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Case Report

Gingival Enlargement during Orthodontic Therapy and Its

Management
Diksha Agrawal, Priyanka Jaiswal
Department of Periodontics, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha,
Maharashtra, India

Abstract
Gingival enlargement is caused by gingival inflammation, fibrous overgrowth, or a combination of both, leading to adverse consequences, such
as difficulty in plaque control, mastication, altered speech, and esthetic and psychological problems. A 24‑year‑old male reported with the chief
complaint of spacing between the teeth in the front region of the jaw. This article reported a case of extreme gingival enlargement which was
periodontally treated, by the removal of all gingival tissue excess using gingivectomy and gingivoplasty. After a 6‑month follow‑up period,
the fixed orthodontic treatment is continued with monthly periodontal checkups that were scheduled to control the gingival inflammation. The
collaboration between the periodontist and orthodontist is the most important key to successful treatment of hyperplasia in patients undergoing
orthodontic treatment.

Keywords: Gingival enlargement, gingivectomy, inflammatory, scaling, surgical therapy

Introduction Complete removal of these harmful substances was required

for the healing process of periodontal tissue[7,8] However,
Fixed orthodontic appliances may be related with chronic
nonsurgical periodontal therapy such as scaling and oral
periodontal diseases. Gingival enlargement (GE) occurs as
hygiene instruction is not effective when GE is extensive
a result of an increase in plaque retention and less efficient
and self‑oral hygiene measures are compromised. When GE
oral hygiene care.[1,2] This mechanism causes GE in patients
further impedes, the oral hygiene care causes destruction of
throughout the orthodontic treatment, but it was not completely
the periodontal tissues, hampers the esthetic and functional
known. The initiation and progression of periodontal disease
appearance, and compromises orthodontic tooth movement.
depends on the equilibrium between the microbial challenge
Hence, it becomes necessary to perform additional treatment
and the host’s immune responses.[3] The presence of fixed
option such as gingivectomy, to correct contours of the gingival
orthodontic appliances influences the accumulation of plaque
margin.[9] Gingivectomy procedure can be done through
and colonization of important periodontopathic bacteria
conventional scalpels, electrosurgery, chemosurgery, and laser.
around the retentive components attached to the surface of
The elimination of the pseudo pockets was the therapeutic
teeth.[4] Kloehn and Pfeifer[5] described some etiologic factors
endpoint for these procedures.[10,11]
for orthodontic treatment‑induced GE such as mechanical
irritation through bands, chemical irritation by cement, The conventional treatment option performed with the use of
accumulation of food, and poor oral hygiene care. a small scalpel has been considered the most common method
because it is accurate and causes minimal damage to the
Inflamed soft tissues occur by the significantly increased
tissue.[12] In such cases where GE is seen during orthodontic
inflammatory cells, which leads to edema, that further
treatment, it worsens the individual’s oral hygiene care. It
influences the subgingival ecosystem to create an anaerobic
surrounding, which, in turn, causes microflora shift.[6]
Address for correspondence: Dr. Diksha Ramesh Agrawal,
Department of Periodontics, SPDC, Wardha, Maharashtra, India.
E‑mail: [email protected]
Submitted: 11-Dec-2019 Revised: 15-Dec-2019
Accepted: 31-Dec-2019 Published: 13-Oct-2020
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DOI: How to cite this article: Agrawal D, Jaiswal P. Gingival enlargement

10.4103/jdmimsu.jdmimsu_218_19 during orthodontic therapy and its management. J Datta Meghe Inst Med
Sci Univ 2020;15:136-9.

136 © 2020 Journal of Datta Meghe Institute of Medical Sciences University | Published by Wolters Kluwer - Medknow
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Agrawal and Jaiswal: Gingival enlargement during orthodontic therapy

hampers the gingival tissue status and causes periodontal tissue

breakdown. Treatment of such cases improves oral hygiene
care and also achieves undisturbed orthodontic treatment.
We present the case of a 24‑year‑old male who was treated for
GE, which was evident during orthodontic treatment.

Case Report
A 24‑year‑old male had reported to the Department of
Orthodontics, Sharad Pawar Dental College and Hospital,
Wardha, with the chief complaint of spacing between the
teeth in the front region of the jaw. He was examined
accordingly and was planned for orthodontic treatment.
After 1 year of orthodontic therapy, it was observed that
Figure 1: GE involved marginal and attached gingiva encroaching toward
there was GE in all the regions of the teeth. It was also the orthodontic brackets
observed that the patient was not able to take proper care
of oral hygiene after the GE was evident. Due to the same
reason, he was referred to the department of periodontics
and oral implantology.
On intraoral examination, it was observed that there was a
variation in the severity of GE at different areas of the oral
cavity. In molar and premolar regions, the GE involved
marginal and attached gingiva encroaching toward the
orthodontic brackets [Figure 1]. There were generalized
bleeding on probing and mild inflammation at the marginal
gingiva and the tips of the interdental papilla. The gingiva,
in general, was firm in consistency with loss of contour and
stippling in the posterior areas. The overall pseudopocket
was found to be about 4–5 mm. Considering all the gingival Figure 2: External bevel incisions were given using no. 15 BP blade or
findings, the following treatment plan was given: Kirkland knife
• Thorough scaling and oral hygiene instruction
• Surgical gingivectomy along with gingivoplasty.

Initially, in a single visit, only supragingival scaling was

performed for the shrinkage of fibrotic component, and a soft
toothbrush was recommended. The modified Bass technique
of brushing was taught to the patient and instructed to gently
brush the teeth.[13] After thorough scaling, the patient had been
recalled after 3 weeks for re‑evaluation.[14] It was noticed
that there was a complete reduction in inflammation and
bleeding on probing, but enlarged gingiva remained soft and
friable even after scaling. Hence, gingivectomy procedure
was planned.
Patient consent was obtained. Under all septic precautions and
conditions, administration of local anesthesia[15] was done. Figure 3: Thinning of the attached gingiva, and shaping of the interdental
Bleeding points were marked by the use of a pocket marker. papilla
Then beyond markings, external bevel incisions were given
using no. 15 BP blade or Kirkland knife [Figure 2]. Then, of the attached gingiva, and shaping of the interdental
Orban knife was used interdentally, as the lesion extended papilla [Figure 3]. After the bleeding was arrested, periodontal
interproximally. Tissue tabs  were removed with the use of dressing was placed. Following the postsurgical instructions,
curette and scissors. The bleeding was controlled by placing the patient was prescribed analgesics and antiseptic mouth
pressure packs with soaked gauze or cotton in local anesthesia. rinse. On every visit, the patient was reinforced with oral
After achieving hemostasis, gingivoplasty with scalpel was hygiene instructions with no evidence of enlargement. The
performed including tapering of gingival margin, thinning same procedure was employed for all the sextants.

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Agrawal and Jaiswal: Gingival enlargement during orthodontic therapy

during orthodontic therapy. Periodic periodontal maintenance

care during the orthodontic therapy would definitely avoid such
consequences and preserve the gingival health.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given his
consent for his images and other clinical information to be
reported in the journal. The patient understands that his name
and initials will not be published, and due efforts will be made
to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
Figure 4: After a month, the follow‑up revealed that there was good
clinical crown exposure and postoperatively, the results were satisfactory There are no conflicts of interest.

After a month, the follow‑up revealed that there was good References
clinical crown exposure and postoperatively, the results were 1. To TN, Rabie AB, Wong RW, McGrath CP. The adjunct effectiveness
satisfactory [Figure 4]. of diode laser gingivectomy in maintaining periodontal health during
orthodontic treatment. Angle Orthod 2013;83:43‑7.
2. Fornaini C, Rocca JP, Bertrand MF, Merigo E, Nammour S,
Discussion Vescovi P. Nd:YAG and diode laser in the surgical management of
soft tissues related to orthodontic treatment. Photomed Laser Surg
GE reported a prevalence of 10% in association with fixed 2007;25:381‑92.
orthodontic therapy.[1] To et al.[1] in their study used the 3. Gong Y, Lu J, Ding X. Clinical, microbiologic, and immunologic factors
combination of gingivectomy along with gingivoplasty of orthodontic treatment‑induced gingival enlargement. Am J Orthod
procedure as the standard approach. The authors concluded Dentofacial Orthop 2011;140:58‑64.
4. Al‑Anezi SA, Harradine NW. Quantifying plaque during orthodontic
that the adjunct use of gingivectomy for controlling gingival treatment. Angle Orthod 2012;82:748‑53.
inflammation was effective than nonsurgical periodontal 5. Kloehn JS, Pfeifer JS. The effect of orthodontic treatment on the
therapy alone at 1, 3, and 6 months’ follow‑up period. periodontium. Angle Orthod 1974;44:127‑34.
6. de Oliveira Guaré R, Costa SC, Baeder F, de Souza Merli LA,
Lione et al., 2020,[16] in their study compared the use of Dos Santos MT. Drug‑induced gingival enlargement: Biofilm control
diode laser with conventional surgery and also evaluated the and surgical therapy with gallium‑aluminum‑arsenide (GaAlAs) diode
effectiveness of gingivectomy as an adjunct to nonsurgical laser‑A 2‑year follow‑up. Spec Care Dentist 2010;30:46‑52.
7. Aoki A, Sasaki KM, Watanabe H, Ishikawa I. Lasers in nonsurgical
periodontal therapy in the treatment of GE during orthodontic periodontal therapy. Periodontol 2000 2004;36:59‑97.
treatment and concluded the adjunct use of both scalpel 8. Ristic M, Vlahovic Svabic M, Sasic M, Zelic O. Clinical and
gingivectomy and laser gingivectomy. The authors achieved microbiological effects of fixed orthodontic appliances on periodontal
effective and predictable results in reducing gingival tissues in adolescents. Orthod Craniofac Res 2007;10:187‑95.
9. Zanatta FB, Ardenghi TM, Antoniazzi RP, Pinto TM, Rösing CK.
inflammation with the adjunct use of gingivectomy when Association between gingivitis and anterior gingival enlargement in
compared to nonsurgical periodontal therapy alone at a subjects undergoing fixed orthodontic treatment. Dental Press J Orthod
follow‑up period of 1, 3, and 6 months. 2014;19:59‑66.
10. Allen EP. Surgical crown lengthening for function and esthetics. Dent
Fixed orthodontic treatment causes more accumulation of Clin North Am 1993;37:163‑79.
plaque, which was considered as the main causative factor 11. McGuire MK, Scheyer ET. Laser‑assisted flapless crown lengthening:
to cause periodontal disease. Therefore, educational efforts A case series. Int J Periodontics Restorative Dent 2011;31:357‑64.
12. Farista S, Kalakonda B, Koppolu P, Baroudi K, Elkhatat E, Dhaifullah
should be made to achieve orthodontic therapy with gingival E. Comparing laser and scalpel for soft tissue crown lengthening:
health to avoid GE. When oral hygiene care remains poor, A clinical study. Glob J Health Sci 2016;8:55795.
surgical approaches are necessary to quickly recover gingival 13. Singh BS, Jaiswal PG, Dhadse PV, Agrawal AA, Pakhare VV.
tissue inflammations that compromise efficient orthodontic Uncommon presentation of inflammatory gingival enlargement:
Resolution by means of nonsurgical periodontal therapy only. J Datta
finishing. However, clinical relevance should be interpreted Meghe Inst Med Sci Univ 2018;13:104.
with care because surgical gingivectomy was not effective in 14. Ghangurde AA, Ganji KK, Bhongade ML, Sehdev B. Role of chemically
the long‑term observation if self‑care was compromised.[17,18] modified tetracyclines in the management of periodontal diseases:
A review. Drug Res (Stuttg) 2017;67:258‑65.
15. Reddy KV, Jadhav A, Bhola N, Mishra A, Dakshinkar P. Is 0.75%
Conclusion ropivacaine more efficacious than 2% lignocaine with 1:80,000
epinephrine for IANB in surgical extraction of impacted lower third
Earlier evaluation of gingival and periodontal status before molar? Oral Maxillofac Surg 2019;23:225‑31.
orthodontic therapy was a prerequisite. Clinicians should also be 16. Lione R, Pavoni C, Noviello A, Clementini M, Danesi C, Cozza P.
able to assess the oral hygiene care ability of patients before and Conventional versus laser gingivectomy in the management of gingival

138 Journal of Datta Meghe Institute of Medical Sciences University ¦ Volume 15 ¦ Issue 1 ¦ January-March 2020
[Downloaded free from http://www.journaldmims.com on Tuesday, March 9, 2021, IP: 82.77.225.53]

Agrawal and Jaiswal: Gingival enlargement during orthodontic therapy

enlargement during orthodontic treatment: A randomized controlled jdmimsu.jdmimsu_26_18. [Last accessed on 2019 Nov 12].
trial. Eur J Orthod 2020;42:78‑85. 18. Pakhare V, Khandait C, Shrivastav S, Dhadse P, Baliga V,
17. Singh BS, Jaiswal PG, Dhadse PV, Agrawal AA, Pakhare VV. Uncommon Seegavadi V. Piezosurgery®-Assisted Periodontally Accelerated
Presentation of Inflammatory Gingival Enlargement: Resolution by Osteogenic Orthodontics. J Indian Soc Periodontol 2017;21:422-
Means of Nonsurgical Periodontal Therapy Only. J Datta Meghe Inst 26. Available from: https://doi.org/10.4103/jisp.jisp_255_17. [Last
Med Sci Univ 2018;13:104-7. Available from: https://doi.org/10.4103/ accessed on 2019 Nov 12].

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