GINGIVAL ENLARGEMENT

Introduction

• Increase in size of gingiva is a common feature of gingival disease.

• In past, terms like hypertrophic gingivitis or gingival hyperplasia were used. But now a days this condition is commonly known as gingival enlargement or gingival hyperplasia.

ClassificationI. Inflammatory enlargementII. Drug induced enlargementIII. Enlargements associated with systemic diseases• Conditional enlargements: Pregnancy Puberty Vitamin c deficiency Plasma cell gingivitis Nonspecific conditional enlargement (pyogenic granuloma)• Systemic diseases Leukemia Granulomatous diseasesI. Neoplastic enlargements: benign and malignantII. False enlargement

Grading

• Grade 0 : no signs of gingival enlargement• Grade 1: enlargement confined to interdental

papilla.• Grade 2:enlargement involves papilla and

marginal gingiva• Grade 3:enlargement covers three quarters or

more of crown.

Inflammatory enlargement

• Gingival enlargement may result from chronic or acute inflammatory changes ;chronic changes are much more common.

• These are commonly secondary complication to any of the other types of enlargement, creating a combined gingival enlargement.

Chronic inflammatory enlargementClinical features:• It originates as a slight ballooning of the interdental papilla

and marginal gingiva.• In early stages it produces a life saver bulge around the

involved teeth which increases in size.• It may be localized or generalized and progresses slowly and

painlessly, until it is complicated by trauma or infection.• Occasionally, it occurs as discrete sessile or pedunculated

mass resembling tumor.• it may be interproximal or on the marginal or attached

gingiva.

• The lesions are slow growing masses and usually painless.• They may undergo spontaneous reduction in size, followed by

exacerbation and continued enlargement.• Painless ulceration sometimes occurs in the fold between the

mass and the adjacent gingiva.

Histopathology_-• Lesions that are clinically deep red or bluish red are soft and

friable with a smooth, shiny surface, and they bleed easily. They also have a preponderance Of inflammatory cells and fluids, with vascular engorgement, new capillary formation and associated degenerative changes.

• Lesions that are relatively firm, resilient, and pink have a greater fibrotic component with an abundance of fibroblasts and collagen fibers.

Chronic inflammatory gingival enlargement

Etiology

• It is caused by prolonged exposure to dental plaque.

• Factors that favor plaque accumulation and retention include poor oral hygiene, as well as irritation by anatomic abnormalities and improper restorative and orthodontic appliances.

Acute inflammatory enlargement

Gingival abscess:• It is a localised,painful,rapidly expanding lesion that is usually of

sudden onset.• It is generally limited to the marginal gingiva or interdental

papilla.• In early stages, it appears as red swelling with a smooth, shiny

surface. Within 24-48hrs, the lesion actually becomes fluctuant and pointed with a surface orifice from which a purulent exudate may be expressed.

• The adjacent teeth are often sensitive to percussion. If permitted to progress the lesion generally ruptures spontaneously.

Histopathology:• It consists of a purulent focus in the connective tissue, surrounded by

a diffuse infiltration of polymorphonuclear leucocytes, edematous tissue and vascular engorgement.

• The surface epithelium has varying degrees of intra cellular and extra cellular edema, invasion by leucocytes and sometimes ulceration.

Etiology-• It results from bacteria carried deep into the tissues when a foreign

substance is forcefully embedded into the gingiva.• The lesion is confined to the gingiva and should not be confused with

periodontal or lateral abscesses. Periodontal abscess generally produce enlargement of the gingiva

but also involve the supporting periodontal tissue.

Acute inflammatory enlargement

Drug induced gingival enlargement• It is well known consequence of the administration of some

anticonvulsants,immunosuppresants and calcium channel blockers and may create speech, mastication, tooth eruption and aesthetic problems.

Clinical features.• The growth starts as a painless bead like enlargement of the

interdental papilla and extends to the facial and lingual gingival margins.

• As condition progresses the marginal papillary enlargement unite; they may develop into a massive tissue fold covering a considerable portion of the crowns and they may interfere with occlusion.

• When un complicated by inflammation the lesion is mulberry shaped, firm ,pale pink and resilient with a minutely lobulated surface and no tendency to bleed.

• The enlargement characteristically appears to project from beneath the gingival margins from which it is separated by linear groove. However the presence of enlargement makes plaque control difficult often resulting in a secondary inflammatory process that complicates the gingival overgrowth caused by the drug.

• The resultant enlargement then becomes a combination of the increase in size caused by the drug and the complicating inflammation caused by the bacteria.

• Secondary inflammatory changes not only add to the size of the lesion caused by the drug but also produce a red or bluish red discolouration,obliterate the lobulated surface demarcations and increase bleeding tendency.

• The enlargement is usually generalized throughout the mouth but is more severe in maxillary and mandibular anterior regions.

• It occurs in areas in which teeth are present ,not in edentulous spaces and the enlargement disappears in areas from which teeth are extracted. Hyperplasia of the mucosa in edentulous mouth is rare.

Histopathology

• It consists of a pronounced hyperplasia of the connective tissue and epithelium.

• There is acanthosis of the epithelium and elongated rete pegs extent deep into the connective tissue which exhibits densely arranged collagen bundles with an increase in the number of fibroblasts and new blood vessels.

Anticonvulsants:• The first drug induced gingival enlargement reported were

those by phenytoin (dilantin)• Other hydantoins known to induce gingival enlargementa are

ethotoin and mephenytoin while anticonvulsants are succinimides,methsuxinimide and valproic acid.

• It occurs more often in younger patients. • Tissue culture experiments indicate that phenytoin stimulate

proliferation of fibroblast like cells and epithelium.• Two analogues of phenytoin (1 allyl 5 phenyl hydratoinate and

5methyl 5phenyl hydrationate)have a similar effect on fibroblast like cells.

• Fibroblast on the phenytoin induced gingival overgrowth shows increased synthesis s of sulphated glycosaminoglycans in vitro.

• Phenytoin may induce a decrease in collagen degradation as a result of the production of an inactive fibroblastic collagenase.

• Systemic administration of phenytoin accelerates the healing of gingival wounds in non epileptic humans and increases the tensile strength of healing abdominal wounds in rats.

Phenytoin induced gingival enlargement

Facial view Occlusal view

Immunosuppressants• Cyclosporine is a potent immunosuppressive agent used to

prevent organ transplant rejection and to treat several diseases of autoimmune origin.

• It appears to selectively and reversibly inhibit helper t cells, which play a role in cellular and humoral immune responses.

• Cyclosporine A is administered intravenously or by mouth, and dosages greater than 500 mg/day induce gingival overgrowth. It is more vascularised than phenytoin enlargement.

• It affects children more frequently, and its magnitude appears to be related more to the plasma concentration than to the patients periodontal status.

• Gingival enlargement is greater in patients who are medicated with both cyclosporine and calcium channel blockers.

• The microscopic finding of many plasma cells plus the presence of an abundant amorphous extracellular substance has suggested that the enlargement is a hypersenstivity response to the cyclosporine.

• In addition to gingival enlargement cyclosporine induces other major side effects such as nephrotoxicity,hypertension and hypertrichosis.

Calcium channel blockers• These drugs developed for the treatment of cardiovascular

condition such as hypertension,angina pectoris,coronary artery spasms and cardiac arrhythmias.

• They inhibit calcium ion influx across the cell membrane of heart and smooth muscle cells blocking intracellular mobilization of calcium.

• This induces direct dilatation of the coronary arteries and the arterioles ,improving oxygen supply to the heart muscles and also reduces hypertension by dilating the peripheral vasculature.

• Some of the drugs which can induce gingival enlargement are nifedipine, diltiazem,felodipine,nitrendipine,verapamil.

• Nifidipine is also used with cyclosporine in kidney transplant recipients and the combined use of both induce larger overgrowth.

Cyclosporine induced gingival enlargement

Idiopathic gingival enlargement

Clinical features• The enlargement affects the attached gingiva, as well as the

gingival margin and interdental papillae.• The facial and lingual surfaces of the mandible and maxilla are

generally affected, but the involvement may be limited either jaw.

• The enlarged gingiva is pink,firm,and almost leathery in consistency and has a characteristic minutely pebbled surface.

• In severe cases the teeth are almost covered ,and the enlargement projects into oral vestibule.

• The jaw appears distorted because of bulbous enlargement of the gingiva.

Idiopathic gingival enlargement

Histopathology

• It shows a bulbous increase in the amount of connective tissue that is relatively avascular and consists of densely arranged collagen bundles and numerous fibroblasts.

• The surface epithelium is thickened and acanthotic with elongated rete pegs.

Etiology:• The cause is unknown, and thus the condition is designated as

“idiopathic.”The enlargement usually begins with the eruption of the primary or secondary dentition and may regress after extraction, suggesting that the teeth may be initiating factors.

• The presence of bacterial plaque is a complicating factor.

Enlargements associated with systemic diseases

• These diseases and conditions can affect the periodontium by two different mechanism, as follows:

1. Magnification of an existing inflammation initiated by dental plaque.

2. Manifestation of the systemic disease independently of the inflammatory status of the gingiva.

Conditioned enlargement• It occurs when the systemic condition of the patient

exaggerates or distorts the usual gingival response to the dental plaque.

• The specific manner in which the clinical picture of conditioned gingival enlargements differs from that of chronic gingivitis depends on the nature of the modifying systemic influence.

• Bacterial plaque is necessary for the initiation of this type of enlargement. However, plaque is not the sole determinant of the nature of the clinical features.

• The three types of conditioned gingival enlargements are hormonal, nutritional and allergic.

Enlargement in pregnancy• Pregnancy enlargement may be marginal and generalized or

may occur as single or multiple tumor-like masses.• During pregnancy there is an increase in levels of both

progestrone and estrogen,which,by the end of the third trimester, reach levels 10 and 30 times the levels during the menstrual cycle, respectively.

• These hormonal changes induce changes in vascular permeability, leading to gingival edema and an increased inflammatory response to dental plaque. The subgingival microbiota may also undergo changes, including an increase in Prevotella intermedia

Localised gingival enlargement in pregnant patient

Marginal enlargement• Marginal gingival enlargement during pregnancy results from

the aggravation of previous inflammation, and its incidence has been reported as 10% and 70%.

• The gingival enlargement does not occur without the presence of bacterial plaque.

• The clinical picture varies considerably. The enlargement is usually generalized and tends to be more prominent interproximally than on the facial and lingual surfaces.

• The enlarged gingiva is bright red or magenta, soft,and friable and has a smooth, shiny surface.

• Bleeding occurs spontaneously or on slight provocation.

Tumor-like gingival enlargement• The so-called pregnancy tumor is not a neoplasm;it is an

inflammatory response to bacterial plaque and is modified by the patients condition.

• It usually appears after the third month of pregnancy.• The lesion appear as a discrete mushroom like flattened

spherical mass that protrudes from the gingival margin or more often from the interproximal space and is attached by a sessile or pedunculated base.

• it tends to expand laterally and pressure from the tongue and the cheek perpetuates its flattened appearance. Generally dusky red or magenta, it has smooth glistening surface that often exhibits deep red pinpoint markings.

• It is a superficial lesion and does not invade the underlying bone.• The consistency, the mass is usually semifirm,but it may have

various degrees of softness and friability.• It is usually painless unless its size and shape foster accumulation

of debris under its margin or interfere with occlusion, in which case painful ulceration will occur.

• Most gingival disease during pregnancy can be prevented by the removal of plaque and calculus, as well as the institution of fastidious oral hygiene at the onset.

• In pregnancy, treatment of the gingiva that is limited to the removal of tissue without complete elimination of local irritants is followed by recurrence of gingival enlargement

• Although spontaneous reduction in the size of gingival enlargement typically follows the termination of pregnancy, complete elimination of the residual inflammatory lesion requires the removal of all plaque deposits and factors that favor its accumulation.

Histopathology:• Gingival enlargement in pregnancy is called angiogranuloma,

both marginal and tumor like enlargements consist of a central mass of connective tissue, with numerous diffusely arranged newly formed and engorged capillaries lined by cuboid endothelial cells, as well as a moderately fibrous stroma with varying degrees of edema and chronic inflammatory infiltrate

• The stratified squamous epithelium is thickened with prominent rete pegs and some degree of intracellular and extracellular edema, prominent intercellular bridges and leucocytes infiltration.

Gingival enlargement in puberty

• Enlargement of the gingiva is sometimes seen during puberty. It occurs in both male and female adolescents and appears in areas of plaques accumulation.

• The size of the gingival enlargement greatly exceeds that usually seen in association with comparable local factors. It is marginal and interdental and is characterized by prominent papillae.

• Often, only the facial gingiva are enlarged, and the lingual surfaces are relatively unaltered, the mechanical action of the tongue and the excursion of food prevent a heavy accumulation of local irritants on the lingual surface.

• It is the degree of enlargement and the tendency to develop massive recurrence in the presence of relatively scant plaque deposits that distinguish pubertal gingival enlargement from uncomplicated chronic inflammatory gingival enlargement

Conditioned gingival enlargement in puberty

Enlargement in vitamin C deficiency

• Enlargement of the gingiva is generally included in classic description of scurvy.

• Acute vitamin C deficiency itself does not cause gingival inflammation, but it does cause hemorrhage, collagen degeneration and edema of the gingival connective tissue.

• These changes modify the response of the gingiva to plaque to the extent that the normal delimiting reaction is inhibited and the extent of inflammation is exaggerated resulting in the massive gingival enlargement.

• Gingival enlargement is marginal the gingiva is bluish red, soft and friable and has a smooth shiny surface. Hemorrhage occurring either spontaneously or on slight provocation and surface necrosis with pseudo membrane formation are common features.

Gingival enlargement in vitamin c deficiency

Plasma cell gingivitis

• It is referred to as atypical gingivitis and plasma cell gingivostomatitis,often consists of mild marginal gingival enlargement that extends to the attached gingiva localized lesion referred to as plasma cell granuloma has also been described.

• The gingiva appears red, friable and sometimes granular and bleeds easily. Usually it does not induce a loss of attachment.

• This lesion is located in the oral aspect of the attached gingiva and therefore differ from plaque induced gingivitis.

• An associated cheilitis and glossitis have been reported. It is thought to be allergic in origin possibly related to components of chewing gum,dentrifices or various diet component. Cessation of exposure to allergens brings resolution of the lesion.

Plasma cell gingivitis

Nonspecific conditioned enlargement(pyogenic granuloma)

• It is a tumor like gingival enlargement that is considered exaggerated conditioned response to minor trauma. The exact nature of systemic conditioning factor has not been identified.

• The lesion varies from discrete spherical tumor like mass with a pedunculated attachment to a flattened keloid like enlargement with a broad base.

• It is bright red or purple and either friable or firm depending on its duration in the majority of cases it presents with surface ulceration and purulent exudation. The lesion tends to involute spontaneously to become a fibroepithelial papilloma or it may persist relatively unchanged for years.

• Treatment consists of removal of lesion and the elimination of irritating local factors.

Granulomatous diseasesWegener’s granulomatosis:• It is a rare disease characterized by acute granulomatous

necrotizing lesions of the respiratory tract, including nasal and oral defects.

• It may involve orofacial region and include oral mucosal ulceration, gingival enlargement, abnormal tooth mobility, exfoliation of teeth, and delayed healing response.

• The granulomatous papillary enlargement is reddish purple and bleeds easily on stimulation.

Sarcoidosis:• Predominantly affects blacks, and can involve any organ,

including gingiva, where a red smooth, painless enlargement may appear.

Leukemic gingival enlargement

Neoplastic enlargementEpulis:• It is a generic term used clinically to designate all discrete

tumors and tumorlike masses of the gingiva.Fibroma:• They arise from gingival connective tissue or from the

periodontal ligament. They are slow growing, spherical tumors that tend to be so firm and nodular but may be soft and vascular. They are usually pedunculated .

Papilloma:• They are benign proliferation of surfce epithelium associated

with the human papilloma virus. Viral subtypes HPV-6 and HPV-11have been found in most of cases. They appear as solitary,wartlike or cauliflower like protuberances.

Peripheral giant cell granuloma:• Giant cell lesions of the gingiva arise interdentally or from the

gingival margin,occur most frequently on the labial surface,and may be sessile or pedunculated.

• They vary in appearance from smooth,regularlyoutlined masses to irregularly shaped,multilobulated protuberances with surface indentations.

• Ulcerations of the margin is occasionally seen.• Lesions are painless, vary in size, and the color varies from

pink to deep red or purplish blue.• There are no pathogonomic clinical features whereby these

lesions can be differentiated from other forms of gingival enlargement.

Papilloma vs gingival giant cell granuloma

Central giant cell granuloma:• These lesions arise within the jaws and produce central

cavitation.they occasionally create deformity of the jaw that makes gingiva appear enlarged.

Leukoplakia:• It is a white patch or plaque that does not rub off and cannot

be diagnosed as any other disease.• Histopathologically, it exhibits hyperkeratosis and

acanthosis.premalignant and malignant cases have a variable degree of atypical epithelial changes that may be mild, moderate or severe, depending on the extent of involvement of epithelial layers.

• Inflammatory involvement of connective tissue is also associated.

Gingival cyst:• These cysts of microscopic proportion are common, but they

seldom reach a clinically significant size,• When they do, they appear as localized enlargements that

may involve the marginal and attached gingiva.• They occur in mandibular canine and premolar areas, most

often on the lingual surface.• They are painless, but with expansion, they may cause erosion

of the surface of alveolar bone.

Malignant tumors of gingiva

• carcinoma• Malignant melanoma Sarcoma metastasis

False enlargement

• These are not true enlargements but may appear as such as a result of increase in size of underlying osseous and dental tissues.

• It usually present with no abnormal clinical features except massive increase in size.

Underlying osseous lesions• Most commonly tori and exostosis.• Also occur in pagets disease, fibrous dysplasia,cherubism

giant cell granuloma,ameloblastoma,osteoma and osteosarcoma.

Underlying dental tissues:• During the various stages of eruption, particularly of primary

dentition, the labial gingiva may show a bulbous marginal distortion caused by superimposition of bulk of gingiva on the normal prominence of enamel in gingival half of crown. This enlargement has been termed developmental enlargement and often persists until the functional epithelium has migrated from the enamel to the cement enamel junction.

• These are physiologic and ordinarily present no problems, but is complicated by gingival inflammation.

• Treatment to alleviate the marginal inflammation, rather than resection of the enlargement, is sufficient in these cases.

Treatment of gingival enlargement

Chronic inflammatory enlargement• These are treated by scaling and root planing,provided the

size of the enlargement does not interfere with complete removal of deposits from the involved tooth surfaces.

• When these enlargements include a significant fibrotic component that does not undergo shrinkage after scaling and root planing or are of such size that they obscure deposits on the tooth surfaces and interfere with access to them, surgical removal is the treatment of choice.

• Two techniques are available for this purpose:gingivectomy and flap operation.

• After scaling and root planing gingivectomy is use to remove enlargement because a flap requires a firmer tissue to perform the incision and other steps in the technique.

• However ,if the gingivectomy incision removes all the attached gingiva creating a mucogingival problem, then a flap operation is indicated.

• Tumorlike inflammatory enlargements are treated by gingivectomy as follows:

With the patient under local anaesthia the tooth surfaces beneath the mass are scaled to remove calculus and other debri.the lesion is separated from the mucosa as its base with #12 bardparker blade.

If the lesion extends interproximally in the interdental gingiva is incluede in the incision to ensure exposure of irritating root deposit.

After the lesion is removed the involved root surfaces are are scaled and planed and the area is cleansed with warm water.

A periodontal pack is applied and removal after a week, then patient is instructed in plaque control.

Periodontal and gingival abscessTreatment options for periodontal abscess:1. Drainage through pocket retraction or incision2. Scaling and root planing3. Periodontal surgery4. Systemic antibiotics5. Tooth removal

Indications or antibiotic therapy in patients with acute abscess:6. Cellulitis(nonlocalized,spreading infection)7. Deep, inaccessible pocket8. Fever9. Regional lymphadenopathy10. Immunocompromised patient

Acute abscess

• It is treated to alleviate symptoms, control the spread of infection and establish drainage. Before the treatment the patients medical history, dental history and systemic condition are reviewed and evaluated to assit the diagnosis and to determine the need for systemic antibiotic.

Antibiotic options:Antibiotic of choice: amoxicillin, 500mg• 1g loading dose, then 500mg 3 times a day for 3 days.• Reevaluation after 3 days to determine need for continued or adjusted

antibiotic therapy.

Penicillin allergy: clindamycin• 600mg loading dose, then 3oomg 4 times a day for 3 daysAzithromycin:• 1g loading dose, then 500mg 4times a day for 3 days.

Drainage through periodontal pocket• The peripheral area around the abscess is anesthetised with sufficient

topical and local anesthetic to ensure comfort.• The pocket wall is gently retracted with a periodontal probe or curette in

an attempt to initiate drainage through the pocket entrance.• Gentle digital pressure and irrigation may be used to express exudates and

clear the pocket .• If the lesion is small and access uncomplicated, debridement in the form

of scaling and root planing may be undertaken.• If the lesion is large and drainage cannot be established ,root

debridement by scaling and root planing or surgical access should be delayed until the major clinical signs have abated.

• Antibiotic therapy alone without subsequent drainage and subgingival scaling is contraindicated.

Drainage through external incision:• The abscess is dried and isolated with gauze sponges. Topical anesthetic is

applied, followed by local anesthetic injected peripheral to the lesion.• A vertical lesion through the most fluctuant center of the abscess is made

with a #15 surgical blade.• The tissue lateral to the incision can be separated with a curette or

periosteal elevator. Fluctuant matter is expressed and the wound edges approximated under light digital pressure with a moist gauze pad.

• In abscess presenting with severe swelling and inflammation, aggressive mechanical instrumentation should be delayed in favor of antibiotic therapy so as to avoid damage to healthy contiguous periodontal tissues.

• Once bleeding and suppuration have ceased ,the patient may be dismissed. For those who do not need systemic antibiotics,posttreatment instructions include frequent rinsing with warm salt water(1tbsp/8-oz.glass)and periodic application of chlorhexidine gluconate either by rinsing or locally with a cotton –tipped applicator. Reduced exertion and increased fluid intake are often recommended for patients showing systemic involvement.

• Analgesics may be prescribed for comfort .

Patient taking drug to cause gingival enlargemant

Gingival enlargement not present

Gingival enlargement

Oral hygiene reinforcement,professional

calls

Oral hygiene reinforcement,chlorhexidine gluconate rinses,

Scaling and root planing,Possible drug substitution,

Professional recalls.

reevaluationGingival enlargement

regresses

Maintain good oral hygiene,Maintain professional recalls.

Gingival enlargement persists

Periodontal surgery indicated

Periodontal surgery indicated

Small areas of enlargement,No attachment loss or,Horizontal bone loss,

Abundance of keratinized tissue.

Large areas of enlargements,Presence of osseous defects,

Limited keratinized tissue.

gingivectomy Periodontal flap

Maintenance:Good oral hygiene,

Chlorhexidine gluconate rinses,Professional recalls,

Use of positive pressure appliance.

Consider periodic surgical retreatment

Drug-associated gingival enlargement

• Gingival enlargement has been associated with the administration of three different types of drug: anticonvulsants, calcium channel blockers and immunosuppressant cyclosporine.

• Examination of cases o drug-induced gingival enlargement reveals the overgrown tissues to have two components:fibrotic,caused by the drug and inflammatory, induced by bacterial plaque.

Treatment options:• It should be based on the medication being used and the clinical features

of the case.• First, consideration should be given to the possibility of discontinuing the

drug or changing medication but should be examined with patient physician.

• If any drug substitution is attempted ,it is important to allow for a 6-12 month period to elapse between discontinuation of the offending drug and the possible resolution of the gingival enlargement before a decision to implement surgical treatment is made.

• Alternative medication to the anticonvulsant phenytoin include carbamazepine and valproic acid, both of which have been reported to have a lesser effect in inducing gingival enlargement;.

• while nifedipine is substituted with diltiazem or verapamil.also, consideration may be given to the use of another class of antihypertensive medication rather than calcium channel blockers ,none of which is known to induce gingival enlargement.

• Cyclosporine –induced gingival enlargement can spontaneously resolves if tacrolimus is substituted.

• Azithromycin may aid in decreasing the severity of cyclosporine induced gingival enlargement.

• Second, emphasis should be given on plaque control ,it decreases the degree of gingival enlargement and improves overall gingival health. It is associated with pseudopocket formation, frequently with abundant plaque accumulation, which may lead to development of pericoronitis;meticulous plaque control therefore helps maintain attachment levels. Also, adequate plaque control may aid in preventing the recurrence of gingival enlargement in surgically treated cases.

• Third, if gingival enlargement still persists .it may require surgery, either gingivectomy or the periodontal flap.

Gingivectomy• It has the advantage of simplicity and quickness but presents

the disadvantages of more postoperative discomfort and increased chance of postoperative bleeding.

• It also sacrifices keratinized tissue and does not allow for osseous recontouring

• The surgical technique to be used must consider the extension of the area to be operated, the presence of periodontitis and osseous defects, and the location of the be off pocket in relation to the mucogingival junction.

• The amount of keratinized tissue present ,remembering that at least 3mm in the apicocoronal direction should remain after surgery is completed.

Flap technique

• Larger areas of gingival enlargement or areas where attachment loss and osseous defects are present should be treated by flap technique.

• The technique to be followed for correction of gingival enlargement is as follows :

• after anaesthetizing the area,sounding of the underlying bone is performed with a periodontal probe to determine

the presence and extent of osseous defects.

• With a #25 Bard-Parker blade, the initial scalloped internal bevel incision is made at least 3mm coronal to the

mucogingival junction, including the creation of new interdental papillae.

• The same blade is used to thin the gingival tissue in a buccolingual direction to the mucogingival junction. At this point the blade establishes

contact with the alveolar bone, and a full-thickness or a split thickness flap is elevated.

• Using an orban knife, the base of each papilla connecting the facial and the lingual incision is incised. The excised marginal

and interdental tissues are removed with curettes.Tissue tabs are removed, the roots are thoroughly scaled and

planed ,the bone is recontoured as needed.

• The flap is replaced and, if necessary ,trimmed to reach the bone-tooth junction exactly. The flap is then sutured with an interrupted or a continuous mattress technique, and the area

is covered with a periodontal dressing

• Sutures and pack are removed after 1 week, and the patient is instructed to start plaque control methods. Usually use of chlorhexidine oral rinses once or twice daily for 2-4 weeks is advised.

• Recurrence is usually present in surgically treated cases.

• Chlorhexidine gluconate and professional cleaning can decrease the speed and the degree to which recurrence occurs.

• The primary closure of the surgical site with flap procedure is a great advantage over the secondary open wound resulting from the gingivectomy technique.

Leukemic gingival enlargement• It occurs in acute or subacute leukemia and is uncommon in the chronic

leukemic state. The medical care of leukemic pateints is often complicated by gingival enlargement and superimposed painful acute necrotising ulcerative gingivitis, which interferes with eating and creates toxic systemic reactions. The patients bleeding and clotting times and platelet count should be checked and the hematologist consulted before periodontal treatment is instituted.

Rationale: it is to remove the local irritating factors to control the inflammatory component of the enlargement.

• The enlargement is treated by scaling and root planing carried out in stages under topical anesthesia.

• The initial treatment consists of gently removing all loose accumulations with cotton pellets ,performing superficial scaling and instructing the patient in oral hygiene for plaque control, which should include, at least initially, daily use of chlorhexidine mouthwashes.

• Deeper scaling is carried out at subsequent visits. Antibiotics are administered systemically the evening before and for 48 hours after each treatment to reduce the risk of infection.

Gingival enlargement in pregnancy

• Treatment requires elimination of all local irritants responsible for precipitating the gingival changes in pregnancy. Marginal and interdental gingival inflammation and enlargement are treated by scaling and curettage.

• Treatment of tumorlike gingival enlargements consist of surgical excision and scaling and planing of the tooth surfaces. The enlargement recurs unless all irritants are removed. Food impaction is frequently an inciting factor.

• Gingival lesion in pregnancy should be treated as soon as they are detected,although not necessarily by surgical means(mainly in second trimester).

• In pregnancy the emphasis should be on:1. Preventing gingival disease before it occurs2. Treating existing gingival diseases before it worsens.

Gingival enlargement in puberty

• Gingival enlargement in puberty is treated by performing scaling and curettage, removing all sources of irritation and controlling plaque.

• surgical removal may be required in severe cases.

• The problem in these cases is poor oral hygiene.