Gingival enlargement during orthodontic therapy and its management

Diksha Agrawal; Priyanka Jaiswal

doi:10.4103/jdmimsu.jdmimsu_218_19

CASE REPORT

Year : 2020 | Volume : 15 | Issue : 1 | Page : 136-139

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

Date of Submission	11-Dec-2019
Date of Decision	15-Dec-2019
Date of Acceptance	31-Dec-2019
Date of Web Publication	13-Oct-2020

Correspondence Address:
Dr. Diksha Agrawal
Department of Periodontics, SPDC, Wardha, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_218_19

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

How to cite this article:
Agrawal D, Jaiswal P. Gingival enlargement during orthodontic therapy and its management. J Datta Meghe Inst Med Sci Univ 2020;15:136-9

How to cite this URL:
Agrawal D, Jaiswal P. Gingival enlargement during orthodontic therapy and its management. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 23];15:136-9. Available from: http://www.journaldmims.com/text.asp?2020/15/1/136/297979

Introduction

Fixed orthodontic appliances may be related with chronic periodontal diseases. Gingival enlargement (GE) occurs as a result of an increase in plaque retention and less efficient oral hygiene care.^[1],[2] This mechanism causes GE in patients throughout the orthodontic treatment, but it was not completely known. The initiation and progression of periodontal disease depends on the equilibrium between the microbial challenge and the host's immune responses.^[3] The presence of fixed orthodontic appliances influences the accumulation of plaque and colonization of important periodontopathic bacteria around the retentive components attached to the surface of teeth.^[4] Kloehn and Pfeifer^[5] described some etiologic factors for orthodontic treatment-induced GE such as mechanical irritation through bands, chemical irritation by cement, accumulation of food, and poor oral hygiene care.

Inflamed soft tissues occur by the significantly increased inflammatory cells, which leads to edema, that further influences the subgingival ecosystem to create an anaerobic surrounding, which, in turn, causes microflora shift.^[6]

Complete removal of these harmful substances was required for the healing process of periodontal tissue^[7],[8] However, nonsurgical periodontal therapy such as scaling and oral hygiene instruction is not effective when GE is extensive and self-oral hygiene measures are compromised. When GE further impedes, the oral hygiene care causes destruction of the periodontal tissues, hampers the esthetic and functional appearance, and compromises orthodontic tooth movement. Hence, it becomes necessary to perform additional treatment option such as gingivectomy, to correct contours of the gingival margin.^[9] Gingivectomy procedure can be done through conventional scalpels, electrosurgery, chemosurgery, and laser. The elimination of the pseudo pockets was the therapeutic endpoint for these procedures.^[10],[11]

The conventional treatment option performed with the use of a small scalpel has been considered the most common method because it is accurate and causes minimal damage to the tissue.^[12] In such cases where GE is seen during orthodontic treatment, it worsens the individual's oral hygiene care. It 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 there was GE in all the regions of the teeth. It was also 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 findings, the following treatment plan was given:

Figure 1: GE involved marginal and attached gingiva encroaching toward the orthodontic brackets

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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. Bleeding points were marked by the use of a pocket marker. Then beyond markings, external bevel incisions were given using no. 15 BP blade or Kirkland knife [Figure 2]. Then, Orban knife was used interdentally, as the lesion extended interproximally. Tissue tabs were removed with the use of curette and scissors. The bleeding was controlled by placing pressure packs with soaked gauze or cotton in local anesthesia. After achieving hemostasis, gingivoplasty with scalpel was performed including tapering of gingival margin, thinning of the attached gingiva, and shaping of the interdental papilla [Figure 3]. After the bleeding was arrested, periodontal dressing was placed. Following the postsurgical instructions, the patient was prescribed analgesics and antiseptic mouth rinse. On every visit, the patient was reinforced with oral hygiene instructions with no evidence of enlargement. The same procedure was employed for all the sextants.

Figure 2: External bevel incisions were given using no. 15 BP blade or Kirkland knife

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Figure 3: Thinning of the attached gingiva, and shaping of the interdental papilla

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After a month, the follow-up revealed that there was good clinical crown exposure and postoperatively, the results were satisfactory [Figure 4].

Figure 4: After a month, the follow-up revealed that there was good clinical crown exposure and postoperatively, the results were satisfactory

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Discussion

GE reported a prevalence of 10% in association with fixed orthodontic therapy.^[1] To et al.^[1] in their study used the combination of gingivectomy along with gingivoplasty procedure as the standard approach. The authors concluded that the adjunct use of gingivectomy for controlling gingival inflammation was effective than nonsurgical periodontal therapy alone at 1, 3, and 6 months' follow-up period.

Lione et al., 2020,^[16] in their study compared the use of diode laser with conventional surgery and also evaluated the effectiveness of gingivectomy as an adjunct to nonsurgical periodontal therapy in the treatment of GE during orthodontic treatment and concluded the adjunct use of both scalpel gingivectomy and laser gingivectomy. The authors achieved effective and predictable results in reducing gingival inflammation with the adjunct use of gingivectomy when compared to nonsurgical periodontal therapy alone at a follow-up period of 1, 3, and 6 months.

Fixed orthodontic treatment causes more accumulation of plaque, which was considered as the main causative factor to cause periodontal disease. Therefore, educational efforts should be made to achieve orthodontic therapy with gingival health to avoid GE. When oral hygiene care remains poor, surgical approaches are necessary to quickly recover gingival tissue inflammations that compromise efficient orthodontic finishing. However, clinical relevance should be interpreted with care because surgical gingivectomy was not effective in the long-term observation if self-care was compromised. ^[17],[18]

Conclusion

Earlier evaluation of gingival and periodontal status before orthodontic therapy was a prerequisite. Clinicians should also be able to assess the oral hygiene care ability of patients before and 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

There are no conflicts of interest.

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