Nodule of Inflammatory Fibrous Hyperplasia in the Lower Anterior Region: A Case Report

INTRODUCTION

Nodules of inflammatory fibrous hyperplasia also called gingival fibroma are very common lesions that occur over a wide age range.^1,2 It is a response to trauma from teeth or dental prosthesis which was first discovered in 1846 as fibrous polyp or polypus. Here the term fibroma is not used to covey a neoplastic origin. Gingival fibroma remains the most common mucosal mass submitted for biopsy.^3,4,5 Typically the mass is painless and twice more likely to develop in females than males. It more often involves the anterior maxillary interdental papilla.¹ Here we report a case of a gingival fibroma in a 50 year old male patient.

CASE REPORT

A 50 years old male patient reported with a chief complaint of painless swelling in the lower anterior right tooth region for 4 months. The swelling was insidious in onset and increased to the present size. The patient gives no history of pain. The general health of the patient was normal. The patient has no significant medical history. On intraoral examination, the swelling was located in the right anterior region with respect to 42 and 43. The mass measured in size of about 2.0 X 2.0 cm. [Figure 1] It had characteristic features of a sessile base and normal mucosa colour and hard in consistency. Surgical excision of the mass was performed [Figure 2] and the mass was sent for biopsy [Figure 3]. The histological evaluation of the specimen revealed an unencapsulated, solid, nodular mass of dense and hyalinized fibrous connective tissue that is arranged in haphazard fascicles. A mild chronic inflammatory infiltrate is present. The surface epithelium is hyperkeratotic, hyperplastic. Thus based on the clinical and histopathological findings a final diagnosis of gingival fibroma was made.

DISCUSSION

The common localized intraoral gingival lesions include gingival fibroma, peripheral ossifying fibroma, focal fibrous hyperplasia, pyogenic granuloma, inflammatory hyperplasia, and peripheral giant cell granuloma. Among these, gingival fibroma or irritational fibroma is the most common response of submucosa secondary to trauma.^6,7

Aetiology: The most common cause of gingival fibroma is a source of irritation which may be a tooth or dental prosthesis. Some lesios may also arise as a result of irritation due to plaque microorganisms and other local irritants. Bakers and Lucas hypothesized that gingival fibromas exhibit a pattern of collagen arrangement depending on the site of the lesion and the amount of irritation. There are two types of patterns namely radiating pattern and circular pattern. When there is a greater degree of trauma, the radiating pattern of collagen arrangement appears in sites which are immobile in nature (e.g., palate), while lesser trauma induces circular pattern of collagen arrangement and it occurs in sites that are flexible in nature (e.g., cheeks).^8,9

Clinical features: Gingival fibroma occurs at any age involving more often the tongue, gingiva, and buccal mucosa which is characterized by a slow, painless growth accumulated over months or years.^8,10 The mass is usually localized with a sessile or pedunculated base and is smaller than 1.5cm at its largest diameter. The mass is characterized by a smooth surface and a hard consistency usually with normal colored mucosa. Furthermore, it occurs commonly in the anterior maxillary interdental papilla region.^8,11 In edentulous or partially edentulous patients these lesions can occur on the alveolus concerning ill-fitting prosthesis.¹²

Histopathology: Histology shows hyperplastic and keratinized epithelium overlying nodular fibrous connective tissue. The extent of collagenisation and vascularity of the body of the lesion depends on its maturity and the presence or absence of inflammation. The fibroblast component is bland and in most cases comprises fine spindle-shaped cells. However, in some cases, the fibroblasts may be large and stellate in morphology, and occasionally multinucleated.^1,13

Management: The first step towards the treatment of gingival fibroma is the elimination of etiological factors which may be scaling of the adjacent tooth, replace the ill-fitting dentures, or occlusal adjustments in case of a sharp tooth. Following the elimination of the etiological factor complete surgical excision is performed along with involved periodontal ligament and periosteum to minimize the possibility of recurrence.

CONCLUSION

Gingival fibroma is a very commonly occurring gingival lesion that has several differential diagnoses such as Periodontal abscess, Keloids, Pyogenic Granuloma, Angiofibroma, Neurofibroma, Gorlin Syndrome (Nevoid Basal Cell Carcinoma Syndrome), Epulis Fissuratum, Squamous Cell Carcinoma Or Verrucous Carcinoma. As most of these lesions are reactive, a definite diagnosis is required to ensure that appropriate management plans are enacted, including removal of the initiating factors. Meanwhile, it is also important to keep rare diagnoses in mind as some lesions possess significance beyond the gingiva

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