CLINICAL PRACTICE
CASE REPORT |
Pyogenic granuloma subsequent to apical fenestration of a primary tooth
LUZ AGUILÓ, M.D., Ph.D., D.D.S. and
JOSÉ V. BAGÁN, M.D., Ph.D., D.D.S.
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ABSTRACT
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Background. The authors present two case reports of patients exhibiting pyogenic granulomas in the maxillary labial mucosa, which were related to an apical fenestration of a primary incisor.
Case Descriptions. Several researchers have reported that the gingival wound and surrounding inflammatory tissue typically heal spontaneously after extraction of a fenestrated primary tooth. However, in the cases presented here, the gingival lesion did not heal after the fenestrated teeth were extracted.
Clinical Implications. After extracting fenestrated teeth, clinicians need to examine the labial area at a follow-up appointment to ensure that the gingival hyperplasia heals properly. The authors suggest performing curettage of the surrounding abnormal tissue at the time of the tooth extraction.
After the extraction of a fenestrated primary tooth, the gingival wound and the surrounding inflammatory tissue typically heal spontaneously. However, in the two patients described below, the surrounding gingival lesion did not heal after the fenestrated teeth were extracted. We describe two girls who exhibited pyogenic granulomas in the maxillary labial mucosa that were related to the apical fenestration of a primary incisor.
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PYOGENIC GRANULOMA
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Pyogenic granuloma has been described as a benign exophytic lesion, which manifests as small erythematous papules that enlarge and may become pedunculated. The clinical development is slow and asymptomatic.
Extraction of a fenestrated tooth may not be sufficient to heal a gingival lesion.
The condition develops predominantly in females in the second decade of life, and is most often found in the maxillary labial gingiva. It is a hyperplastic inflammatory tissue response associated with minor injury or nonspecific local irritation. Treatment of the lesion includes surgical excision, as well as removal, if possible, of the causative irritants. In 14 to 16 percent of cases, a relapse occurs after treatment.1–10
The differential diagnosis for pyogenic granuloma includes hemangioma, giant-cell granuloma and lymphomas.1,3,10
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APICAL FENESTRATION
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The condition known as apical fenestration is characterized by a perforation of the labial bone and mucosa plate near the apex of a primary tooth root. It is a rarely seen pathologic condition that usually involves the primary maxillary incisors. Clinicians have observed apical fenestration primarily in 5-year-old children (mostly boys).11–13 The basic etiologic factors appear to be threefold:
- – disturbed root resorption of the primary teeth;
- – loss of vitality in these primary teeth;
- – possible pressure from eruption of the permanent teeth.11–13
Clinically, the area of fenestration may be surrounded by hyperplastic tissue.11–15 In cases of chronic irritation, this tissue may appear similar to an irritation fibroma.13
In all cases, treatment of apical fenestration involves the extraction of the affected tooth. Clinicians need to take special care to avoid fracturing the root and damaging the thin layer of mucosa that covers the central part of the root. Several researchers have reported that the gingival wound and surrounding hyperplastic tissue usually heal spontaneously after extraction of the involved teeth.11–15
The purpose of this article is to draw attention to two patients who exhibited a pyogenic granuloma subsequent to treatment of an apical fenestration of a primary incisor. As the cases illustrate, the surrounding gingival lesion did not heal after the fenestrated teeth were extracted.
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CASE REPORTS
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Case 1.
One of us (L.A.) first examined a 13-month-old female infant at a private dental clinic in Valencia, Spain. The clinician observed that an intrusion of the primary maxillary right central and lateral incisors had developed. These intruded teeth later re-erupted. A radiograph obtained at 3 years of age showed that the right central incisor appeared to be nonvital by its periapical radiolucency.
When she was 6 years old, the patient came to the clinic with an apical fenestration of the maxillary right central incisor (Figure 1
). The examining clinician (L.A.) carefully removed the tooth.
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Figure 1. Clinical appearance of an apical fenestration of a primary maxillary right central incisor in a patient 6 years of age. A gingival ulceration can be seen around the apical fenestration.
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At a periodic follow-up examination when she was age 7
years, the patient exhibited a red lesion in the labial alveolar mucosa of the permanent right central incisor (Figure 2). On review of slides obtained when the permanent incisor erupted with a labial hypoplasia defect, we determined that this lesion had been present when the tooth erupted. However, we did not carefully inspect the labial mucosa at the time the tooth erupted.
We found no evidence of any injury, and confirmed the vitality of the permanent central incisor. We suspected the presence of a pyogenic granuloma and surgically excised the lesion. The histologic findings confirmed our clinical diagnosis of pyogenic granuloma (Figure 3). We observed no periapical pathologies radiographically, and no relapse of the lesion has occurred to date.
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Figure 3. Histologic findings of the surgically excised pyogenic granuloma in case 1. The small erythematous papules are composed of nodules of proliferating capillary-sized blood vessels.
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Case 2.
This patient was a 4-year-old girl at the time of her first visit to the private dental clinic in Valencia. Clinical inspection showed a fenestration of the primary maxillary left central incisor (Figure 4). Two years previously, the patient had experienced an injury, which caused intrusion of the incisor. One of us (L.A.) removed the tooth and arranged for a follow-up appointment 10 days later. On the second visit, we carefully observed the labial mucosa of the fenestrated area. The gingival lesion had not healed.
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Figure 4. Clinical appearance of a primary maxillary fenestrated left central incisor in a patient 4 years of age. Inflammatory tissue can be seen around the fenestration.
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Six months after the fenestrated tooth was extracted, the gingival lesion still had not healed (Figure 5). We decided to enucleate the lesion, and the subsequent histologic diagnosis was a pyogenic granuloma (Figure 6). To date, no relapse of the lesion has occurred.
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DISCUSSION
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Several researchers have reported that the gingival wound and surrounding reactive or hyperplastic tissue will heal spontaneously after extraction of a fenestrated tooth.11–13,15 However, in the cases described above, we observed a delayed healing of the gingival hyperplasia during follow-up examinations. A pyogenic granuloma appeared in the same area as the fenestration, despite the fact that there was no obvious difference in the clinical characteristics of these patients compared with other patients treated in our practice.
In the cases described, the authors observed a delayed healing of the gingival hyperplasia during follow-up examinations.
In accordance with the typical apical fenestration pattern,11–15 the involved teeth in our two patients could be moved without spontaneous bleeding or pain resulting, root resorption was delayed and the condition occurred at about 5 years of age. In contrast to the typical apical fenestration pattern, however, the crowns of the fenestrated teeth had not been destroyed. The oral hygiene and dental care of the two patients was adequate. The roots extruding through the labial mucosa were surrounded by a slight gingival inflammation, which is somewhat unusual.
In the cases presented above, the labial gingival lesions located in the area of the apical fenestration persisted after the teeth were extracted. The lesions were painless, exophytic and red, which is typical of the pyogenic granuloma pattern.1–9
Contrary to what we would expect, however, no bleeding or enlargement of the lesions was visible clinically, and these patients were younger than those commonly described in the literature (that is, during the second decade of life). During follow-up examinations after treatment, we observed no relapse of the lesions.4,6
The differential diagnosis in these cases included a pyogenic granuloma, other oral lesions,1,3,10 an abscess and a fistula. After enucleation of the lesions, the clinical diagnosis of pyogenic granuloma was confirmed histologically.
The pyogenic granulomas in these two patients became evident after the fenestrated teeth were extracted. Initially, we considered them to be the commonly found hyperplastic tissue surrounding an apical fenestration of a tooth. However, this tissue possibly originated as a pyogenic granuloma. Therefore, a pyogenic granuloma may develop as a hyperplastic inflammatory response to local irritation caused by the apical fenestration.
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CONCLUSION
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As the above cases illustrate, extraction of the fenestrated tooth may not be sufficient to heal a gingival lesion. Clinicians need to examine the labial area at a follow-up appointment shortly after extraction to ensure that the gingival hyperplasia has been treated successfully. We suggest that dentists perform curettage of the surrounding abnormal tissue when the fenestrated tooth is extracted.
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Dr. Aguiló is in private practice in pediatric dentistry, Ave. Ma Cristina No. 12-2, 46001 Valencia, Spain, e-mail "luzaguilo@hotmail. com". Address reprint requests to Dr. Aguiló.
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Dr. Bagán is an associate professor, Department of Oral Pathology, Faculty of Medicine and Odontology, University of Valencia, Spain, and chairman, Department of Oral Pathology, University General Hospital, Valencia.
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ABSTRACT
PYOGENIC GRANULOMA
