|Year : 2016 | Volume
| Issue : 1 | Page : 23-27
Fibrous hyperplasia: Two case reports
Kshitij Vipin Pardeshi, Neha M Mirchandani, Amit A Agrawal, Triveni M Kale
Department of Periodontics, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India
|Date of Web Publication||23-Jun-2016|
Kshitij Vipin Pardeshi
10 Vishwagaurav Apartment, Plot No. 3, Gat No. 76, Near Old Jain Pipe Factory, Nimkhedi Road, Jalgaon - 425 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Fibrous hyperplasia is a nonneoplastic lesion of fibrous connective tissue origin considered to be a histologic variant of fibroma that causes esthetic and functional problems. The choice of treatment should always be founded on basic principles of pathology and sound surgical judgment. Diode lasers have several distinct advantages over other therapy, as they provide a bloodless field and also allow histological examination without distortion, resulting in a painless postoperative period and no collateral damage to adjacent tissues. This article present two cases of fibrous hyperplasia occurring on gingiva and labial mucosa in the second decade of life, treated by diode laser therapy with 1 year follow-up and no recurrence.
Keywords: Creeping attachment, diode laser, fibrous hyperplasia
|How to cite this article:|
Pardeshi KV, Mirchandani NM, Agrawal AA, Kale TM. Fibrous hyperplasia: Two case reports. J Dent Lasers 2016;10:23-7
| Introduction|| |
Local reactive focal overgrowth is frequently found in the oral cavity, and they usually present clinically and histopathologically as nonneoplastic nodular swellings that increase in response to chronic recurring tissue injury which stimulates an exuberant or extreme tissue response. 
On the basis of site involved reactive lesions can be classified under various headings as listed in [Table 1].
The scalpel, lasers, and conventional electrosurgery unit are the instruments of choice for soft tissue surgery. Scalpels have been used for many years because of their ease of use, accuracy, and minimal damage to the surrounding tissue. On the other hand, scalpels cannot provide the hemostasis that is helpful for use on highly vascular tissue.  One characteristic difference between a laser and a scalpel cut is the generation of a coagulated tissue layer along the walls of the laser incision. Research has consistently revealed that laser surgery can be performed safely using parameters which protect underlying bone and tooth structures.  Laser systems and their application in dentistry and especially oral surgery are rapidly improving today. Advantages of this tool include greater precision, a relatively bloodless surgical and postsurgical course, sterilization of the surgical area, minimal swelling and scarring, coagulation, vaporization, and cutting, minimal or no suturing, and much less or no postsurgical pain. Diode laser with wavelengths ranging from 810 to 980 nm in a continuous or pulsed mode can be used in excisional surgery of lesion.
The present article reports two cases of fibroma surgical excised with the help of 810 nm diode laser.
| Case Reports|| |
Case report 1: Focal fibrous hyperplasia on gingiva
Focal fibrous hyperplasia (FFH), also known as irritation or traumatic fibroma, is a localized reactive, progressive, and proliferation of oral mucosa in response to injury or local irritation.  The term "focal fibrous hyperplasia" implies a reactive tissue response and is, therefore, preferable to the term "fibroma" which implies incorrectly, a benign neoplastic proliferation of fibrous connective tissue. 
An 18-year-old female reported to the Department of Periodontics with the chief complaint of swelling in lower left back teeth region. The swelling was initially small which enlarged gradually to the present condition over the period of 6 months. Swelling was painless, but the patient complained of discomfort associated with swelling. The patient had a history of trauma (needle prick) at the site of the lesion. There was no contributory dental and medical history. Extraoral examination revealed asymmetrical swelling on the left side. On intraoral examination, a solitary fibrous pedunculated nodular growth (3 cm × 2.5 cm × 1.5 cm) was seen in relation to the buccal attached gingiva, extending from distal of #22 to mesial of #19 [Figure 1]a. This asymptomatic lesion was pale pink with black pigmentation, having a rough, nonulcerated surface [Figure 1]b. On palpation, the growth was nodular, movable, noncompressible, firm, fibrous, and nontender with the absence of discharge. However, bleeding on provocation was present.
|Figure 1: (a) An intraoral solitary pedunculated growth seen on buccal aspect of mandibular left posterior teeth. (b) Pale pink with black pigmentation, firm, nonulcerated surface of the lesion. (c) Occlusal radiograph showing no significant finding. (d) Intraoral periapical radiograph showing no significant finding|
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Preoperatively, complete hemogram showed all blood counts to be within normal limits. An intraoral, periapical, and occlusal radiograph revealed no relevant significant findings [Figure 1]c and d. Full-mouth scaling was done to remove local irritants. Excisional biopsy was planned, and patient's consent was taken for the same.
Adequate local anesthesia and aseptic techniques were employed. The lesion was held with the help of forceps for convenient handling and was separated from the base with the help of diode laser (adjusted at 2W, interrupted mode pulsed at 30 s) [Figure 2]a-c. Postoperatively, no suturing was required. The excised lesion (measured 3 cm × 2.5 cm × 1.5 cm) was stored in formalin and sent for histopathologic examination. The patient presented for follow-up examination 7-days, 2-months, and 12-months postoperatively [Figure 3]a-c. The healing was uneventful, and there was no evidence of recurrence of the lesion.
|Figure 2: (a) Excision of lesion with diode laser at 2W interrupted pulsed mode for 30 s. (b) Surgical site after excision of lesion. (c) Excised tissue|
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|Figure 3: (a) Healing after 7 days. (b) Healing after 2 months. (c) Healing after 12 months|
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Microscopically, hematoxylin and eosin stained section showed parakeratinized stratified squamous epithelium which was atrophic. The connective tissue was composed of dense bundles of collagen fibers. Areas of hyalinized collagen fibers were noted. Few fibroblast and very few blood vessels were seen [Figure 4]. The histopathological findings confirmed the lesion as fibrous hyperplasia.
|Figure 4: H and E showing atrophic parakeratinized stratified squamous epithelium at ×10|
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Case report 2: Focal fibrous hyperplasia on buccal mucosa
A 24-year-old male came with the chief complaint of swelling on the right side buccal mucosa. The swelling was small initially and gradually increased to the present condition over a period of 1 year. The patient had a history of cheek biting in the same region. Extraoral examination revealed apparently bilateral symmetry. On intraoral examination, buccal mucosa revealed a solitary, sessile growth near the corner of the mouth (1 cm × 1 cm) which was oval. The lesion was asymptomatic, pale pink in color with smooth nonulcerated surface and was well-demarcated from surrounding mucosa [Figure 5]. On palpation, growth was soft in consistency, compressible, nontender, and no discharge was observed.
|Figure 5: An intraoral solitary pedunculated growth seen on buccal aspect of mandibular left posterior teeth|
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Excision and microscopic examination were planned, and patient's consent for the same was taken. All blood counts were within normal limits. After giving adequate local anesthesia, the lesion was held with forceps and separated from the base with the help of diode laser (adjusted at 2W interrupted mode pulsed at 30 s) [Figure 6]a and b. No suturing was required, and analgesics were prescribed postoperatively. The excised lesion was stored in formalin and sent for histopathologic examination. The patient was followed up for 6 months. The surgical site appeared healing well, and there was no evidence of recurrence of the lesion [Figure 6]c and d.
|Figure 6: (a) Excision of lesion with diode laser. (b) Excised tissue. (c) Surgical site after excision of lesion. (d) Healing after 6 months|
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The histopathological examination revealed parakeratotic stratified squamous epithelium [Figure 7]a. Underlying connective tissue shows bundles of collagen arranged haphazardly [Figure 7]b. Few endothelial lined blood vessels are noted. The diffuse chronic inflammatory infiltrate is shown in [Figure 7]c. The histopathologic findings confirmed the diagnosis of fibroma.
|Figure 7: (a) H and E showing parakeratotic stratified squamous epithelium at ×10. (b) H and E showing dense hyalinized bundles of collagen fibers arranged haphazardly. (c) H and E showing endothelial lined blood vessels with diffuse chronic inflammatory infiltrate|
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| Discussion|| |
One of the applications of lasers in dentistry is soft tissue surgery and excision of exophytic lesions. Laser instantly disinfects the surgical wound and causes less mechanical trauma to the tissue.  The term exophytic means any pathological growth that projects above the normal contours of the oral surface. The terminology oral fibroma implies a benign neoplasm, but most of these lesions represent reactive FFH due to trauma, local irritation or habits such as lip biting, dental malposition, or dental abnormalities.  The word "inflammatory hyperplasia" is used to describe a huge range of commonly occurring nodular growths of the oral mucosa that histopathologically stand for inflamed epithelium, fibrous, or granulation tissues.  The size of these reactive hyperplastic masses may be greater or lesser, depending on the degree to which one or more of the components of the inflammatory reaction and healing response are exaggerated in the particular lesion.
Fibrous hyperplasia can occur anywhere in the mouth, the most common location is the buccal mucosa along the bite line. The labial mucosa, tongue, and gingiva are the common sites, but according to Zarei et al.,  the lesion is mostly found on the gingiva. The lesion is usually symptomless, most common in the fourth to sixth decade of life, and the male to female ratio is almost 1:2.  According to Thiago de et al.,  mechanical trauma is closely related to the development of FFH indicating that it is a true neoplasm. In the present article, the lesion in the first patient had occurred at the age of 18 years. The high female predilection and a peak occurrence in the second decade and declining incidence after the third decade of life suggested the possibility that female hormones contribute to an increased production and accumulation of collagen by fibroblasts in the presence of a chronic injury.
Localized overgrowths of fibrous tissues are of frequent occurrence in the oral mucosa. Several authors  believed that many of these lesions are true fibromas, whereas Cooke 1952 believed that the cause being local irritation as they are reactive in nature.  They appear in the interdental papilla as a result of local irritation from calculus; caries or restorations with irregular margins. Approximately 60% of irritation fibromas occur in the maxilla, and they are found more often in the anterior region, with 55-60% presenting in the incisor-cuspid region.  Case one in the present report had a history of trauma (needle prick) as an irritating factor over the gingiva in premolar region. The lesion is seen involving the buccal aspect in the mandible which is the less common site.
For a definitive diagnosis, the biopsy specimen was subjected to histopathological examination, and a final diagnosis of fibrous hyperplasia was made. Histologically, FFH is characterized by an unencapsulated, solid, nodular mass of dense and sometimes hyalinized fibrous connective tissue. The surface epithelium is usually atrophic, but may show signs of continued trauma, such as excess keratin, intracellular edema of the superficial layers, or traumatic ulceration.  About 1% of the FFH present stellate and giant cells.  Similar histological features were seen in both the present cases without ulceration in the surface epithelium with the occasional vascular channel and variable inflammatory infiltrate in connective tissue. The fibroblast is apically narrow and elongated and relatively few.
Simple excision is the treatment of choice of FFH and recurrence is unlikely unless the inciting trauma continues or is repeated. 
"Creeping attachment" is a phenomenon that was described by Goldman as the "postoperative migration of the gingival marginal tissue in a coronal direction over portions of a previously denuded root."  Gingival recession of 3 mm was seen with 21 after excision of the lesion which was covered after 12 months which can be attributed due to creeping attachment.
In the second case of fibroma, the differential diagnosis also includes lipoma and mucocele. Lipoma is rarely seen in the oral cavity which has a pale yellow color soft and has slip sign positive on palpation. The appearance of the mucocele is pathognomonic, so the data about the lesion location, history of trauma, rapid appearance, variations in size, bluish color, and the consistency help in the diagnosis of such lesions. The lesion has soft and elastic in consistency which depends on tissue present over the lesion. In certain cases, the histology may reveal the presence of spindle or stellate cells and multinucleated giant cells both of which appear to be of fibroblastic origin. These lesions have been termed by several authors as "giant cell fibroma." , There were no such giant cells noticed histologically.
Both the present cases were treated using diode laser. The advantages of laser application are relatively bloodless surgery, minimal swelling, scarring and coagulation, no need for suturing, reduction in surgical time and less or no postsurgical pain. It also produces less scar tissue contraction and maintains the elastic tissue properties. 
| Conclusion|| |
The treatment modality of the gingival lesion is the removal of local irritants, and conservative complete excision of the lesion with regular follow-up to prevent recurrence. Laser surgery can be considered first choice due to faster action, better hemostasis, less pain, better healing, and less patient discomfort.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]