Diagnostic Information

Although the gingival enlargement had been present for about 10 years, recently, it had increased in size. The gingival protuberance was only slightly tender when she occluded on the soft tissue. She was unaware of bleeding, purulence, or surface changes at this site, but the adjacent teeth were slightly mobile and sensitive during mastication. The patient wore an interim, maxillary partial prosthesis that was ill fitting. The clasp adjacent to the gingival mass had been removed several years ago, so that she could increase the longevity of the temporary appliance. Previously, she had sought treatment for the lesion, but she was informed that it represented excessive bone growth and did not require removal.

Figure 1. Partially edentulous occlusion with a well-demarcated gingival enlargement on the right anterior gingiva.

Medical History Review of the patient’s medical history revealed that she was healthy, except for occasional episodes of chronic sinusitis. She had no known allergies to foods or medications, although she suspected that she had some environmental allergies to molds and pollen. Infrequently, she took ibuprofen when she had sinus or stress-induced headaches. Clinical Examination Findings

Figure 2. Labial view of the sessile gingival nodule with a smooth surface.

Figure 3. Occlusal view of the gingival mass, exhibiting displacement of the maxillary lateral incisor and canine.

Radiographic Findings A periapical radiograph demonstrated an irregular, radiopaque focus within the soft tissue mass between the lateral incisor and canine. (Figure 4) The periodontal ligament space was widened slightly on the mesial aspect of the canine, while dentinal caries was detected on the distal surface of this tooth. A modified periapical view showed a crescent shaped opacity that was mesial and distal to the canine. (Figure 5) Except for mild loss of alveolar crestal bone height, no other bony findings were identified.

Figure 4. Periapical radiograph of the maxillary incisor-canine region, showing an irregular opaque focus within the soft tissue enlargement.

Figure 5. Modified occlusal radiograph of the maxillary incisor-canine region, exhibiting crescent-shaped opacities in the interproximal soft tissue adjacent to the canine.

Incisional Biopsy and Photomicrographs Due to the significant size of the lesion, an incisional biopsy was performed under local anesthesia for a definitive diagnosis. A crescent-shaped tissue sample was obtained adjacent to the canine with extension to the alveolar crestal bone. (Figure 6) The surgical incision was not obvious clinically with normal lip movements and only direct pressure to the site was needed for hemostasis.

Figure 6. Incisional biopsy of the gingival mass.

Microscopic examination revealed a wedge of gingiva, consisting of cellular fibrous connective tissue that contained foci of mineralized product. (Figure 7) Both trabeculae of bone (Figure 8) and globules of cementum-like material (Figure 9) were interspersed within the stroma. Occasionally, multinucleated giant cells were seen in close proximity to the mineralized tissue.

Figure 7. Low power photomicrograph showing surface epithelium and islands of mineralized material in the underlying connective tissue.

Figure 8. Medium power photomicrograph showing bony trabeculae within a background of moderately dense fibrous connective tissue.

Figure 9. High power photomicrograph showing droplets of cementum-like material within the connective tissue.

One Month Follow-up The patient delayed treatment because she was anxious about the surgical procedure and was concerned the she would prematurely lose additional anterior teeth. She returned in one month because the lesion was increasing in size (Figure 10) with increased erythema and bleeding at the biopsy site. (Figure 11)

Figure 10. Labial view, one month following the incisional biopsy.

Figure 11. Occlusal view, one month following the incisional biopsy.