Giant Fibrous Epulis in the Posterior Segment of Mandible ...
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International Medical Journal Vol. 26, No. 3, pp. 241 - 242 , June 2019 CASE REPORT Giant Fibrous Epulis in the Posterior Segment of Mandible: A Clinical Note Anisuzzaman M. M. 1) , Alam M. K. 2) , Khan S. R. 1) , Kamrujjaman M. 1) ABSTRACT Background: The fibrous epulis (Ep), a common tumor-like lesion of the gingiva, appears in the interdental papilla as a result of local irritation. Lesions are painless ulcerated and have a variable growth rate. Case presentation: A 52-year-old man was referred for the evaluation of a large painless gingival mass. It had started 2 months back and has been increasing rapidly day by day. According to radiological evaluation no bone involvement was noted. The tumor was totally removed by excision with help of surgical scalpel and electrocautery under general anesthesia with extraction of involving tooth. Finally, the microscopic findings were suggestive of a fibrous Ep. Differential diagnosis, clinical considerations and factors to prevent recurrence are discussed. Conclusion: Successful management followed by patient satisfaction was achieved. KEY WORDS epulis, pedunculated lesion, gingival disease Received on May 23, 2018 and accepted on August 18, 2018 1) Department of Oral and Maxillofacial Surgery, Bangladesh Dental College Dhanmondi, Dhaka 2) College of Dentistry, Jouf University Sakaka, Al-Jouf, Saudi Arabia Correspondence to: Mostafa Md. Anisuzzaman (e-mail: [email protected]) 241 INTRODUCTION The most common soft tissue lesion in the oral cavity included reac- tive hyperplasia and neoplasia. The majority of local overgrowths are considered to be reactive rather than neoplastic in nature 1) . The Ep is a relatively frequent benign lesion of the oral cavity 2) . The name derives from the ancient Greek and is a specific clinical term that bares a topo- graphic meaning, indicating a lesion located over the gingiva 3,4) . It is twice more common in females and the reasons for this remain unclear 5) . There are four types of Ep depending on the prevalent histological com- ponent: fibrous, granulomatous (pyogenic granuloma), angiomatous and giant cells Ep. According to some authors, they correspond to different developing stages of a single pathological entity that, at the initial stages, would be rich with vascular and cellular components while the fibrous constituent progressively increases over time. It usually appears as a sin- gle pedunculated lesion rising from gingiva of posterior segment of man- dible. It is indolent, and the dimensions may considerably variable. Its consistency as well is variable, and the color depends on the prevalent histologic component ranging from pink to dark red 6) . The pathogenesis is not completely clear but seems to be related to several factors in which a key role is played by the reactive inflammatory component that deter- mines its action on cells within the periodontal ligament. Poor oral hygiene seems to be a predisposing factor 7) . Histologically intact lesion consists of bundles of collagen fibers covered with keratinized squamous cell epithelium. When traumatized, the lesion contains inflammatory infiltrate and ulcerated area will be covered with fibrin and organisms from the oral flora 8) . We present an interesting case of a massive swelling arising from the gingiva of posterior segment of mandible. Because of the unusual size and duration, the investigation, differential diagnosis and clinical considerations are discussed. CASE REPORT A 52 year old male patient reported to our department with a soft tissue swelling present on right posterior segment of mandible that he noticed 2 months earlier. Its dimensions increased over time and diame- ter was approximately (7.5 X 6 X 4.5 cm). The mass first appeared nod- ular, non tender, ulcerated, pink to white and its consistency was tough. It was mobile, anchored to gingiva via a thin pedical and did not evoke pain when palpated. Then we planned to perform a biopsy under local anesthesia. The biopsy was Traumatic fibroma. Due to ulceration rebi- opsy was taken and the diagnosis was contact ulcer. CT scan showed mild heterogeneously enhanced soft tissue mass (5.2 x 4.1 x 5 cm) at medial and lateral aspect of right side lower gum (alveolar process), buccal mucosa and floor of the mouth. Mild scalloped erosion of right side alveolar process of the mandible was noted and diagnosed as case of fibroma. Following confirmation of the diagnosis, the patient hospi- talized. Therefore, we decided to completely remove it by resection of its thin pedicle, under general anesthesia. After excision of the soft tis- sue mass, curettage and complete debridement were carried out. Then washed the operative area and proper hemostasis was achieved by elec- tro cautery. Suturing was completed using 3-0 vicryl in an interrupted manner. The throat pack was removed the patient recovered successfully from anesthesia and was brought to the recovery room in a satisfactory condition. DISCUSSION The term Ep was first introduced by Virchoff in 1864 and, later, its histological variants have been described (fibrous, granulomatous, angi- omatous and with giant cells). This clinical note concerns a fibrous Ep in an advanced stage of growth. Some authors believe that the various C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation
Transcript of Giant Fibrous Epulis in the Posterior Segment of Mandible ...
International Medical Journal Vol. 26, No. 3, pp. 241 - 242 , June 2019
CASE REPORT
Giant Fibrous Epulis in the Posterior Segment of Mandible: A Clinical Note
Anisuzzaman M. M.1), Alam M. K.2), Khan S. R.1), Kamrujjaman M.1)
ABSTRACTBackground: The fibrous epulis (Ep), a common tumor-like lesion of the gingiva, appears in the interdental papilla as a
result of local irritation. Lesions are painless ulcerated and have a variable growth rate. Case presentation: A 52-year-old man was referred for the evaluation of a large painless gingival mass. It had started 2
months back and has been increasing rapidly day by day. According to radiological evaluation no bone involvement was noted. The tumor was totally removed by excision with help of surgical scalpel and electrocautery under general anesthesia with extraction of involving tooth. Finally, the microscopic findings were suggestive of a fibrous Ep. Differential diagnosis, clinical considerations and factors to prevent recurrence are discussed.
Conclusion: Successful management followed by patient satisfaction was achieved.
KEY WORDSepulis, pedunculated lesion, gingival disease
Received on May 23, 2018 and accepted on August 18, 20181) Department of Oral and Maxillofacial Surgery, Bangladesh Dental College Dhanmondi, Dhaka2) College of Dentistry, Jouf University Sakaka, Al-Jouf, Saudi ArabiaCorrespondence to: Mostafa Md. Anisuzzaman (e-mail: [email protected])
241
INTRODUCTION
The most common soft tissue lesion in the oral cavity included reac-tive hyperplasia and neoplasia. The majority of local overgrowths are considered to be reactive rather than neoplastic in nature1). The Ep is a relatively frequent benign lesion of the oral cavity2). The name derives from the ancient Greek and is a specific clinical term that bares a topo-graphic meaning, indicating a lesion located over the gingiva3,4). It is twice more common in females and the reasons for this remain unclear5). There are four types of Ep depending on the prevalent histological com-ponent: fibrous, granulomatous (pyogenic granuloma), angiomatous and giant cells Ep. According to some authors, they correspond to different developing stages of a single pathological entity that, at the initial stages, would be rich with vascular and cellular components while the fibrous constituent progressively increases over time. It usually appears as a sin-gle pedunculated lesion rising from gingiva of posterior segment of man-dible. It is indolent, and the dimensions may considerably variable. Its consistency as well is variable, and the color depends on the prevalent histologic component ranging from pink to dark red6). The pathogenesis is not completely clear but seems to be related to several factors in which a key role is played by the reactive inflammatory component that deter-mines its action on cells within the periodontal ligament. Poor oral hygiene seems to be a predisposing factor7). Histologically intact lesion consists of bundles of collagen fibers covered with keratinized squamous cell epithelium. When traumatized, the lesion contains inflammatory infiltrate and ulcerated area will be covered with fibrin and organisms from the oral flora8). We present an interesting case of a massive swelling arising from the gingiva of posterior segment of mandible. Because of the unusual size and duration, the investigation, differential diagnosis and clinical considerations are discussed.
CASE REPORT
A 52 year old male patient reported to our department with a soft tissue swelling present on right posterior segment of mandible that he noticed 2 months earlier. Its dimensions increased over time and diame-ter was approximately (7.5 X 6 X 4.5 cm). The mass first appeared nod-ular, non tender, ulcerated, pink to white and its consistency was tough. It was mobile, anchored to gingiva via a thin pedical and did not evoke pain when palpated. Then we planned to perform a biopsy under local anesthesia. The biopsy was Traumatic fibroma. Due to ulceration rebi-opsy was taken and the diagnosis was contact ulcer. CT scan showed mild heterogeneously enhanced soft tissue mass (5.2 x 4.1 x 5 cm) at medial and lateral aspect of right side lower gum (alveolar process), buccal mucosa and floor of the mouth. Mild scalloped erosion of right side alveolar process of the mandible was noted and diagnosed as case of fibroma. Following confirmation of the diagnosis, the patient hospi-talized. Therefore, we decided to completely remove it by resection of its thin pedicle, under general anesthesia. After excision of the soft tis-sue mass, curettage and complete debridement were carried out. Then washed the operative area and proper hemostasis was achieved by elec-tro cautery. Suturing was completed using 3-0 vicryl in an interrupted manner. The throat pack was removed the patient recovered successfully from anesthesia and was brought to the recovery room in a satisfactory condition.
DISCUSSION
The term Ep was first introduced by Virchoff in 1864 and, later, its histological variants have been described (fibrous, granulomatous, angi-omatous and with giant cells). This clinical note concerns a fibrous Ep in an advanced stage of growth. Some authors believe that the various
C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation
Anisuzzaman M. M. et al.242
forms of Ep are distinct entities, while others think that they are evolu-tionary stages of the same initial lesion. We agree with the latter. Usually, the dentists represent the professional figures to initially deal with this pathological entity. Instead, in our case, the patient was sent by the general dentist. Some doctors mistake large or recurrent Ep for malignant lesions, such as fibrosarcoma, Burkitt's lymphoma, or squa-mous cell carcinoma6). In literature there is agreement that the treatment of the Ep consists of the complete removal together with the underlying periostium associated with a thorough curettage of the bone and local irritative factors should also be removed2). When these lesions arise from the periodontal ligament of a tooth, it should also be performed a radicular levigature in order to remove the tissue which probably give origin to them. These lesions can recur, at a rate of about the 10%2) and in this case, it might be necessary to remove the tooth associated with the lesions themselves. In our case, given the presence of a very thin pedicle, we decided to remove the mass with curettage of underlying bone of the alveolar ridge and after a follow up of about 3 months. The lesion has not recurred. We can conclude that a thorough knowledge about various aspects of a gingival lesion is the key to successful diag-nosis and treatment planning.9) Because of the unusual size discussion and consideration of the various differential diagnoses should be done tactfully to prevent unnecessary distress to the patient and family10).
CONCLUSIONS
The diagnosis and treatment of fibrous Ep may be troublesome even for experienced clinicians, especially in areas such as oral cavity where there is ulceration and giant mass, usually a delay in presentation by the
patients. Adequate excision and histological examination of tissue is the best management procedure for fibrous Ep in oral cavity.
REFERENCES
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8) Kfir Y, Buchner A, Hansen L S. Reactive lesions of the gingiva. A clinicopathological study of 741 cases. J Periodontol. 1980; 51(11): 655-661.
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10) Alam MN, Chandrasekaran SC, Valiathan M. Fibroma of the gingiva: a case report of a 20 year old lesion. Int J Contemp Dent. 2010; 1(3): 107-109.
Figure 1. Preoperative extraoral, OPG, CT-Scan and intraoral photo. Postoperative clinical specimen and intraoral photo.
