NaSSiP 6

The International Online Seminar Series on Periodontology in conjunction with

KnE Medicine Scientific Seminar
Volume 2022

Research article

Management of Fibrous Epulis of Anterior

Maxillary Teeth: A Case Report of a
1.5-Year-Old Lesion
Mentari Salma Nurbaiti1 and Kwartarini Murdiastuti2*
1
Periodontic Specialist Program, Faculty of Dentistry, Gadjah Mada University, Yogyakarta,
Indonesia
2
Department of Periodontology, Faculty of Dentistry, Gadjah Mada University, Yogyakarta,
Indonesia
ORCID
Kwartarini Murdiastuti: https://orcid.org/0000-0001-5128-0944
Mentari Salma Nurbaiti: https://orcid.org/0000-0002-1423-2190

Abstract.
Background: Epulis is a gingival hyperplasia (tumor-like) that originates from periodontal
connective tissue. It can be caused by many factors such as a chronic local irritation.
Epulis that grows on the anterior maxilla area can be inconvenient because it disrupts
Corresponding Author: the aesthetics and also the function of the teeth. Therefore, it has to be completely
Kwartarini Murdiastuti; email: removed by surgery.
[email protected] Objective: To correct the condition of epulis by excision and gingival contouring for
aesthetic need.
Published: 25 April 2022
Case Report: A 30-year-old female patient presented with a complaint of a mass on the
Publishing services provided by gum of the anterior teeth on her upper jaw that made her unconfident to smile. The
Knowledge E mass had been there for 1.5 years.
Conclusion: The condition of epulis can be corrected by excision procedure and by
authors. This article is
distributed under the terms of
removing the cause of the epulis (sub-gingival calculus). The aesthetic result can be
the Creative Commons obtained by gingival contouring after the excision.
Attribution License, which
permits unrestricted use and
Keywords: epulis, fibrous epulis, gingival hyperplasia, excision, gingival contouring,
redistribution provided that the gingival biopsy
original author and source are
credited.

Selection and Peer-review under

the responsibility of the NaSSiP
1. Introduction
6 Conference Committee.
Swelling on the gingiva is usually lead to epulis diagnosis. Epulis is a gingival hyperplasia
(tumor-like lesion of the gingiva). Lesions are swelling that is appear as a response to
a chronic or recurring tissue injury, that will stimulate excessive response from the
tissue [1,2]. Epulis is categorized into three main type that usually found: granulomatous
epulis, fibrous epulis, and giant cell epulis [3]. Histologically, epulis contain of bundles
of collagen fibers covered with keratinized squamous cell epithelium. Inflammatory
infiltrate and ulcerated area will be seen also if the lesion get trauma (from chewing or
brushing) [4].

How to cite this article: Mentari Salma Nurbaiti and Kwartarini Murdiastuti, (2022), “Management of Fibrous Epulis of Anterior Maxillary Teeth: A
Case Report of a 1.5-Year-Old Lesion” in The International Online Seminar Series on Periodontology in conjunction with Scientific Seminar, KnE Page 333
Medicine, pages 333–342. DOI 10.18502/kme.v2i1.10866
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Interdental papilla is the site that fibrous epulis usually appears. This happens as
a result from local irritation (calculus, plaque, caries, radices, or irregular margins of
restorations) [4]. The other causes of fibrous epulis are hormonal changes, pregnancy,
and drugs (such as phenytoin) [2]. The lesion can be pedunculate or sessile [5]. The
treatment for this condition includes excision of the lesion and gingival contouring [2].
In this paper, we will present a case of fibrous epulis on maxillary gingiva that is quite
big for fibrous epulis on interdental papilla caused by subgingival calculus.

2. Case Report

A 30-year-old female patient came to the Prof. Soedomo Dental Hospital, complained
about a mass on her gum of anterior teeth that made her unconfident when smiling. The
mass had been there for 1,5 years. The patient felt no pain at the mass, the mass kept
growing to its current state for 1 year. The mass stopped growing in the past 6 months.
The patient last scaling treatment was 6 years ago. Two years ago, patient went through
exodontia for her left first molar in mandible, it was not pulled out completely and patient
was in pain during the exodontia. Couple days after the exodontia there was an abscess
on the exodontia site that still had remaining radices. The patient was prescribed with
analgesics and antibiotics by her dentist. The patient did not have a habit of smoking
or consuming alcohol, and denied having a history of systemic illness or allergies, but
her mom had history of leukemia and already healed.
Extraoral examination, there were no abnormalities. In intraoral examination, there
was supra and subgingival calculus in all regions. Enlarge gum on labial side left lateral
incisor sized 14 x 10 x 2 mm, reddish, un-stippling, fibrotic, well-defined (Figure 1)

Figure 1: Intraoral photo shows intraoral condition on patients first visit. The gingival hyperplasia can be
seen on the labial side of left lateral incisor with calculus sub and supra gingiva almost in all region of the
mouth (Source: Author’s documentation).

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Figure 2: Panoramic radiograph taken on first visit, no bone loss around the left lateral incisor of the maxilla.

Based on all of the examinations on first visit it was concluded that the diagnosis
of this case was gingival enlargement with the suspect of fibrous epulis, caused by
local irritation from subgingival calculus. The prognosis was good considering patient
motivation and age.
The treatment plans were initial phase therapy by scaling and root planning also
dental health education to the patient. Patient were also given the prescriptions for
taking panoramic radiography and also complete routine blood test. Blood test were
taken because the history of the family and also the history of the previous dental
treatment (Figure 3).
From the panoramic radiograph could be seen that there was no severe bone loss
on the area of the left lateral incisor of maxilla. The blood test also shown normal, only
some are higher and lower than the normal value due to the inflammation condition
that was going on in patient’s body.
On patient’s second visit, excision of the epulis was performed. Before beginning
the surgery, the patient was given explanations about the procedure. The patient
agreed and signed the informed consent. Patient were healthy, already got the second
dose of the covid19 vaccine and have normal vital sign. The procedure was done
inside the negative chamber and the operator and the assistants were using level 3
personal protectiveequipment that was a necessity during this pandemic. Instruments
and materials that would be used were prepared (diagnostic set, scalpel, blade no
15c, needle holder, scissors, nylon thread, gracey’s curettes, orban knife, Kirkland knife,
cytoject, local anaesthesia, povidone iodine, saline water, resopack)
Disinfection of the surgical area was done first using povidone iodine, before adminis-
tering the local anaesthesia. The anaesthesia was done on the labial area of the surgical
site (Figure 4). After that, nylon thread was used to hold the epulis so the margin can
be seen as a guide for excision. Excision of the epulis was done using scalpel until
the entire tissue of the epulis separated from the healthy gingiva, and excision done

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until the stalk detach (Figure 5). The tissue then was put inside 10% of formalin and
sent to the Pathology Anatomy Laboratory (Figure 9). As the epulis was removed, it was
clearly shown that there was sub gingival calculus on the interdental of lateral incisor
and canine. Root planning was done using gracey’s curettes. After that, the gingival
contouring was done using Kirkland and orban knives around the teeth until the crown
was fully shown (Figure 6). Irrigation of the surgical site using saline water. Before
putting on resopack, gingival of the surgical site was adapted so it could make a new
attachment (Figure 7). Resopack was placed on the surgical area and covering all the
excised gingival (Figure 8).

Figure 3: Complete routine blood test result.

The patients were prescribed with 500mg amoxicillin every 8 hours for 5 days, 500
mg of mefenamic acid every 8 hours for 5 days, and chlorhexidine gluconate 0,2% twice
daily for 4 weeks. After surgery instructions were given such as not to chew on the left
side (surgical area), not to drink or eat anything hot for the first 24 hours, and take all
the prescriptions on time. The patient was also instructed to comeback a week after
surgery.
A week after surgery, the patient came back without any complain or discomfort.
The gingiva on the surgery site was still erythematous, especially at the interdental

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Figure 4: anaesthesia was done using infiltration method on labial gingival area. (Source: Author’s
documentation).

Figure 5: a nylon thread was used to hold the epulis, and excision was done using 15c blade. (Source:
Author’s documentation).

Figure 6: Gingival contouring using Kirkland and Orban knife (Source: Author’s documentation).

Figure 7: Gingiva after excision of epulis and gingival contouring (Source: Author’s documentation).

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Figure 8: Resopack placement on surgery site (Source: Author’s documentation).

Figure 9: Tissue sample that would be sent to be analysed on pathology anatomy department faculty of
medicine Gadjah Mada University. (Source: Author’s documentation).

of lateral incisor and canine (Figure 10). The pathology anatomy result was received
and showed that the tissue was connective tissue covered with monomorphic complex
stratified squamous epithelium, including ulceration on some areas. On sub epithelial
area were fibrous connective tissues, and dominated with lymphocyte, ossification was
also found. The conclusion from the analysis, the diagnosis was Fibrous Epulis (Figure
12).
On the second week after the surgery patient was recalled to see the healing progress
of surgical site (Figure 11). The erythema was almost gone, only found on the tip of

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interdental papilla of lateral incisor and canine. The patient was also satisfied with the
result and gain more confidence.

Figure 10: One week after the surgery. (Source: Author’s documentation).

Figure 11: Two weeks after the surgery. (Source: Author’s documentation).

3. Discussion

Swellings on the gingiva normally called epulis. Epulis is usually caused by gingival
hyperplasia that happen due to trauma or systemic conditions. Fibrous epulis also
come with the term fibrous inflammatory hyperplasia [6,7]. It is usually unpainful, but will
caused some
trouble in chewing and also affect the aesthetic aspect if happened in the anterior
region. It is slowly grown and will stop growing at a certain size [1,2]. Local aetiology for
this patient is the subgingival calculus that were trapped on the interdental maxillary
left lateral incisor and canine.
Previous studies found that fibrous lesion usually appear on patient aged 21 – 60
years old, and also the prevalence is higher in female compared to male. Another study

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Figure 12: The results of Pathology Anatomy analysis.

showed that gingival hyperplasia affects adult patients on their 3rd or 4th decade of
life. It is relatable to our presented case that happened to a 30 years old female [8].
Fibrous epulis has some common clinical aspects such as well-defined encircle tissue
on a smooth surface, usually same coloured with the surrounding tissue, sessile or
pedunculated base, most of the time located on anterior maxilla in interdental papilla.
In this case, the clinical appearance is the same with the description above [5,9]. But
to make the definitive diagnosis is challenging for clinician. Thus, clinician normally
check the histopathology of the tissue [10]. The result of the histopathology analysis is
connective tissue covered with monomorphic complex stratified squamous epithelium,
including ulceration on some areas. On sub epithelial area were fibrous connective
tissues, and dominated with lymphocyte, ossification was also found, no malignancy
indicated. The conclusion from the analysis, the diagnosis was Fibrous Epulis. According
to the 10 th International Classification of Disease published by the WHO, fibrous epulis
is classifies as ‘other disorder of the gingival and edentulous ridge’ (K06.8) [11].
The treatment for this case usually includes complete excision of the lesion and
curettage of the surrounding area because most of the time it is originated from

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periosteum and periodontal ligament. So, the curettage must be done thoroughly to
prevent recurrency of the lesion. The commonly used instrument is surgical scalpel.
But in some cases that suspected involving important vascular component, electrical
scalpel or CO2 laser are the choice, as they
can afford bloodless surgical site [12]. In this case we used surgical scalpel to make
a controlled excision of the lesion. We are assured that the used of controlled excision,
curettage and root planning on the periodontal membrane and periosteum will eliminate
the irritants and can avoid recurrency. A gingivectomy also performed to recontouring
the gingival margin of the teeth so we can get the aesthetic goal of the surgery.

4. Conclusion

Fibrous epulis is a tumor-like lesion that it unpainful and benign. It can grow to a certain
size and stop growing. In this case fibrous epulis was originated from the subgingival
calculus hidden in interdental maxillary left lateral incisor and canine. The treatment of
excision and gingival contouring was performed by surgical scalpel. Curettage and root
planning was done thoroughly to eliminate all the stalk and prevent recurrence of the
lesion. Patient was satisfied with the result.

5. Acknowledgements

The authors would like to thank the staffs and supervisors of Department of Periodon-
tology, Gadjah Mada University for the assistance. There is no conflict of interest stated
by the author regarding this case.

References

[1] Scully C. Oral and maxillofacial medicine: The basis of diagnosis and treatment. 2𝑛𝑑
ed. Edinburg: Churchil Livingstone; 2008.
[2] Dabholkar JP, Vora KR, Sikdar A. Giant fibrous epulis. Indian Journal of Otolaryn-
gology and Head & Neck Surgery. 2008;60(1):69-71. https://doi.org/10.1007/s12070-
008-0022-0
[3] Liu C, Qin ZP, Fan ZN et al. New treatment strategy for granulomatous epulis:
Intralesional injection of propranolol. Medical Hypotheses. 2012;78(2):327– 329.
[4] Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva. A clinicopathological
study of 741 cases. Journal of Periodontology. 1980;51(11):655–661.

DOI 10.18502/kme.v2i1.10866 Page 341

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[5] Alam MN, Chandrasekaran SC, Valiathan M. Fibroma of the gingiva: A case report of
a 20 year old lesion. International Journal of Contemporary Dentistry. 2010;1(3):107–
109.
[6] Bataineh A, Al-Dwairi ZN. A survey of localized lesions of oral tissues: A clinicopatho-
logical study. The Journal of Contemporary Dental Practice. 2005;6(3):30-39.
[7] Reddy S. Essentials of clinical periodontology and periodontics. 3𝑟𝑑 ed. Bemgaluru:
Jaypee; 2011.
[8] Peralles PG, Viana APB, Azedevo ALR, Pires FR. Gingival and alveolar hyperplastic
reactive lesions: Clinicopathological study of 90 cases. Brazilian Journal of Oral
Science. 2006;5(18):1085-1089.
[9] Ajagbe HA, Daramola JO. Fibrous epulis: Experience in clinical presentation and
treatment of 39 cases. Journal of the National Medical Association. 1978;70(5):317–
319.
[10] Rajanikanth BR, Srinivas M, Suragimath G et al. Localized gingival enlargement — A
diagnostic dilemma. Indian Journal of Dentistry. 2012;3(1):44–48.
[11] Canadian Institute for Health Information. International statistical classification of
diseases and related health problems, Vol. 1 – Tabular list. 10𝑡ℎ ed. Ottawa: Canadian
Institute for Health Information; 2012.
[12] Tamarit-Borra M, Delgado-Molina E, Berini-Ayte L et al. Removal of hyperplastic
lesions of the oral cavity. A retrospective study of 128 cases. Medicina Oral, Patologia
Oral y Cirugia Bucal. 2005;10(2):151–162.

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