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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2011  |  Volume : 29  |  Issue : 3  |  Page : 264-269
 

Laser-assisted gingivectomy in pediatric patients: A novel alternative treatment


1 Department of Periodontics, Jodhpur Dental College and General Hospital, Jodhpur National University, Jodhpur, Rajasthan, India
2 Department of Pedodontics and Preventive Dentistry, Jodhpur Dental College and General Hospital, Jodhpur National University, Jodhpur, Rajasthan, India
3 Formerly Dean, V. S. Dental College and Hospital, Bangalore, Karnataka, India
4 Department of Periodontics, V. S. Dental College and Hospital, Bangalore, Karnataka, India

Date of Web Publication10-Oct-2011

Correspondence Address:
S Bhatnagar
C/o Dr. Sudhanshu Bhatnagar, 40, Hospital Road, C - Scheme, Jaipur, Rajasthan
India
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DOI: 10.4103/0970-4388.85839

PMID: 21985887

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   Abstract 

Gingival enlargement is quite a common pathology in pediatric patients and may be inflammatory, noninflammatory, or a combination of both. Idiopathic gingival fibromatosis, although rare, is a slowly progressive benign enlargement that affects the marginal gingiva, attached gingival, and interdental papilla. The fibromatosis may potentially cover the exposed tooth surfaces, causing esthetic and functional problems. The treatment of gingival fibromatosis is essential because it causes difficulties with mastication, speech problems, mispositioning of teeth, esthetic effects, and psychological difficulties for the patient. Traditional gingivectomy procedures have been a challenge for dentists who confront issues of patient cooperation and discomfort. In the last decade, laser procedures in oral cavity had shown many optimum effects in both hard and soft tissue procedures. Laser soft-tissue surgery has been shown to be well accepted by children. The following case report describes a laser-assisted gingivectomy procedure performed on a 13-year-old female.


Keywords: Diode laser, gingival enlargement, gingivectomy, topical anesthesia


How to cite this article:
Gontiya G, Bhatnagar S, Mohandas U, Galgali S R. Laser-assisted gingivectomy in pediatric patients: A novel alternative treatment. J Indian Soc Pedod Prev Dent 2011;29:264-9

How to cite this URL:
Gontiya G, Bhatnagar S, Mohandas U, Galgali S R. Laser-assisted gingivectomy in pediatric patients: A novel alternative treatment. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2014 Sep 20];29:264-9. Available from: http://www.jisppd.com/text.asp?2011/29/3/264/85839



   Introduction Top


Gingival enlargements are quite common findings and may be inflammatory, noninflammatory, or a combination of both. Idiopathic gingival hyperplasia is a rare condition of undetermined etiology described variously as fibromatosis gingivae, gingivostomatitis, hereditary gingival fibromatosis, idiopathic fibromatosis, familial elephantiasis, and diffuse fibroma. Diffuse gingival enlargement is also found to be associated with syndromes such as Cross syndrome, Rutherford syndrome, Ramen syndrome, and Zimmerman-Laband syndrome. [1]

Idiopathic gingival fibromatosis is a slowly progressive benign enlargement that affects the marginal gingiva, attached gingiva, and interdental papilla. The fibromatosis may potentially cover the exposed tooth surfaces, causing esthetic and functional problems, and may distort the jaws in extreme cases. The condition has been classified into two forms: the first is the nodular form that is characterized by the presence of multiple tumors in dental papillae, and the other form that is symmetric results in uniform enlargement of gingiva and represents the most common type. [2] The condition may sometimes be associated with physical developmental retardation and hypertrichosis. [3] Although gingival tissue may appear normal at birth, hyperplastic gingival fibromatosis may become evident with the eruption of primary or permanent dentition, suggesting a trauma-induced tissue reaction during the eruption.

The treatment of gingival fibromatosis is essential because it causes difficulties with mastication, speech problems, mispositioning of teeth, aesthetic effects, and psychological difficulties for the patient. The appropriate time of the removal of gingival enlargement varies. Emmerson recommended that the best time is when all the permanent teeth have erupted. [4] Traditional gingivectomy procedures have been a challenge for dentists who confront issues of patient cooperation and discomfort.

The treatment of pediatric patients must involve minimal operative and postoperative discomfort. In the last decade, laser procedures in oral cavity had shown many optimum effects in both hard and soft tissue procedures. Laser soft-tissue surgery has been shown to be well accepted by children. The following case report describes a laser-assisted gingivectomy procedure performed on a 13-year-old female.


   Case Report Top


A 13-year-old girl with the chief complaint of misaligned teeth reported to the outpatient department of our institute. An intraoral examination revealed a moderate-to-severe gingival overgrowth [Figure 1],[Figure 2],[Figure 3] of a firm, dense, and fibrotic consistency that involved palatal and lingual surfaces of both the maxillary and mandibular arches (posterior teeth). The occlusal and incisal thirds of teeth were barely visible on the palatal aspect, as they were buried deep within the growth. There was no hypertrichosis. Nothing in the patient's medical and family history seemed related to the condition. The patient was not receiving any antiepileptic, antihypertensive, or immunosuppressive medications that could contribute to the gingival enlargement. Her weight and height were considered to be within normal limits. She did not appear to have any mental impairment. The peripheral blood results were normal and thus correlated with an absence of any history of systemic disease.
Figure 1: Anterior palatal view

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Figure 2: Second quadrant palatal view

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Figure 3: Lingual view of third quadrant

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Histopathologic findings

Histologically, gingival hyperplasia occurs mainly due to an increase in the thickening of mature collagen bundles in the connective tissue stroma. [5] The nodular appearance can be attributed to the thickened para-hyperkeratinized epithelium. [6]

The marginal gingiva of this patient excised from the buccal and interdental areas during surgery and was sent for the histopathologic examination. Sections showed a para-hyperkeratinized, hyperplastic stratified squamous epithelium, with the underlying fibrous connective tissue showing dense wavy bundles of collagen fibers containing numerous fibrocytes and fibroblasts. Some sections in the connective tissue exhibited infiltration of chronic inflammatory cells, a few scattered multinucleated giant cells, and areas of neovascularization that had red blood corpuscles within the lumen of the blood vessels. On the basis of all these findings, a provisional diagnosis of an idiopathic gingival enlargement was made.

Treatment

When the enlargement is minimal, a good scaling of teeth and homecare may be all that is required to maintain good oral health. As the excess tissue increases, appearance and function indicate need for surgical intervention. [7] The patient initially underwent phase 1 periodontal therapy that comprised scaling,root planing andoral hygiene instructions. The most efficacious method of removing large quantities of gingival tissue, particularly when there has been no attachment loss and all the pocketing is false, is the conventional external bevel gingivectomy. In this case, the treatment consisted of sextent-by-sextent external bevel gingivectomy [Figure 4] and [Figure 5]. The patient was required to take analgesics for 2 days postoperatively.

Tissue healing after 2 weeks of conventional gingivectomy was uneventful. But the gingival contour remained bulky and scalloping was not regained. It was then decided to contour the gingival tissue by using the diode laser fiber optic technology (SIROLaser® , Sirona, Bensheim, Germany). Diode laser units are characterized by their compact dimensions and relatively low cost. The patient was instructed to wear protective goggle, and local anesthesia was given using the topical spray technique [Figure 6].
Figure 4: Immediate post operative palatal aspect

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Figure 5: Immediate post operative second quadrant palatal aspect

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Figure 6: Patient wearing protective goggles during laser treatment

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Bleeding points were marked with the help of the Crane-Kaplan pocket marker. A laser handpiece was activated, and gingival tissue was removed in a sweeping stroke joining the bleeding points [Figure 7]. A high-volume suction device was used during the procedure. The patient was recalled the next day and on day 3 and day 7 for the site examination. Postoperative healing was uneventful. She did not complain of post-operative pain or discomfort; there was no complaint of postoperative bleeding also. Although the patient complained of mild discomfort at the time of pack removal and wound irrigation on day 1 and day 3, pain was recorded on a visual analog scale [Figure 8]. On day 1, the patient marked it as 4 (uncomfortable); and on day 3, between 2 and 1, thus denoting it as mild annoying pain.
Figure 7: Immediate laser post operative

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Figure 8: Visual analogue scale for pain

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The same procedure with the laser handpiece was repeated with a lingual aspect of 34, 35, 36, 37 and 44, 45, 46, 47 [Figure 9]. No periodontal pack was placed, and there was no bleeding and discomfort immediately after the procedure. The patient was recalled on day 3 and day 7. She reported no pain, and thus there was no need to take analgesics as well. On the visual analog scale, she marked the pain between 0 and 1. Gingival contour and scalloping were regained.
Figure 9: Immediate post operative lingual view of third quadrant

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The patient also had an operculum covering a distal aspect of 37 and 47 [Figure 3]. The operculectomy of gingival tissue over and around mandibular molars is often needed. Laser-assisted operculectomy was done for this patient under topical anesthesia for both the teeth in one sitting [Figure 10]. The patient was comfortable after the procedure, and 1-week postoperative healing was fairly good [Figure 11].
Figure 10: Immediately after laser operculectomy

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Figure 11: First week post operative after operculectomy of 47

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The patient was recalled after 1 month for checkup [Figure 12] and [Figure 13] and is currently undergoing orthodontic treatment for the anterior open bite. She is under follow-up observation.
Figure 12: One month post operative palatal aspect

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Figure 13: One month post operative lingual aspect

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   Discussion Top


Idiopathic gingival fibromatosis may be congenital or hereditary. Although the genetic mechanism is not well understood, the majority of the authors who reported cases attributed the condition to hereditary factors. The mode of transmission is mainly autosomal dominant. Histopathologically, the bulbous increased connective tissue is relatively avascular and has densely arranged collagen fiber bundles, numerous fibroblasts, and mild chronic inflammatory cells. The overlying epithelium is thickened and acanthotic and has elongated rete ridges. [8]

Alternatives for gingival tissue removal include the use of a scalpel, electrosurgery, and/or lasers. The traditional surgical approach utilizing a scalpel blade exhibits the disadvantage of eliciting bleeding. Alternatively, electrosurgery has been utilized effectively to excise gingival tissue while simultaneously providing adequate hemostasis and is therefore preferred by many restorative dentists. Heat generation with this technique, however, occurs to a degree where an irreversible damage to the alveolar crest may result. [9] Lasers offer the potential of increased operator control and minimal collateral tissue damage. Diode lasers, specifically, operate at a wavelength that is easily absorbed by the gingival tissues while posing a little risk of damaging the tooth structure.

The laser wound in the soft tissue has unique characteristics that are not found in any other surgically created wound. The result is a very superficial wound; it is not a burn, and the thermal damage caused by the irradiation is only a few tenths of a millimeter in depth. The cellular disintegration caused at the impact does not allow for the release of chemical mediators of inflammation, which leads to a reduced acute inflammatory response compared with scalpel-created wounds. A thin layer of denatured collagen on the surface of the wound also reduces the degree of tissue irritation from oral fluids and serves as an impermeable dressing. Additionally, there is very little wound contraction. [10]

The prime rationale for the use of laser in this pediatric patient was to give a painless and bloodless substitute for the scalpel-facilitated surgical procedures. It also reduces the perception of fear and anxiety in the patient, thus instilling a positive attitude toward the dental treatment. Lasers also reduced the use of local anesthesia, suturing, periodontal dressing, and postoperative medications. It also reduces the effective chairside time, thus leading to more cooperative behavior of the pediatric patient.

These qualities have led to better patient acceptance for laser surgery and fewer postoperative adverse sequelae. The result exhibited in this case is in agreement with Romanos and Nentwig, who suggested that the laser treatment results in minimal or no postoperative swelling with less discomfort. [11] This also agrees with a study that compared the use of laser in treating gingival enlargement with the conventional method and showed good results. [12] Thus, it may be considered as a novel alternative to the other well-established treatment modalities in pediatric patients.

 
   References Top

1.Bakcen G, Scully C. Hereditary gingival fibromatosis in a family of Zimmerman-Laband syndrome. J Oral Pathol Med 1991:20;457-9.   Back to cited text no. 1
    
2.Bozzzo L, Almedia OP, Scully C, Akfred MJ. Hereditary gingival fibromatosis, report of an extensive 4 generation pedigree. Oral Surg Oral Med Oral Path 1998:86;304-7.  Back to cited text no. 2
    
3.Synder CH. Syndrome of gingival hyperplasia, hirsutism and convulsions. J Pediatr 1965:67;499-502.  Back to cited text no. 3
    
4.Emmerson TG. Hereditary gingival hyperplasia. A family pedigree of four generations. Oral Surg Oral Med Oral Path 1965:19;1-4.  Back to cited text no. 4
    
5.Zachin SJ, Weisberger D. Hereditary gingival fibromatosis - report of a family. Oral Surg Oral Med Oral Pathol 1961;14:825-35.  Back to cited text no. 5
    
6.Brightman VJ. Benign tumours of the oral cavity including gingival enlargement. In Burkets of Oral Medicine, Diagnosis and Treatment Plan. 8 th ed. JB Lippincott, Philadelphia 1984. p. 367-71.  Back to cited text no. 6
    
7.Ramer M, Marrone J, Stahl B, Burakoff R. Hereditary gingival fibromatosis: Identification, treatment and control. J Am Dent Assoc 1996:127;493-5.   Back to cited text no. 7
    
8.Takagi M, Yamamoto H, Mega H, Hsieh KJ, Shioda S, Enomotos S. Heterogeneity in the gingival fibromatosis. Cancer 1991;68:2202-12.   Back to cited text no. 8
    
9.Kalkwarf KL, Krejci RF, Edison AR, Reinhardt RA. Lateral heat production secondary to electrosurgical incisions. Oral Surg Oral Med Oral Pathol 1983;55:344-8.  Back to cited text no. 9
[PUBMED]    
10.Rossmann JA, Cobb CM. Lasers in periodontal therapy. Periodontol 2000 1995;9:150-64.  Back to cited text no. 10
    
11.Romanos GE, Nentwig GH. Present and future of lasers in oral soft tissue surgery. Clinical application. J Clin Laser Med Surg 1996;14:179-84.  Back to cited text no. 11
[PUBMED]    
12.Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM. Study comparing the efficacy of laser excision versus conventional gingivectomy in the management of drug-induced gingival overgrowth. J Clin Periodontol 2006;33:677-82.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


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