|Year : 2013 | Volume
| Issue : 2 | Page : 77-80
Diode laser assisted management of denture induced fibrous hyperplasia
Kamal Sagar, Shruti Tandon, Arundeep Kaur Lamba, Neha Yadav
Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
|Date of Web Publication||3-Jan-2014|
Department of Periodontics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Epulis fissuratum is an overgrowth of intraoral tissues resulting from chronic irritation by ill-fitted dentures. The etiology is persistent mucosal irritation and trauma, mostly seen over alveolar ridges or in vestibular sulcus. This report describes a case of 58-year-old female with soft tissue hyperplastic growth in labial vestibule of upper anterior region. This lesion was removed by using diode laser. The healing was uneventful and no suture, periodontal pack or analgesics were required. The histopathological report confirmed the presurgical diagnosis. The follow-up did demonstrate any relapse of the growth.
Keywords: Denture induced hyperplasia, diode laser, epulis fissuratum
|How to cite this article:|
Sagar K, Tandon S, Lamba AK, Yadav N. Diode laser assisted management of denture induced fibrous hyperplasia. J Dent Lasers 2013;7:77-80
| Introduction|| |
Epulis fissuratum  is the painless hyperplastic growth of gums which is also known as inflammatory fibrous hyperplasia, denture epulis, and denture induced fibrous hyperplasia.  The word epulis can be used to denote any gingival tumor, but it is widely used in association with the growth associated with the edges of denture that irritates the mucosa which results in its formation. Depending on the intensity of trauma, the surface may become ulcerated.  The epulis fissuratum caused by chronic irritation from poorly adapted prostheses presents itself as a connective tissue tumor closely related to and in many case indistinguishable from fibroma.  Although the growth can be attributed to varying factors, trauma and irritation are important etiological factors and lesion arises in areas of persistent mucosal injury. Clinically, it presents a raised lesion, commonly sessile with a smooth surface and coloration similar to that of normal mucosa. The size of the lesion may vary from localized hyperplasia less than 1 cm in size to larger lesions that involve most of the length of vestibule almost entire length of tissue around a denture.  It is of three types namely acanthomatous, ossifying, and fibromatous depending upon their metastatis potential and tissue invasion.
It is more commonly seen in middle age and older females. It can appear in either the mandible or maxilla, but is more commonly present on the labial aspect of alveolar ridge. It can be superinfected by fungus. An epulis fissuratum not associated with denture can be a diagnostic feature of Crohn's disease.  Treatment modalities includes topical application of antifungal agents, surgical excision of the entire lesion and fabrication of new denture. Although elimination of trauma/irritation and inflammation can lead to modest decrease in the lesion size, conservative excisional surgery is the definitive treatment. Recurrences are rare as long as the sources of trauma and/or the patient's habits are eliminated and the appropriate prosthetic reconstruction is provided. ,
Various lasers have been used earlier for the removal of the hyperplastic lesion. These include carbon dioxide laser, neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, and erbium, chromium: Yttrium, scandium, gallium, garnet (Er, Cr: YSGG). Lasers like the CO 2 and Nd: YAG has been used for their soft tissue ablation capacity, but they cause profound thermal effects on target tissues.
This case report describes a case where epulis fissuratum was treated with diode laser. Diode laser has been reported to be effective for excision of intraoral soft tissue lesions and mucogingival surgeries.  It offers the advantages like minimal intraoperative bleeding, thus offering a clear surgical field and reduced surgery time, disinfection of surgical site, faster healing without scarring, and minimal or no postoperative pain. 
| Case Report|| |
A female patient of 58 years of age reported to the Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi with chief complaint of tissue overgrowth in the upper labial vestibule for last 3 years [Figure 1]. On intraoral examination, soft tissue hyperplastic growth was seen extending from canine to canine on the anterior alveolar ridge of maxillary arch. The growth was localized, pink, fibrous, sessile in nature with irregular borders present over the edentulous anterior maxillary ridge. The past dental history of patient revealed that she has been using this denture since the time she has been edentulous which was about 5 years [Figure 2] and [Figure 3]. Systemic examination revealed no significant abnormality. A provisional diagnosis of epulis fissuratum was made and excision biopsy was planned using diode laser.
The etiology of the lesion could be attributed to prolonged usage of the ill-fitted upper denture which had led to chronic irritation of the tissues of the denture bearing area and an area of soft tissue hyperplasia of approximate dimensions of 5.8 mm × 15.4 mm had developed [Figure 4]. An excisional biopsy of the lesion was planned, using a diode laser, under local anesthesia. The area surrounding the lesion was infiltrated with local anesthetic (lignocaine 2% with adrenaline 1:80,000). The lesion was removed using diode laser (Picasso, AMD LASERS® , Indianapolis, USA) with 810 nm wavelength in contact mode and pulse of 30 ms duration and 30 ms interval with initiated tip at 1.5 W power [Figure 5] and [Figure 6]. Excised lesion was put in 10% formalin and sent for histopathological examination. The operative field was irrigated with sterile normal saline. The wound was allowed to heal without sutures, periodontal pack and stent [Figure 7]. Patient was advised to avoid hot and spicy foods for 3 days. No medications were prescribed. Healing was assessed at 1 week and was found to be uneventful [Figure 8].
Light microscopy with hematoxylin and eosin (H and E) staining revealed parakeratinized stratified squamous epithelium. The underlying connective tissue showed dense bundles of collagen fibers and dilated blood vessels [Figure 9],[Figure 10]a dn [Figure 11].
|Figure 11: H and E section at ×40 magnification showing collagen bundles and dilated blood vessels|
Click here to view
| Discussion|| |
The inflammatory fibrous hyperplasia, is also known as epulis fissuratum or denture fibrosis.  It is a generalized hyperplastic enlargement of mucosa and fibrous in alveolar mucosa and vestibular area in relation to ill-fitted dentures. It is more common in middle age group females with an incidence of 3.5% in males and 4.4% in females according to an epidemiology survey.  The etiology of epulis fissuratum is most commonly attributed to an ill-fitting denture which results in excessive pressure on the oral tissues which in turn increases keratinization and proliferation of connective tissues. The differential diagnosis of epulis fissuratum includes giant cell fibrous epulis, adamantinoma, Burkitt's lymphoma, and fibrosarcoma.  Careful clinical examination and biopsy are the main tools for the diagnosis of epulis.  Mainly there are three treatment modalities available are conventional excisional biopsy, electrosurgery, and laser technique which depends upon the size and extension of the lesion. , When the size is minimal, electrosurgery can provide a good result. If the size is moderate, a simple excision suffices but with due consideration for obliteration of vestibular depth on complete excision.
Laser therapy offers the advantage of minimal bleeding, instant sterilization of surgical site, reduced bacteremia, decreased trauma, minimal postoperative swelling, and minimal postoperative pain. Additionally there is little wound contraction and minimal scarring.
| Conclusion|| |
Laser is the latest treatment modality available for any dental soft tissue growth. They have many advantages over conventional techniques like allowing complete removal without excessive bleeding and scarring. They are much better in terms of healing and postoperative pain. The advantage of excision with laser is that they provide a bloodless field, making visibility better. Diode lasers are an excellent alternative to conventional modalities. The case presented demonstrates the ease of use along with better predictable results associated with the use of diode laser.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]