Gingival Reactive Lesions in Orally Rehabilitated Patients by Free Revascularized Flap




Introduction

Reactive hyperplastic lesion is defined as an excessive proliferation of connective tissue in response to chronic irritation. In the oral cavity, the gingival reactive hyperplastic lesions are pyogenic granuloma (PG), peripheral fibroma, fibroepithelial hyperplasia, peripheral ossifying fibroma, and peripheral giant-cell granuloma. The gingival reactive hyperplastic lesions are commonly described as “epulides,” which is a Greek word, means “on the gingiva.”

Case Report

A 28-year-old female complained of an intraoral swelling in the lower left region. This swelling appeared few months ago. There was a complaint of bleeding on brushing without pain. Regarding her medical and dental history, she was suffering from ossifying fibroma at the left premolar-molar region of the mandible. It was excised and simultaneously rehabilitated by a FRF of iliac crest in 2013.

Diagnosis

The oral examination revealed that an erythematous exophytic sessile lesion with granulomatous appearance and soft-elastic consistency on the lower left retromolar region. This lesion developed after approximately 2 years of the reconstruction by FRF.

Treatment

A presence of mechanical irritation at the lesion area related to the upper second left molar was observed. Radiographic investigation did not show any bone resorption in relation to the lesion.The provisional diagnosis was probably a reactive lesion like PG or peripheral giant-cell granuloma. Routine blood tests, exclusion of dysplasia by cold-blade incisional biopsy, and elimination of contributing triggering factors were done.Smoothing of the cusp tips of the upper left second molar was done in addition to improvement of the oral hygiene.Complete excision of the lesion by CO2 laser was performed under local anesthesia with the help of Allis forceps. The histological examination of the excised lesion confirmed the diagnosis of PG.

Discussion

The management of head and neck cancer has been improved by the introduction of microvascular surgery and FRF reconstruction. The ability of tissue transfer from a distant site enables the surgeons to reconstruct the bone and the soft tissues in a single-staged procedure. The most common donor sites for the reconstruction of maxilla and mandible with FRF are the iliac crest, scapula, radial forearm, and fibula flap.Few complications of FRF in the recipient sites are reported such as vascular thrombosis and second primary squamous cell carcinoma (SCC). Many factors have been proposed to be associated with the development of complications after FRF reconstruction such as patients' age, tobacco use, and prolonged surgical time.There are four suggested hypotheses for the development of SCC as a complication of FRF; which are the presence of cancer cells into the flap during the implementation of tumor ablation, lymphatic dissemination of the original tumor, the existence of another tumor in the donor site before raising the flap, and the exposure of the skin of the flap to a stimulus in the oral environment that is not normally experienced.The etiology of PG is still unclear. About 30–50% of the patients with PG have a history of local trauma. Infection and poor oral hygiene are frequently reported as triggering factors. Also, the hormonal cause may be added to these factors.In a retrospective study by Jané-salas et al., it is suggested adding incorrect or inadequate prosthesis (implant cap or healing cap, poorly adjusted suprastructures, etc.) as possible causative factors. In general, the association of PG with implants is still controversial.In the literature, it is reported a presence of hyperplastic/inflammatory response and formation of granulation tissues around implant abutments that are implemented in orally rehabilitated sites by FRF.Anitua and Pinas stated that the implant-related PG seems to be a response to the same stimulus that triggers tooth-related PG. They confirmed the absence of significant correlation between PG and the marginal bone loss around dental implants.In the presented cases, there is only one case of PG around implants in the rehabilitated sites. The poor oral hygiene was the common trigger factor in all the cases, in addition to trauma from the upper left second molar in the first case, pericoronitis related to a partially erupted lower right third molar in the third case, and the poor stability of an upper RPD in the fourth case.The incidence of recurrence of PG is estimated to be between 2.9 and 8.2%, with a slight increase in cases associated with implants.In the second case, the recurrence was observed probably due to the incomplete elimination of suspected triggering factors. While in the other three cases, the recurrence was not observed. These suggest that the reconstruction by a FRF may be an aggravating condition rather than being a triggering factor of PG.It seems that the triggering factors are aggravated due to the limitation in oral functions, the difficulty of maintaining the oral hygiene measures following the reconstruction surgery, and the difference in nature between the skin of flap and the normal oral tissues when they are subjected to stimuli, resulting in the development of PG in relation to the site of reconstruction rather than in the common sites that are reported in the literature.PG is histologically characterized by a prominent capillary growth in hyperplastic granulation tissue. The presence of little vascular fibrotic septa separating a clustered or medullary pattern of the blood vessels leads sometimes to considering PG as a polypoid form of capillary hemangioma.The histological reports of the third and the fourth cases were not with a definitive diagnosis; therefore, these cases were confirmed to be PG through the consultation of an oral pathologist and the clinical picture.The differential diagnosis of PG includes peripheral giant-cell granuloma, peripheral ossifying fibroma, hemangioma, conventional granulation tissue, and hyperplastic gingival inflammation. In some cases, malignant lesions, such as metastatic carcinoma, melanotic melanoma, or non-Hodgkin's lymphoma, can be a differential diagnosis.

Keywords

Gingival Reactive Lesions, Orally Rehabilitated Patients, Free Revascularized Flap

Author : Gianluca Tenore et al