surgery, at which time the sutures were to be removed.

2.2. Case 2

2.2.1. Case History and Examination

A 42‐year‐old male heavy smoker with no relevant medical history was referred to the Department of Periodontology for implant placement. After implant placement and an adequate healing period, the patient continued to wear his previous denture despite being advised not to do so. Excessive soft‐tissue overgrowth subsequently developed around the implants and partially covered the fixtures (Figure 2A,B). The lesion was firm on palpation. It was decided to remove the overgrown keratinized tissue partially and to use it as an FGG. The procedure was explained to the patient and written informed consent was obtained.

FIGURE 2.

Surgical management of peri‐implant denture‐induced hyperplasia in Case 2 (maxillary implant site). (A, B) Preoperative views showing excessive soft‐tissue overgrowth partially covering the implant fixtures. (C) Excision of the hyperplastic tissue and apical suturing of the flap margin at the vestibular depth. (D) The excised hyperplastic tissue prepared as a free gingival graft (FGG). (E) The graft divided into two segments, prepared using the accordion technique, positioned apically around the healing abutments and immobilized with sutures. (F) Clinical view at the 2‐month follow‐up visit, showing favorable healing and clinically stable keratinized peri‐implant mucosa.

2.2.2. Investigation and Treatment

Local anesthesia was achieved with 2% lidocaine and epinephrine (1:80,000). The hyperplastic tissue was excised with a #15c surgical blade (Swann‐Morton, England) and the graft was carefully separated. The flap margins adjacent to the mucosa were sutured apically at the vestibular depth with Vicryl 6‐0 (Supalon, SUPA, Iran) (Figure 2C). The graft was then divided into two segments and prepared using the accordion technique (Figure 2D). The segments were positioned apically around the healing abutments in order to preserve keratinized mucosa, support peri‐implant health, and increase vestibular depth, and were secured with Nylon 6‐0 sutures (Supalon, SUPA, Iran) (Figure 2E).

The patient was instructed to follow a soft diet and to minimize facial movements for 2 weeks, to apply an ice pack to the upper lip and to use chlorhexidine 0.2% mouthrinse twice daily for 2 weeks. Given the patient's heavy smoking status and the extent of surgical manipulation, amoxicillin 500 mg was prescribed as prophylactic antimicrobial therapy. A non‐steroidal anti‐inflammatory drug (Novafen) was also prescribed for postoperative pain control. The sutures were removed at the 2‐week follow‐up appointment. The first postoperative follow‐up visit was likewise scheduled 2 weeks after surgery, and the sutures were removed at that appointment.

3. Results

Histopathological examination of the specimens from both Case 1 (Figure 3A) and Case 2 (Figure 3B) showed hyperplastic and acanthotic parakeratinized stratified squamous epithelium. The connective tissue contained an increased number of collagen fibers arranged in interlacing bundles between fibroblasts, together with an inflammatory infiltrate. Denture‐induced fibroepithelial hyperplasia was confirmed in both cases.

FIGURE 3.

Histopathological appearance of the excised lesions in (A) Case 1 and (B) Case 2 (hematoxylin and eosin stain), both consistent with denture‐induced fibroepithelial hyperplasia. The stratified squamous epithelium is parakeratinized, hyperplastic, and acanthotic. The underlying connective tissue stroma shows dense interlacing bundles of collagen fibers, scattered fibroblasts, small blood vessels in cross‐section, and a mild chronic inflammatory infiltrate.

Both patients were followed according to the same protocol, with examinations scheduled at 2 weeks, 2 months, and 10 months after surgery. In Case 1, healing was uneventful at the 2‐week visit, and the sutures were removed. At the 2‐ and 10‐month visits, the site had healed with a clinically adequate band of keratinized mucosa and a stable vestibular depth (Figure 1F,G). In Case 2, the sutures were likewise removed at the 2‐week visit, and healing was uneventful. At 2 months, the peri‐implant tissues had healed with clinically stable keratinized mucosa and an increased vestibular depth (Figure 2F); this patient did not attend the recall visit scheduled at 10 months.

4. Discussion

These two cases illustrate that EF caused by an ill‐fitting prosthesis can be managed by surgical excision combined with vestibuloplasty, using an FGG harvested from the excised lesion itself. Although the two cases differed in etiology and clinical presentation, they shared the same surgical principle underlying the proposed in situ FGG technique. In both cases, excessive keratinized tissue that would otherwise have been excised and discarded was repurposed as an autogenous FGG, thereby avoiding the need for harvesting from a separate donor site. The cases were therefore selected to illustrate the potential applicability of this concept in different clinical situations rather than to represent a homogeneous disease‐based case series. In both patients, healing was uneventful and a clinically acceptable band of keratinized tissue and vestibular depth were obtained over the available follow‐up period, allowing prosthetic rehabilitation to proceed. The management options reported for EF, against which this approach should be considered, are summarized below.

4.1. Conservative Management

The first step in the treatment of EF is correction or replacement of the poorly fitting prosthesis, which may lead to partial regression of the lesion and relief of symptoms [2, 6]. In minor cases, discontinuation of denture wear combined with topical antifungal or anti‐inflammatory agents may allow the hyperplastic tissue to resolve without surgery [2]. In larger lesions, relining the existing denture with a soft tissue conditioner eliminates pressure points and allows the inflamed tissue to recover, which can substantially reduce lesion size over several weeks [6, 7]. Conservative therapy is therefore most appropriate for mild to moderate EF and for medically compromised patients who cannot tolerate surgery [2, 7]; it is less predictable in longstanding, highly fibrous lesions, in which surgical removal of the residual fibrous tissue is usually still required [3, 6].

4.2. Surgical Excision and Its Alternatives

When EF is large or fibrotic, or persists after conservative management, surgical removal is indicated [2, 8]. Conventional excision with a scalpel is followed by suturing of the wound edges to each other or to the periosteum [1, 4]; its main drawback is a reduction in vestibular depth caused by scar contraction and inward rolling of the tissue after primary closure [4].

Several adjunctive and alternative techniques have been proposed. Autologous platelet concentrates can be applied to accelerate wound healing: Mozzati et al. [9] reported that a plasma rich in growth factors (PRGF) membrane placed over the wound improved early healing and reduced complications, pain scores, and visible scarring. Electrosurgery offers good hemorrhage control and shorter operating times, but induces thermal damage that may delay initial healing [4]. Laser surgery, particularly with the CO2 laser, has become popular because its energy is absorbed superficially by water‐rich tissue and seals small vessels and nerve endings during ablation, resulting in minimal bleeding and reduced postoperative pain and edema [8]; randomized trials have confirmed less intraoperative bleeding compared with conventional excision [10], and Er,Cr:YSGG and diode lasers have shown faster early wound healing and lower analgesic requirements [1]. Cryotherapy with liquid nitrogen is a further minimally invasive option that requires no incision or sutures and provides excellent hemorrhage control, making it suitable for patients at risk of bleeding, with generally minimal postoperative pain and edema [11]; bulky fibrous folds may, however, require repeated freezing sessions and longer healing times [3]. A limitation common to all of these techniques is that none of them restores vestibular depth or replaces the attached keratinized mucosa lost with the excised tissue, which is the specific problem addressed by grafting [3].

4.3. Excision Combined With Vestibuloplasty and FGG

FGG is regarded as the reference technique in periodontal plastic surgery for increasing the width of keratinized tissue, deepening the vestibule and managing mucogingival deficiencies [3, 4]. The vestibule is surgically deepened and autogenous keratinized mucosa is grafted onto the exposed periosteum, reconstructing a band of attached gingiva [4]. Three advantages are reported: preservation of vestibular depth, since the graft covers the denuded periosteum and allows healing in an expanded state instead of the retraction and scar contraction that follow primary closure [4]; an increase in attached keratinized mucosa in an area that would otherwise heal with movable alveolar mucosa—Lee et al. [5] reported a mean gain of 3.65 mm of keratinized tissue at 12 months around mandibular molar implants with FGG, compared with 1.72 mm for apically positioned flaps; and a possible reduction in the risk of recurrence, since a deeper keratinized vestibule and improved prosthetic support are thought to reduce re‐irritation, which remains the principal cause of recurrence [3, 6]. Both cases in the present report showed a clinically adequate vestibular depth and band of keratinized tissue at the last available examination, in agreement with these reports.

Two comparable case reports are available. Khalifa et al. [4] used a single‐stage procedure in the mandible: a band of hyperplastic tissue extending across the anterior vestibule from premolar to premolar was removed, the lower incision edge was sutured apically to deepen the vestibule, and a thin palatal FGG obtained by partial‐thickness dissection was trimmed to fit the site and immobilized; the denture was relined with a soft conditioner and worn as a stent, and the graft had taken by the second postoperative week. González Gómez et al. [3] used a two‐stage approach in the maxilla: the hyperplastic tissue was excised with primary closure, and vestibuloplasty with FGG was performed approximately 6 weeks later using two palatal grafts (each about 18 × 5 mm) combined into a single graft of about 36 mm, with full integration confirmed at 1 month.

Graft dimensions depend on the extent of the vestibuloplasty required; in the present cases the harvested grafts measured 24 mm for the maxillary EF and 18 mm for the implant site. Reported grafts for vestibuloplasty have a vertical dimension of approximately 4–10 mm and a thickness of 1.0–2.0 mm, with 1.5 mm suggested as a functional compromise between healing and tissue integration [5, 12, 13]; thin grafts are preferred because they contract less and are revascularized more rapidly on a relatively avascular periosteal bed [3]. Neither of the two case reports cited above quantified graft shrinkage [3, 4]. In larger series, horizontal shrinkage was minimal whereas vertical resorption averaged 26.5% and total graft surface area decreased by approximately 35% over 6 months, most of it early in the postoperative period, although the grafts keratinized and stabilized without long‐term complications [12]. Ku and Leem [13] placed FGGs under titanium mesh at implant sites and reported that a 10 mm palatal graft retained 76.7% of the vestibular depth and 51.7% of the keratinized tissue over a mean of 34 months, with no graft failures. These figures indicate that the clinical stability seen in the present cases would need to be confirmed over a comparable period.

4.4. EF Tissue as a Graft Source

FGGs are most commonly harvested from the palatal premolar region, as in both cited case reports [3, 4]. Palatal mucosa is composed of stratified squamous keratinized epithelium overlying a dense collagenous lamina propria firmly bound to the periosteum, which explains its predictable behavior as donor tissue. EF, in contrast, shows epithelial hyperplasia with variable hyperkeratosis over dense fibrous connective tissue containing a chronic inflammatory infiltrate. In longstanding lesions, repeated mechanical stimulation may promote epithelial thickening and collagen maturation, so that the tissue partially resembles masticatory mucosa; unlike palatal tissue, however, EF may be heterogeneous in its degree of keratinization and retain inflammatory components. The use of excised EF as an FGG should therefore be restricted to carefully selected cases in which the superficial keratinized portion is preserved, inflammatory and granulation tissue are thoroughly removed, and a well‐vascularized recipient bed is prepared.

The main practical argument for this approach is the avoidance of a second surgical site. Donor site morbidity after palatal harvesting is usually mild but real, and patients may report a burning sensation for several days, managed with analgesics and a protective stent or dressing [4]. Alternatives that avoid palatal harvesting have been investigated: skin grafts, used historically for vestibuloplasty, are no longer employed because of undesirable intraoral changes, and xenogeneic collagen matrices, although able to integrate and revascularize intraorally, yield mucosa of inferior quality and width compared with FGG [14] and do not consistently produce a stable band of keratinized tissue, despite reducing patient morbidity [15]. Autogenous FGG therefore remains the preferred option for extensive vestibuloplasty in denture‐induced hyperplasia [3, 4]. In the present cases no additional donor surgery was needed, since the graft was obtained from the firm hyperplastic tissue that was being removed in any event, which simplified the procedure and limited patient discomfort.

4.5. Limitations

This report has several limitations. It is based on two patients without a control group, so the technique cannot be compared with palatal FGG, and the findings are not generalizable. Although both cases were assessed at the same standardized time points of 2 weeks and 2 months, only one patient attended a longer recall at 10 months. Since FGGs undergo most of their vertical resorption early and continue to lose vestibular depth and keratinized tissue width thereafter [12, 13], this period is too short to assess long‐term stability, and the absence of calibrated baseline and follow‐up measurements of vestibular depth, keratinized tissue width, and graft shrinkage further weakens the observations. In addition, FGG is technique‐sensitive, and harvesting from the lesion itself adds variability because the quantity, thickness, and keratinization of the graft are dictated by the lesion rather than planned as at a palatal site. Outcomes may therefore be influenced by operator experience and by case selection, and lesions that are small, ulcerated, markedly inflamed, or of uncertain nature are unlikely to be suitable. Prospective studies with larger samples, standardized measurements, and follow‐up of at least 12–24 months, ideally comparing EF‐derived and palatal grafts, are required before routine use can be recommended.

5. Conclusion

Within the limitations of this two‐case report with short follow‐up, excision of EF combined with vestibuloplasty using an FGG harvested from the lesion itself resulted in uneventful healing and a clinically acceptable vestibular depth for subsequent prosthetic treatment, while avoiding the need for a second donor site. These preliminary observations suggest that the technique may be a useful option in selected cases; however, longer‐term controlled studies are needed to demonstrate its long‐term efficacy.

Author Contributions

Seyedsaeid Mahdizadeh: investigation, writing – original draft, methodology. Moein Khojaste: conceptualization, methodology, investigation, writing – review and editing, project administration, supervision. Farid Shiezadeh: project administration, writing – review and editing, investigation, conceptualization, methodology, supervision. Seyedehnahid Tabatabaei: writing – original draft, investigation, methodology.

Funding

The authors have nothing to report.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.