|Year : 2014 | Volume
| Issue : 1 | Page : 34-38
Excision of fibroma with diode laser: A case series
Jagadish B. S. Pai1, R Padma1, Divya1, Sachin Malagi1, Vinesh Kamath1, Annaji Shridhar1, Alex Mathews2
1 Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Kodagu, Karnataka, India
2 Department of Prosthodontics, PMS Dental College, Trivandrum, Thiruvananthapuram, Kerala, India
|Date of Web Publication||9-Jun-2014|
Jagadish B. S. Pai
Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Kodagu - 571 218, Karnataka
Source of Support: None, Conflict of Interest: None
Traumatic or irritation fibroma is a common benign exophytic oral lesion that develops secondary to tissue injury. It is the most common benign reactive lesion, and the treatment of choice is surgical excision. The use of lasers in different dental procedures has become very common. The diode laser which was introduced in dentistry since 1999. It is a solid-state semiconductor laser that typically uses a combination of gallium (Ga), arsenide (Ar), and other elements such as aluminium (Al) and indium (In). It has a wavelength ranging from 810 to 980 nm. This energy is absorbed by pigments in the soft tissues and makes the diode laser an excellent hemostatic agent and helps in ablation of soft tissue. Lasers have obvious benefits for all the patients without administering anesthetic shots and that means less time spent in the dental chair. Procedures were performed more conservatively, with less trauma for patients. Laser applications also enable the patient to enjoy a more relaxed dental experience, reducing or diminishing their fears, and resulting excellent post-operation experience for patients. This case series describes the use of diode laser on the excision of fibromas. The excision of fibroma using the diode laser was a quick clinical procedure without bleeding. During the days following surgery, the patient reported no pain or discomfort. The wound healing of the soft tissue was satisfactory and no scarring could be seen in the region of the surgery. The excision of the fibroma with the diode laser is a safe, quick procedure, with minimum postoperative discomfort and complications.
Keywords: Diode laser, fibroma, hemostatic agent
|How to cite this article:|
Pai JB, Padma R, Divya, Malagi S, Kamath V, Shridhar A, Mathews A. Excision of fibroma with diode laser: A case series. J Dent Lasers 2014;8:34-8
| Introduction|| |
Gingival growths are one of the most frequently encountered lesions in the oral cavity. Most of these lesions, such as irritational fibroma, pyogenic granuloma, peripheral ossifying fibroma, and peripheral giant cell granuloma are innocuous and rarely present with aggressive features. In the majority of cases, these lesions are the result of trauma or chronic irritation. 
Traumatic fibroma, also known as irritation fibroma, is a common benign exophytic oral lesion that develops secondary to tissue injury. The traumatic fibroma is among the most common benign reactive lesions. , Fibroma is a result of a chronic repair process that includes granulation tissue and scar formation resulting in a fibrous submucosal mass.  Recurrences are rare and may be caused by repetitive trauma at the same site. This lesion does not have a risk for malignancy.  The most common sites of traumatic fibroma are the tongue, buccal mucosa, and lower labial mucosa.  Clinically, they appear as broad-based lesions, lighter in color than the surrounding normal tissue, with the surface often appearing white because of hyperkeratosis or with surface ulceration caused by secondary trauma. The growth potential of fibroma does not exceed 10-20 mm in diameter.  Irritation fibroma is treated by surgical excision, but the source of irritation and trauma must also be eliminated. Conservative excisional biopsy is curative and its findings are diagnostic; however, recurrence is possible if the exposure to the offending irritant persist. 
The role of lasers in dentistry is well-established in conservative management of oral diseases and also in effectively eliminating it. , The diode laser system has found wide recognition in the areas of lasers as a result of its practical characteristics and is considered as an important tool for a large number of application.  Diode laser has shown satisfactory results when used as an adjunct to conservative methods in the management of inflamed periodontal tissues and peri-implant tissue as well.  According to a Deppe and Horch, the use of diode laser systems for the treatment of oral and maxillofacial diseases has shown efficient removal of premalignant lesion of oral mucosa.  The diode laser which was introduced in dentistry since 1999 is a solid-state semiconductor laser that typically uses a combination of gallium (Ga), arsenide (Ar), and other elements such as aluminium (Al) and indium (In). It has a wavelength ranging from 810 to 980 nm. This energy level is absorbed by pigments in the soft tissues and makes the diode laser an excellent hemostatic agent. Thereby, it is a tool for soft tissue surgeries as well. 
The laser surgery can be used for ablation of lesions, incisional and excisional biopsies, gingivectomies, gingivoplasties, soft tissue tubersosity reductions, and certain crown lengthening procedure.  This case series shows patients with a fibroma on various areas of the oral cavity and followed by diode laser application for the fibroma excision without infiltrated local anesthesia.
| Case Reports|| |
A 28-year-old female patient reported to the department of periodontics complaining of a small enlargement seen in relation to the corner of the mouth, which had caused a hindrance with function of the oral cavity and resulted in esthetic problem as well. Detailed case history was recorded wherein no allergies were reported. Clinical examination showed that there was no lymph node enlargement. Intraoral examination revealed a solitary, sessile lesion in relation to the corner of the mouth measuring 0.5 × 0.5 cm 2 [Figure 1]. Based on its clinical presentation, a provisional diagnosis of fibroma was established.
A 45-year-old female patient reported to the outpatient section of the department of periodontics with a chief complaint of lesion on the gums on the left upper back side of the jaw that had persisted for the past 6 months. History revealed that the lesion initially started as a small lesion which had gradually increased to its present size. It was not associated with pain, but bleeding on provocation was noticed. Intraoral examination revealed a localized sessile lesion on the buccal side of gingiva in relation to the interproximal areas of teeth #25 and #26 measuring about 1.5 cm × 1.0 cm. The lesion also extended on to the marginal and attached gingiva of 26. The lesion was pale pink with a granular surface, soft in consistency, and had a tendency to bleed on provocation [Figure 2]. Radiographic examination of the intraoral periapical (IOPA) region of the left second premolar and first molar and occlusal view of the maxilla revealed no significant findings [Figure 3] and [Figure 4].
|Figure 3: Intraoral periapical radiograph of case 2 showing normal bone pattern|
Click here to view
A 36-year-old female patient was referred to the department of periodontics with a chief complaint of a lesion in midpalatal region of the maxilla since 1 month and difficulty in eating and speaking since 15 days. The patient noticed that growth was small in size initially which had gradually increased to the present size of 2.5-3 cm. Clinical examination revealed an exophytic lesion, that measured 2.5-3 cm in diameter, seen in midpalatal region extending from the mesial aspect of the first premolar to the distal aspect of the second premolar. Lesion was pedunculated, margins were well-defined and regular. It was non-tender on palpation and did not bleed. Consistency of growth was soft to firm and color was pinkish [Figure 5]. Excised tissue is shown in [Figure 6].
After the treatment plan was explained, for all the patients, an informed consent was obtained. After topical anesthetic agent was applied, complete excision of the gingival growth was done utilizing a diode laser unit (Picasso, AMD laser technologies, USA; wavelength 810 nm). Laser parameters were 1 W at continuous mode. The procedure was done in contact mode. Surgical assistant grasped the gingival growth with tissue pliers and retracted with minimum tension. The fiberoptic tip was placed at the periphery and gradually moving around the lesion, continuously firing the laser to dissect out the fibroma completely. The excised tissue was immersed in a 10% formalin solution and sent for histopathological examination. The immediate postoperative view of case 1 and 2 are shown in [Figure 7] and [Figure 8], respectively. One-month postop picture of case 3 is shown in [Figure 9]. There was no bleeding, the patients were comfortable, and no sutures were necessary. Antibiotics were not given postoperatively. Patients were instructed to take analgesics if needed. Patients were recalled after 1 week to evaluate the healing which was uneventful.
| Discussion|| |
Sixty-six percent of irritation fibromas are found in females. It is extremely rare during the 1 st decade of life. Patients with multiple fibromas may represent cases of familial fibromatosis, fibrotic papillary hyperplasia of the palate, tuberous sclerosis, or multiple hamartoma syndromes (Cowden syndrome). Those with a generalized fibrous overgrowth of the gingival tissues are said to have fibrous gingival hyperplasia or gingival fibromatosis. 
In the oral cavity, buccal, labial, and lateral tongue sites account for 71% of all fibromas. The mass may be sessile or pedunculated and usually reaches its maximum size within a few months. Seldom does it exceed 1.5 cm in size. Usually it is an asymptomatic, moderately firm, immovable mass with a surface coloration that is most often normal, but may show pallor due to decreased vascularity, thickened surface keratin, or ulceration from recurring trauma.
Diode laser radiation is an excellent, simple, and safe form of treatment of oral lesions. This procedure is virtually bloodless, postoperative edema, and discomforts are minimal. With laser irradiation, there is less damage to adjacent tissues and better visibility. Compared to conventional methods, laser surgery is less time consuming, less painful, more precise in the treatment of soft tissue lesions, produces less scar-tissue contraction, and maintains the elastic tissue properties.  In the above mentioned case, patient was satisfied with laser surgery since it was a painless procedure both intra- and postoperatively. The mechanisms of diode laser that lead to ablation or decomposition of biological materials are photochemical, thermal, or plasma mediated.  The diode laser has been approved by the Food and Drug Administration for virtually all the soft tissue procedures. These procedures include soft tissue curettage, incisions, pocket debridement, and ablative excisions.
Numerous treatment modalities have been employed for the treatment of gingival fibroma consisting of surgical excision, electrocautery, etc., depending upon the clinical and anatomic considerations. With the advent of lasers in dentistry, lasers like CO 2 , neodymium-doped yttrium aluminium garnet (Nd: YAG), and erbium-doped YAG (Er: YAG) have been used to treat a number of intraoral soft tissue lesions such as papilloma, pyogenic granuloma, hemangioma, etc.  The safety and efficacy of laser systems and especially diode laser is already evaluated for the treatment of facial pigmentation and vascular lesions, fibroma, excision of epulis fissuratum, and gingival hyperplasia. 
Dental lasers offer a number of clinical advantages (especially for soft tissues), including hemostasis (the sealing of local vasculature), the ability to seal nerve endings and lymphatic vessels, reduced postoperative pain and swelling (thus reducing the need for postoperative analgesics/narcotics), reduced bacterial counts, and a minimized need for sutures in most surgical procedures. 
| Conclusion|| |
Case reports described here showed that diode laser treatment was highly effective. Diode laser is used according to the protocol, is a relatively simple and safe method. Easy handling of the fiberoptic tip combined with the properties of diode laser helped in obtaining a clean, thin, and fast cut; often without bleeding or scarring. Because of the sterilizing and tissue growth stimulating properties of the laser, we were able to obtain excellent healing in a few days, even without surgical suturing.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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