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J Pak Dent Assoc.2011; 20 (1): 000-000
Hereditary gingival fibromatosis (HGF) is a bizarre condition that may lead to retention of deciduous teeth, malpositioned teeth, masticatory disturbances, and has potential effects on oral hygiene, aesthetic, functional and psychological aspects of life. A case report of 17 year old young girl suffering from gingival fibromatosis is presented. Surgical reduction and recontouring of the gingiva were performed. Electrocautery and reverse bevel incision were utilized to cut gingiva back to its expected normal level, along with reduction of abnormal excessive tissue to improve the functional and aesthetic concerns of girl.
Hereditary gingival fibromatosis, HGF.
Hereditary gingival fibromatosis is a benign extensively diffuse inherited gingival lesion of buccal and lingual soft tissue of maxillo-mandibular region. First reported by Goddard and Gross as ‘fungus excrescence of gingiva’ in 1856. 1
The keratinized gingiva shows progressive, proliferative and fibrous gingival enlargement due to an increase in submucosal connective tissue element. There are no symptoms, inflammation or pain. 2
In literature hereditary gingival fibromatosis has also been termed as elephantiasis gingiva, hereditary gingival hyperplasia/growth, hypertrophied gingiva, fibromatosis gingiva, gigantism of gingiva, symmetric fibroma of palate and congenital macrogingivae.3 It is a rare condition estimated to affect 1/750,000 people.4 Distribution among male and female is equal.5.
The patient observed was a female of 17 years reported to Oral and Maxillofacial Surgery department at Islamic International Dental Hospital Islamabad with past history non contributory to the condition and no drug history. Extra oral examination revealed protrusion of upper and lower lips (fig 1).
Intra oral examination showed thick gingiva covering the teeth with only canines and incisal edges
visible in maxillary arch and occlusal and incisal surfaces multiple teeth visible in mandibular arch, covered with heavy gingival tissue (fig 2). Mandibular left central incisor was lingually erupted due to hindrance rendered by thick and fibrous gingiva. There was significant growth of tissue in maxilla around the alveolus as well as palatal side of the ridge up to midline with teeth embedded in gingiva. No other hard and soft tissue abnormality was noticed.
Patient had family history positive for the condition and mentioned that her father and a brother also suffers from the same condition. Diagnosis was established on the basis of clinical picture and as there was no syndrome associated so it was diagnosed as HGF of non-syndromic type. Treatment plan made was to surgically uncover the teeth and reduce the height of gingiva till the expected level. The patient was treated in the maxillofacial surgery department at IIDH
Fig 4. Mandibular Gingival reduction
Gingival reduction was done using electrocautery and reverse bevel incision under local anesthesia and later covered with periodontal dressing. One quadrant was treated in one session of one week interval to reduce excessive surgical trauma and to gain confidence of the patient
She tolerated the procedure well. Six month post operative follow up showed good healing with no sign of recurrence
HGF is a benign hereditary gingival lesion confined to maxillomandibular region. The gingival involvement can be generalized (involving all teeth) or localized, limited to specific area as tuberosity
buccal gingival around lower molars. Its relation with use of certain drugs cannot be ruled out as cyclosporine, Ca channel blockers and nifedipine. 6
Hereditary gingival fibromatosis is principally transmitted as autosomal dominant and infrequently as autosomal recessive trait. As autosomal dominant trait, the chances of a child to develop the said condition is 50% and is often associated with hypertrichosis, corneal dystrophy, craniofacial deformity, nail defects, deafness, epilepsy and mental retardation. 7Onset of the condition is related to the eruption of the permanent dentition and progresses to maximum during active phase of eruption, signifying period of high fibroblast activity.8
However; it can also be encountered with deciduous teeth eruption and rarely at birth. Age of onset can be subdivided as; Pre-eruptive period which is <6 months, deciduous dentition period i.e. 6 months to 6 years, mixed dentition period ranging from 6-12 years, permanent dentition period before adolescence 12-20 years, and permanent dentition period after adolescence (above 20 years of age).9 It may run within the same family generation after generation with variable degree of hyperplasia among different individuals of the same family.10
Clinically it present as asymptomatic hyperplasic gingiva having pink color, firm dense and fibrous consistency, evident stippling and scarce bleeding. Other features manifest as malpositioned teeth, retained deciduous and permanent teeth, poor oral hygiene, halitosis, diastemas, pseudo-pocket formation, lip protrusion leading to aesthetic disfigurement, functional issues, and psychological concerns.11 Histologically, the affected tissue is rich in collagen composed of few fibroblasts and blood vasculature.12 In a review done by Hart he presented 18 different forms of HGF with variation in systemic features.13
Hereditary gingival fibromatosis cannot be cured but controlled with varying degrees of success. The use of carbon-di-oxide laser has been advocated in literature and appears to be promising but further work is required to make its practice more common. However, resective surgery of excess tissue overgrowth i.e., conventional external bevel
gingivectomy remains the most efficacious treatment available. Recurrence is frequent.14 Should the overgrowth re-emerge, excision is to be repeated as psychological benefits resulting from cosmetic improvement outweigh risk of recurrence.
HGF is benign condition which cause aesthetic, functional and psychological distress to an individual. Treatment consists of surgical uncovering of teeth by gingivectomy but long term follow up is necessary to monitor recurrence of the condition. Present case was of non-syndromic inherited gingival enlargement, requiring surgical intervention which appreciably improved aesthetic and masticatory competence without recurrence.
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