Abstract
Exophytic gingival lesions are more frequently encountered intraorally, out of which few are reactive in nature. Pyogenic granuloma (PG) is one of the commonly occurring reactive benign mucocutaneous lesions; exact etiopathogenesis remains unclear. Although surgical excision is the treatment of choice, sometimes it may induce residual soft defect formation which further creates an esthetic problem, root sensitivity, etc., The present case report not only describes the diagnosis and treatment of PG but also the immediate successful management of residual gingival defect in the esthetic area (which was originated as a sequel of the excisional biopsy of recurrent PG) by utilizing platelet-rich fibrin in conjunction with coronally advanced flap in single-stage surgery. Clinical healing was uneventful and satisfactory at 2 weeks, and excellent coverage of residual mucogingival defect with gingival esthetic and normal sulcus depth was observed at 3 and 6 months postoperatively without any sign of a complication.
Key words: Coronally advance flap, excisional biopsy, platelet-rich fibrin, pyogenic granuloma, residual gingival defect
INTRODUCTION
Pyogenic granuloma (PG) is one of the commonly occurring reactive benign lesions with 17.65% prevalence rate.[1] It was routinely found on the marginal gingiva, with only 15% of the tumors on the alveolar part.[2] Although surgical excision is the treatment of choice, recurrence occurs in up to 16% of the lesions.[3] Hence, to minimize reoccurrence, sometimes clinicians have to sacrifice the excessive tissue which indirectly induces residual mucogingival defect which may elicit unesthetic appearance of gingiva; increased root sensitivity, etc.[4] The literature is extremely limited on the immediate management of residual gingival defects after the excision of reactive gingival lesions. Hence, we report platelet-rich fibrin (PRF) in conjunction with coronally advance flap (CAF)-assisted immediate successful management of residual gingival defect elicited after the excision of recurrent PG in maxillary esthetic segment.
CASE REPORT
A 42-year-old female patient reported to the Department of Periodontology with chief complaint of unesthetic gum swelling on the left upper front teeth for 2 years. Lesion was excised twice by family dentist 1 year back but reoccurs. The lesion was initially small and gradually increased to the present size and now interferes in brushing. Intraoral examination revealed a well demarcated, irregular reddish pink growth on the labial gingiva of #22-24. It was soft on palpation, 20X 13mm in size and pedunculated in nature. [Figure 1]. Generalized presence of local factors along with mild bleeding on probing, was also evident. Orthopantomogram revealed generalized mild bone loss [Figure 2]. Routine investigations were within normal range. Provisional diagnosis of PG was made, and incisional biopsy taken after Phase I therapy [Figure 3]. Histopathology shows a mass of granulation tissue with diffuse inflammatory cell infiltrate containing lymphocytes and plasma cells. Numerous vascular spaces are also seen engorged with erythrocytes. The surface epithelium shows atrophy and ulceration in few areas and is replaced with a fibrino-purulent membrane. It is suggestive of PG. [Figure 4].
Figure 1.
Clinical picture showed irregular shape tumor of approximately 20 mm × 13 mm in size with location of stem of tumor growth
Figure 2.
Orthopantomogram showed generalized mild bone loss
Figure 3.
Incisional biopsy taken from distal aspect of growth after scaling and root planing
Figure 4.
Microphotograph at ×10 showed highly vascular connective tissue stroma with mixed inflammatory cell infiltrates with area of hemorrhage and degeneration
As lesion involved interdental papilla with part of attached gingiva in the esthetic zone, extensive surgical excision followed by simultaneous CAF and PRF-assisted regeneration of anticipated gingival defect was planned and discussed with the patient in detail with pros and cons and the patient submitted written signed consent. Three weeks postbiopsy lesion healed uneventfully, reduced half in size, and appeared as round, reddish-pink growth [Figure 5].
Figure 5.
Lesion appeared as reddish growth which reduced to half to half in size
Just before surgery, 10 ml of blood was taken from anticubital vein for the preparation of Choukroun's PRF.[5] First growth was excised from base to evaluate its peripheral extensions of the lesion [Figure 6a], and internal bevel incision was given 2 mm away from the periphery of lesion followed by crevicular incision [Figure 6b and c], and complete lesion excised under local anesthesia resulted in residual gingival defect formation (8 mm × 10 mm) with respect to #23 [Figure 6d]. Root planing was performed with respect to #22, 23, and immediately two vertical releasing incisions were given mesial to #22 and distal to #23 [Figure 7], followed by crevicular incision and full-thickness flap refection up to mucogingival junction and partial thickness beyond it for tension-free displacement of flap [Figure 8]. After thorough irrigation, PRF membrane was placed over the defect site followed by CAF secured with 4-0 vicryl direct loop suture [Figure 9]. Postoperative instructions were given. The surgical site healed uneventfully and the sutures were removed after 10 days. Complete coverage was observed 3 weeks post-operatively [Figure 10]. Maintenance therapy was given at monthly interval up to 3 months. Complete residual defect coverage at the surgical site with well-adapted flap to the underlying bone with knife-edged gingival margins and excellent color matching with adjacent tissue was observed at 3 months post-operatively [Figure 11 a and b]. There was no clinical alteration or complications observed till 6 months [Figure 11 c and d].
Figure 6.
(a) Excision of lesion from the base of stem; (b) Internal bevel incision; (c) Crevicular incision; (d) Residual gingival defect (8 mm × 10 mm) after complete excision
Figure 7.
Crevicular incision given with respect to tooth number 22–23 followed by vertical-releasing incision mesial to 22 and distal to 23 in approximation to residual gingival defect of 8 mm × 10 mm (clinical attachment level of 5 mm × 4 mm) in size
Figure 8.
Full-thickness flap reflected up to mucogingival junction followed by partial-thickness incision apical to mucogingival junction for tension-free displacement of flap with respect to 22–23
Figure 9.
Platelet-rich fibrin membrane placed over the defect site followed by tension-free approximation of coronally advance flap with 4-0 Vicryl suture
Figure 10.
Surgical site healed satisfactory with excellent color blend at 3 weeks postoperatively
Figure 11.
(a and b) Scalloped marginal gingiva with 2 mm of probing depth 3 months postoperatively, whereas c and d also represent the same but at 6 months postoperatively
DISCUSSION
PG is a benign, hyperplastic, localized reactive lesion, occurred at any age with higher female prevalence (2.38:1). Chronic irritation from plaque, calculus, bony spicule, orthodontic appliance, etc., may lead to induce excessive connective tissue with numerous blood vessel-enriched growth which is characterized by red surface, soft consistency, and pedicular base anywhere on the gingiva, lip, and alveolar mucosa as cited in report of Rathore et al.[6] The present case represents similar findings and probable etiology for the same may be because of chronic interplay of plaque, calculus, and toothbrush trauma.
It is always challenging for the clinician to treat recurrent reactive gingival lesions as residual defect is anticipated as a sequel of excision. We planned an immediate refurbishment of the anticipated residual defect in our case, to prevent the post-operative complications like poor esthetics, pain, and dentinal hypersensitivity.[4]
Subepithelial connective tissue graft (SCTG), CAF, free gingival graft (FGG), and PRF, etc., alone or in combinations were described in the literature for the management of mucogingival defects. SCTG has excellent predictability of 88% to 97.4% with perfect color blend to adjacent tissues. But, SCTG is technique-sensitive, consumes more time and needs a second surgical donor site. The disadvantages of FGG are an invasive donor site wound which is prone to pain and bleeding whereas the recipient site is well-distinguished from adjacent tissue.[7] That is why, SCTG and FGG was not opted.[7] Therefore, in the present case, PRF- and CAF-assisted soft-tissue regeneration was opted because PRF is a platelet concentrate obtained by a simple and inexpensive procedure without biochemical handling; its three-dimensional fibrin network promotes effective neovascularization, accelerated wound closing, and fast cicatricial tissue remodeling [8] as well as may alleviate the need for donor site procurement of connective tissue,[9] The prime requisite for CAF is a wide band of keratinized gingiva apical to recession site and a deep vestibule. These criteria were fulfilled in our case. CAF was preferred as it was simple to perform, less time consuming and gives excellent esthetic outcome.[7] The beneficial effects of PRF with CAF in management of single or multiple gingival recessions have been reported with high rate of predictability.[10,11,12] Complete residual gingival defect coverage was obtained in the present case report in accordance to the report of Anilkumar K et al[9], but they have utilized PRF with laterally displaced flap.
CONCLUSION
However, it is very difficult to reach a conclusion on the basis of a single report. But, we have attained a highly appreciable, functional and esthetic outcome with CAF in conjunction with PRF in our case. Reconfirmation can be attained through a controlled clinical trial on a large sample size to reach a final conclusion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name, and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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