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Case Report
Chronic Inflammatory Gingival Enlargement

Associated with Orthodontic Therapy A Case Report
Tanya Jadhav, MDS; K Mahalinga Bhat, MDS; G Subraya Bhat, MDS; Jothi M Varghese, MDS
Introduction
Abstract
Purpose: Gingival enlargement, also synonymous with the

Gingival enlargement, a globterms gingival hyperplasia or hypertrophy, is defined as an abally accepted terminology for an
normal overgrowth of gingival tissues. A case of a 19yearold
increase in the size of the gingiva,
male presenting with maxillary and mandibular chronic inflamis a general feature of gingival dismatory gingival enlargement associated with prolonged ortheases. It is a multifactorial condiodontic therapy is reported here. Surgical therapy was carried
tion that develops in response to
out to provide a good aesthetic outcome. No recurrence was
various stimuli and interactions
reported at the end of 1 year. The importance of patient motivabetween the host and the environtion and compliance during and after therapy as a critical factor
ment. It may be plaqueinduced
in the success of treatment has also been highlighted through
or associated with systemic horthis case report.
monal disturbances. It also occurs
Keywords: Gingival enlargement, chronic inflammation, orthas a manifestation associated with
odontic therapy, compliance, motivation
several blood dyscrasias, such as
leukemia, thrombocytopenia or
This study supports the NDHRA priority area, Clinical Dental
thrombocytopathy. A rare variant,
Hygiene Care: Assess the use of evidencebased treatment
idiopathic gingival fibromatosis,
recommendations in dental hygiene practice.
with a familial inheritance, has also
been reported.1 Based on the extent and severity, these enlargements may lead ties involve obtaining a detailed medical history
to functional disturbances like altered speech, and nonsurgical periodontal therapy, followed
difficulty in mastication and aesthetic and psy- by surgical excision to retain esthetical and funcchological problems.
tional demands.
Inflammatory gingival enlargement may be
categorized as acute or chronic, wherein chronic
changes are much more common.1 The ability to
perform oral hygiene measures is compromised
in some patients with gingival enlargements,
which may be further complicated by the presence of prosthesis and fixed orthodontic appliances. This may lead to more inflammation and
further plaque accumulation perpetuating this vicious cycle. Thus, there is a transformation of the
gingival sulcus into a periodontal pocket creating
an area where plaque removal becomes impossible.
One of the most important determinants of
treatment outcomes is patient compliance. The
willingness to perform adequate oral hygiene
measures and receive timely periodic recalls and
treatment are deemed essential for a successful
outcome. The therapeutic approaches related to
gingival enlargement are based on the underlying etiology and the subsequent changes it manifests on the tissues. The prime treatment modali-
This case report presents a case of chronic

gingival enlargement associated with prolonged
orthodontic therapy.
Case Report
A 19yearold male patient reported to the Department of Periodontology, Manipal College of Dental Sciences, Manipal, India. The patient complained
of swelling of the upper and lower gums in the front
tooth region. The patient had noticed the swelling 3
years prior and reported that it had not increased in
size since then. He also complained of bleeding from
the gums while brushing. The patient revealed that
he had undergone incomplete orthodontic treatment which was initiated 6 years prior. There was
no other relevant medical, dental or family history.
Consistent with the history of incomplete orthodontic treatment, intraoral inspection revealed
orthodontic molar bands and brackets on all teeth
except the maxillary left central incisor. On clinical
examination, marginal and papillary gingiva ap-
Vol. 87 No. 1 February 2013 The Journal of Dental Hygiene
19
peared red and enlarged in the maxillary and mandibular arches, which was more prominent in the
anterior sextants and also more pronounced on the
right side as compared to the left (Figures 13).
Further soft tissue assessment revealed soft and
edematous consistency and bleeding on probing on
all teeth.
A treatment plan consisting of initial periodontal therapy followed by a gingivectomy procedure
was planned to improve aesthetics and function.
The initial periodontal therapy comprising supragingival and subgingival scaling was performed.
Oral hygiene instructions were given and the use
of chlorhexidine mouthwash (0.2% ClohexTM, Dr.
Reddys Laboratories Ltd., India) twice a day for one
week was advised. At the next visit, in spite of use of
the prescribed medicated mouthwash, the gingival
enlargement did not show considerable reduction in
size, but the tissues appeared to be firm in consistency. At this stage, radiographs were taken and
complete blood count investigations (RBC, WBC and
platelet counts, ESR, bleeding time, clotting time,
prothrombin time) were carried out (Figure 4).
Figure 1: Intraoral preoperative right

lateral view
Figure 2: Intraoral preoperative frontal view
Results
These investigations were noncontributory.
An internal bevel gingivectomy was performed for
the maxillary sextant. The excised tissue was sent
for histopathological examination. Following this,
the patient failed to report for subsequent recall
appointments.
The histopathological examination revealed a
hyperplastic parakeratinized epithelium overlying inflamed connective tissue. The underlying
stromal tissue showed numerous proliferating
young fibroblasts admixed with focal aggregates
of chronic inflammatory cells. Few fibroblasts appeared stellate, with numerous nuclei distributed
in a collagenized stroma. At places the stromal
tissue exhibited myxoid degeneration. A histopathological diagnosis suggestive of inflammatory
fibrous hyperplasia was given (Figure 5).
Figure 3: Intraoral preoperative left

lateral view
One year later, the patient reported back to the

clinic. At this stage, the patient also expressed the
unwillingness to continue the orthodontic therapy.
Intraoral examination revealed that the maxillary
surgical site had healed satisfactorily. There was
no recurrence of the gingival enlargement in the
maxillary anterior sextant (Figure 6). However,
enlargements in the untreated areas persisted.
Initial periodontal therapy was performed again
and oral hygiene instructions were reinforced.
To further improve plaque control measures,
the orthodontic appliances were removed at this
20
The Journal of Dental Hygiene
Vol. 87 No. 1 February 2013
Figure 4: Orthopantomograph
stage by the orthodontist. The patient was also

counseled regarding the importance of follow up
and maintenance with special emphasis on motivation.
Figure 5: Histological section showing

hyperplastic parakeratinized epithelium with
fibrocollagenous connective tissue with
chronic inflammatory cells (H&E 10X)
Following this, gingivectomy was performed

in the mandibular anterior sextant (Figure 7)
and maxillary right posterior sextant at different
scheduled appointments. Then the patient was reviewed and healing was found to be satisfactory.
Discussion
Gingival overgrowth varies from mild enlargement of isolated interdental papillae to segmental or uniform and marked enlargement affecting
1 or both of the jaws with a diverse etiopathogenesis.2
Here, we report a case of chronic inflammatory gingival enlargement. These enlargements
are often associated with a longstanding bacterial plaque accumulation. Regular professional
oral prophylaxis and good patient compliance are
required in the management of such cases. In
this case, patient compliance was lacking as evidenced by the history of incomplete orthodontic
treatment and the failure to report for regular
recall appointments. Also, the presence of the
appliances may have further compromised the
maintenance of adequate oral hygiene. This reflects the importance of patient education, motivation and compliance during and after dental
treatment. Reinforcement of effective oral hygiene is essential, since patients have a tendency
to revert to their original behavior. The patient
must be placed into a maintenance schedule to

preserve a healthy dentition.
Consequently, it was noticed that once the appliances were removed and oral hygiene instructions were reinforced, the patient was able to
maintain good oral hygiene. A study by Sallum et
al showed significant impact of orthodontic ap-
21
Figure 6: Maxillary arch 12 months

postoperative view after gingivectomy
Figure 7: Mandibular arch 3 months

postoperative view after gingivectomy
pliance removal and professional prophylaxis on

periodontal health.3
odontal therapy or does not meet the aesthetic

and functional demands of the patient, surgical
removal is the treatment of choice. The most
widely employed surgical approaches for the
treatment of gingival enlargements is gingivectomy or the flap technique.
The patient was recommended to undergo

complete blood investigations to rule out underlying systemic disease and allergies. Some
authors have reported a possible allergic reaction to orthodontic metal which may cause gingival enlargement. Allergic contact stomatitis by
dental metals, particularly nickel, has shown to
cause gingival hyperplasia. zkaya et al reported
2 cases with nickelinduced oral mucosal hyperplasia.4 Although extremely rare, a hyperplastic
form has also been reported in single cases from
nickel in dental appliances5,6 and from gold and
palladium in a dental clasp.7
Orthodontic treatmentinduced gingival overgrowth shows a specific fibrous and thickened
gingival appearance, different from fragile gingiva with marginal gingival redness, which is
seen in allergic or inflammatory gingival lesions.
Histologically, inflammatory gingival hyperplasia
is mainly observed as an increase and thickening of mature collagen bundles in the connective
tissue stroma. Microscopic appearance of fibroblasts in the connective tissue stroma and chronic inflammatory cell component is suggestive of
nonspecific gingival enlargement. Fibrous gingival enlargements associated with fixed orthodontic appliances seem to be transitory, and it
is generally thought that enlargement resolves
after orthodontic therapy.1 However, there are
also studies reporting that this resolution is not
complete.8,9
When chronic inflammatory gingival enlargements include a significant fibrotic component
that does not resolve completely after initial peri-
22
Conclusion
This report helps to highlight the importance of
patient motivation and patient compliance in treatment planning. Oral hygiene education supplemented with positive motivation should be started
at the initial stages of the treatment strategy in
order to obtain predictable outcomes. At each recall visit, the patient should be notified about their
ongoing dental condition and the effects of risk factors like poor oral hygiene, smoking and deleterious habits on the existing oral state. Even though
revolutionary advances have taken place in dental
specialties, these 2 factors still play a critical role
in the success of a therapeutic program. An effective communication is, thus, vital in motivating and
educating patients about their dental problems. As
a consequence, successful treatment outcome is
believed to relate to 2 sides of the same coin, necessitating the combined efforts of both the patient
and the clinician.
Tanya Jadhav, MDS, is involved in Private practice at Pune, Maharashtra-India. K Mahalinga Bhat,
MDS, is a professor at the Department of Periodontics, Manipal College of Dental Sciences. G Subraya
Bhat, MDS, is the Head of Department at the Department of Periodontics, Manipal College of Dental
Sciences. Jothi M Varghese, MDS, is an associate
professor at the Department of Periodontics, Manipal College of Dental Sciences.
The Journal of Dental Hygiene
Vol. 87 No. 1 February 2013
References
1. Carranza FA, Hogan EL. Gingival enlargement.
In: Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranzas Clinical Periodontology.
11th ed. Philadelphia, Penn: W.B. Saunders
Company; 2006:373390.
2. Tiwana PS, Kok IJ, Stoker DS, Cooper LF. Facial distortion secondary to idiopathic gingival
hyperplasia: surgical management and oral reconstruction with endosseous implants. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2005;100(2):153157.
5. Kalkwarf KL. Allergic gingival reaction to esthetic crowns. Quintessence Int Dent Dig.
1984;15(7):741745.
6. Counts AL, Miller MA, Khakhria ML, Strange S.
Nickel allergy associated with a transpalatal arch
appliance. J Orofac Orthop. 2002;63(6):509
515.
7. Kabashima K, Miyachi Y. Gingival hyperplasia due to metal allergy. Clin Exp Dermatol.
2005;30(1):8889.
3. Sallum EJ, Nouer DF, Klein MI, et al. Clinical and

microbiologic changes after removal of orthodontic appliances. Am J Orthod Dentofacial Orthop. 2004;126(3):363366.
8. Ramadan AAF. Effect of nickel and chromium

on gingival tissues during orthodontic treatment: a longitudinal study. World J Orthod.
2004;5(3):230234, 235.
4. zkaya E, Babuna G. Two cases with nickelinduced oral mucosal hyperplasia: A rare clinical
form of allergic contact stomatitis? Dermatol
Online J. 2011;17(3):12.
9. Gursoy UK, Sokucu O, Uitto VJ, et al. The role of

nickel accumulation and epithelial cell proliferation in orthodontic treatmentinduced gingival
overgrowth. Eur J Orthod. 2007;29(6):555558.
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Case Report

Chronic Inflammatory Gingival Enlargement

Purpose: Gingival enlargement, also synonymous with the

This case report presents a case of chronic

Vol. 87 No. 1 February 2013 The Journal of Dental Hygiene

Figure 1: Intraoral preoperative right

Figure 2: Intraoral preoperative frontal view

Figure 3: Intraoral preoperative left

One year later, the patient reported back to the

The Journal of Dental Hygiene

Vol. 87 No. 1 February 2013

stage by the orthodontist. The patient was also

Figure 5: Histological section showing

Following this, gingivectomy was performed

must be placed into a maintenance schedule to

Vol. 87 No. 1 February 2013 The Journal of Dental Hygiene

Figure 6: Maxillary arch 12 months

Figure 7: Mandibular arch 3 months

pliance removal and professional prophylaxis on

odontal therapy or does not meet the aesthetic

The patient was recommended to undergo

The Journal of Dental Hygiene

Vol. 87 No. 1 February 2013

3. Sallum EJ, Nouer DF, Klein MI, et al. Clinical and

8. Ramadan AAF. Effect of nickel and chromium

9. Gursoy UK, Sokucu O, Uitto VJ, et al. The role of

Vol. 87 No. 1 February 2013 The Journal of Dental Hygiene

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