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1.Epulis fissuratum

Epulis fissuratum (also termed inflammatory fibrous hyperplasia, denture-induced fibrous

inflammatory hyperplasia denture injury tumor, denture epulis, denture induced granuloma, and

granuloma fissuratum) is abenignhyperplasia of fibrousconnective tissuewhich develops as areactivelesion to chronic mechanical irritationproduced by the flange of a poorly fittingdenture.

More simply, epulis fissuratum is where excess folds of firm tissue form inside the mouth, as a

result of rubbing on the edge of dentures that does not fit well. It is a harmless condition anddoes not representoral cancer.Treatment is by simple surgical removal of the lesion, and also by

adjustment of the denture or provision of a new denture.

Classification

Epulis (literally, 'on the gingiva') is a general term for anygingival oralveolartumor (i.e. lump).

This term describes only the location of a lump and has no implication on thehistologic

appearance of a lesion. Epulisis also sometimes used synonymously with epulis fissuratum,[1]however other conditions are classified as epulides, e.g. giant cell epulis (peripheral giant cell

granuloma), ossifying fibroid epulis (peripheral ossifying fibroma), andcongenital epulis.[1]

Signs and symptoms

The lesion is usually painless.The usual appearance is of two excess tissue folds in alveolar

vestibule/buccal sulcus, with the flange of the denture fitting in between the two folds.[1]

It mayoccur in either the maxillary or mandibular sulci,

[1]although the latter is more usual.Anterior

locations are more common thanposterior.Less commonly there may be a single fold, and the

lesion may appear on the lingual surface of the mandibular alveolar ridge.

The swelling is firm to pakpation and fibrous, with a smooth, pink surface. The surface may alsoshowulceration orerythema.The size of the lesion varies from less than 1 cm to involving the

entire length of the sulcus.

Causes

The cause is usually pressure from the flange of a denture which causes chronic irritation and a

hyperplastic response in the soft tissues.[5]

Women during pregnancy can also present with an

epulis, which will resolve after birth.Fibroepithelial polyps,pedunculated lesions of the palate

beneath an upper denture, are associated with this condition. A cobble-stone appearance similarto an epulis fissuratum in a patient without dentures can be diagnostic ofCrohn's disease.

[7]

Epulis fissuratum can also appear around dental implants.

Histology-

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The hyperplastic mass of tissue is composed of an excessive bulk of fibrous connectivetissue covered by a layer of stratified squamous epithelium which may be of normal

thickness or show acanthosis.

Pseudoepitheliomatous hyperplasia is often found. Hyperkeratosis is frequently present. Connective tissue is composed mainly of coarse bundles of collagen fibers with fewfibroblast or blood vessels unless there is an active inflammatory reaction present. Often mucopolyssacaride keratin dystrophy also known as plasma pooling is seen in

surface epithelium of inflammatory fibrous dysplasia.it consists of homogenouseosinophilic pools of materials in the superficial spinous layer of the epithelium.

Bone formation is sometimes seen in a fibrous epulis and sometimes called as peripheralossifying fibroma although it has no relation with the ossifying fibroma of the bone and

is not a fibroma.

Treatment

Treatment is by surgical excision (complete removal) of the fibrous tissue overgrowth and

addressing the causative factor to prevent recurrence of the lesion.

Epidemiology

This condition occurs in association with denture wearing, and so those affected tend to be

middle aged or older adults. 66-75% are estimated to occur in women.[1]

Epulis fissuratum is thethird most common reactive lesion that occurs in the mouth, afterperipheral giant cell granuloma

andpyogenic granuloma.[9]

2. Giant cell fibroma

Introduction

The giant cell fibroma is a subtype of irritation fibroma, i.e. it is a localized

inflammatory fibrous hyperplasia, but it differs significantly from routine fibromas

in that its stroma contains scattered fibroblasts with very large, usually angular(stellate), but not hyperchromatic nuclei.

Clinical Features

This type of fibroma can be seen at any age and on any oral mucosal surface, but it

has a predilection for gingival, lateral tongue and tip of tongue locations. It seldombecomes more than 0.5 cm. in greatest diameter and often are comprised of two or

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three lobules, or may have a few small papules on the surface. Most lesions are

pedunculated but sessile examples are not unusual. The surface is almost neverulcerated, unless acutely traumatized, and the color is that of the surrounding

normal mucosa. Occasional patients will have multiple lesions but they are seldomnumerous.

Pathologyand Differential Diagnosis

The lesion is characterized by a diffuse, somewhat immature, rather avascularcollagenic stroma with small bipolar and slightly stellate fibroblasts scattered

throughout in moderate numbers. Occasional fibroblasts will be quite large andangular, and may have more than one nucleus . These pathognomonic cells are

never hyperchromatic, as they would be if they were truly dysplastic fibroblasts,and they often have a smudged appearance. They are most numerous in the zone

immediately beneath the covering epithelium. The epithelium is usually normalbut may have elongated and narrow rete ridges. At the inferior margin the lesional

fibrosis blends into the normal underlying fibrovascular tissues, with no capsule or

pseudocapsule. Occasional lymphocytes may be seen beneath the epithelium oraround capillaries.

Treatmentand Prognosis

The giant cell fibroma is treated by conservative surgical removal but is more

likely to recur with this treatment than a more routine irritation fibroma, even whenthat fibroma is much larger. If left alone, the giant cell fibroma will not enlarge

indefinitely, but will reach its maximum size within a few months and remainunchanged thereafter, unless acute trauma produces edema or areas of granulationtissue proliferation.