Patient description
The patient is a 72-year-old Caucasian female with history of T4 N0 M0 squamous cell carcinoma (SCC) of the right floor of mouth and mandible.
Case history
The patient had a right segmental mandibulectomy and fibula-free flap reconstruction 4 years prior to the events of this case report (Fig. 1). Three years following reconstructive surgery, the patient received restorative dental treatment in the form of mandibular dental implants to support an implant retained denture. The implant placement was carried out without incident.
Presentation
The patient presented with extensive gingival enlargement in the floor of the mouth and lingual gingival tissues (Fig. 2). The firm mass extended bilaterally and partially covered the healing abutments of the implants. The buccal gingivae around the implants were not as severely affected. As the mass presented in the same region as the previous SCC, a biopsy was arranged urgently.
The initial overgrowth was subsequently excised under local anaesthetic which leads to a recurrence 4 months later. This recurrence presented as a firm nodular enlargement over the mandibular ridge (Fig. 3). This was also subsequently biopsied to rule out malignancy.
Results of pathological tests and other investigations
The patient underwent a series of biopsies to determine the cause for the gingival enlargement. An incisional biopsy was taken from the floor of the mouth (Fig. 4). The floor of mouth biopsy showed mucosa with overlying fibrin and neutrophil polymorphs. The underlying stroma contained a proliferation of thin-walled vessels and fibrosis and neutrophil polymorphs permeating through the depth of the biopsy. In particular, there was no convincing evidence of residual squamous cell carcinoma either morphologically or on immunohistochemistry. This biopsy came to the conclusion of granulation tissue with inflammation. Gingival enlargement is characterised by excess extracellular matrix proteins, non-collagenous proteins and chronic inflammatory infiltrate dominated by plasma cells.
The second biopsy incisional biopsy (4 months following the first) was taken from the overlying mucosa of the mandibular ridge. This biopsy showed heavily inflamed connective tissue with prominent exuberant granulation tissue. There was no dysplasia or malignancy identified. The overall findings were granulation tissue with inflammation.
A magnetic resonance imaging (MRI) scan was also requested following the second biopsy. The MRI scan found no abnormal signal at the resection/reconstruction site, and there were no enlarged lymph nodes. The radiologist concluded that there was no convincing MRI evidence for disease recurrence.
Treatment
Advice was sought from specialists in oral medicine. It was concluded that the proliferative growth was induced by the patient’s use of amlodipine. The patient’s general medical practitioner was informed and asked to change the patient’s antihypertensive medication. It was then arranged for the remaining enlarged soft tissue mass to be excised under local anaesthetic by the maxillofacial surgeon.
Outcome
The growth was excised uneventfully and without reoccurrence. Implant treatment was recommenced shortly after. The overgrown tissue was removed as it was obstructive for the patient and reduced her ability to undertake adequate oral hygiene around the dental implants. There was an expectation that non-surgical peri-implant therapy would be required, but due to the complete resolution of the gingival overgrowth after excision and alteration of her medication, this was not required. The patient required multiple appointments of oral hygiene instruction to allow the healing abutments to become visible and useable (Fig. 5).
At the implant-retained wax rim and wax try-in stage, the occlusion was initially prescribed as a class 1 incisal relationship with bilateral buccal overjets (Fig. 6). However, this did not provide sufficient lower lip support and tooth display for the patient to be satisfied, especially on her right hand side (Fig. 7). This tooth position was also uncomfortable lingually for the patient due to a reduced tongue space.
Thus, the patient and dentist agreed to accept an altered occlusion. The new prescribed occlusion was balanced with simultaneous contacts anteriorly and posteriorly and mild lingual imbrication to provide the patient a more natural appearance (Fig. 8). This additional lip support was also pleasing to the patient.