Surgical and Prosthodontic Management of Denture Induced Hyperplastic Lesion in Maxillary Arch – A Case Series

INTRODUCTION

Denture induced hyperplasia also known as epulis fissuratum is an overgrowth of intraoral tissues resulting from chronic irritation. 1 It is considered as a common tissue reaction resulting from chronic ill-fitting dentures and presents as an occurrence of hyper plastic tissue along the denture border. 2 This process results in resorption of the ridge which may occur as a result of over extended denture borders resulting in chronic irritation to oral tissues in the vestibular region. 3 It is characterized by slow development of elongated roll of tissues in the muco-buccal fold region into which denture flange fits and is symptomless until the lesion become ulcerated. Epulis fissuratum is usually treated by conservative management or it is surgically excised depending on the extent of the lesion. 4 Rosenquist stated that persistent trauma to the oral tissues by the rough borders of ill-fitting dentures or sharp edges of teeth may predispose patients to oral cancer. Therefore, ill-fitting dentures and their sequelae should never be neglected. 5
CASE 1
A 63-year-old female patient reported to the department of Prosthodontics, Dr Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Karachi for fabrication of a new set of complete dentures. Past dental history revealed that the patient was a denture wearer since last ten years. On examination of her existing maxillary denture a suction disk was present on the intaglio surface and the borders of left labial flange were sharp and overextended (Fig 1a). Patient had an average denture hygiene with signs of occlusal wear of teeth. Medical as well as family history were non-contributory. Patient had no habit of pan, chalia or tobacco chewing. Extra oral examination showed no atypical features. Intraoral examination disclosed palatal mucosa with a well-defined depression at the middle in the hard palate which was non-tender on palpation.
Furthermore, there was a well-defined multi-lobular hyperplastic lesion in the left vestibular region in maxillary arch extending from central incisor to premolar region with flange of denture fitting in between the tissue folds (Fig 1b). On palpation, the tissue folds were non tender, mobile and had no ulceration on the base of the lesion. Patient did not give any history of pain or swelling hence it was an accidental finding. On basis of history and clinical evaluation a preliminary diagnosis of denture irritation hyperplasia was made. Patient was advised not to use her denture and oral hygiene instructions were given to her. Due to extensive size of hyperplastic tissue pre-prosthetic surgery was planned since conservative management alone would not completely resolve the lesion. Local anesthesia was administered for infraorbital, anterior superior alveolar and lesser palatine nerve. The periphery of the lesion was marked with an indelible pencil and was resected from its base with a no.15 surgical blade followed by primaryclosure with sutures. Patient was given postoperative instructions along with antibiotics and analgesics. The specimen excised was sent for histopathological examination which confirmed the diagnosis (Fig 1c). The patient was recalled after 15 days for follow up and suture removal. On 02 months follow-up, the tissues had healed completely and impression for fabrication of new complete denture was made (Fig 1d). The patient was kept on follow up visits for 7 months and no relapse of lesion was found till date. (Fig 1e).

A 50-year-old female presented to the Prosthodontic department with complaint of an ill-fitting maxillary denture and a painless soft tissue mass in the maxillary arch since last one year. The patient was wearing the denture since the last six years, without removing it at nighttime. Lower arch was rehabilitated with a distal extension RPD which the patient misplaced around 5 years back. On denture examination, over-extended left labial flange border was observed, along with an imprint of suction disk in the center of fitting surface of denture. (Fig 2 a). Extra oral examination was within normal limits. On intraoral examination, generalized erythematous mucosa and folds of fibrous hyperplastic tissues were observed in the maxillary anterior labial sulcus (Fig 2 b). There was no pain and tenderness on palpation of the fibrous tissues. In the mandibular arch, anterior teeth were present with bilateral free end saddle in the posterior region. A provisional diagnosis of denture induced hyperplasia was made based on history and clinical examination. The patient was advised discontinuing wearing of denture to give appropriate tissue rest. Oral hygiene instructions were given such as regular brushing, use of Chlorhexidine mouth wash, warm saline rinses 3 times a day and finger massage of the affected area. On follow-up visit at three weeks, the fibrous tissue showed regression with no sign of inflamed mucosa. Oral hygiene instructions were reiterated. A new prosthesis was fabricated after two months when there was marked decrease in the size of lesion
(Fig 2c & 2d).

A 71-year-old male patient visited dental outpatient department of Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, with chief complaint of loose maxillary complete denture since last 3 months. History revealed that
he was wearing the denture since past two years. There was no significant medical history. Extra oral examination revealed no atypical features. On intraoral examination, inflamed mucosa and fibrous hyperplasia was noticed that was not tender to palpation (Fig 3a). It was associated with a sharp, over extended maxillary denture flange in anterior labial sulcus. Maxillary denture was opposed by full arch porcelain fused to metal fixed prosthesis with which the patient was satisfied and had no complaints. Denture examination revealed poor denture hygiene, worn occlusal surfaces and improperly repaired midline fracture. A provisional diagnosis of denture induced hyperplasia was made based on history and clinical examination. The patient was educated regarding maintenance of oral and denture hygiene, immediate discontinuation of denture wearing, finger massage of affected area and use of anti-inflammatory mouth wash. On recall visit after 2 weeks mucosa was still inflamed, hence maxillary denture was relined with tissue conditioner for improved mucosal healing (Fig 3b). This procedure was repeated twice till the size of lesion regressed. After improvement in health of oral tissues new dentures were fabricated (Fig 3c & 3d).

DISCUSSION
Chronic irritation and continuous trauma to oral mucosa by ill-fitting denture are main causative factors associated with the occurrence of epulis.6 Clinically, epulis fissuratum presents as a raised sessile lesion in folds with a smooth surface that may have a normal or erythematous overlying mucosa.7 The lesion may also occur due to gradual ridge resorption, which leads to reduced ridge height and overextended denture flanges causing chronic irritation to the mucosa.8 The size of the fibrous tissue ranges from a smaller mass to an extensive lesion which may involve the entire vestibule. Although the lesion is often symptomless, occasionally inflammation and ulceration may occur.9
In our reported cases, overextended and ill-fitting denture flanges of maxillary complete denture were the main etiologic factors identified. These findings are similar to other studies in which ill-fitting denture flanges were the main reason for denture induced hyperplasia.10,11

Firoozmand and Buchner et al reported occurrence of these lesions mostly in the maxillary arch with female patients (78%) being mostly affected.12,13 These findings are comparable to our reported cases where two out of three cases were female patients with the lesion present in maxillary arch.
In two of our reported cases, patient presented with rubber suction disk retained maxillary dentures. These were placed in palatal region on the intaglio surface to improve retention of the maxillary denture. Suction cup induces immense negative pressure on the mucosal surface and may cause soft tissue changes and in extreme cases loss of palatal bone and perforation.14 Despite its known ill effects many cases of suction disc dentures are still reported in our clinical settings. Palatal suction cups should be highly discouraged as they have pathological effects on palatal tissues. In our reported cases, palatal soft tissue changes due to suction disk were minimal. Therefore, patients were advised to discontinue use of dentures and apply analgesic gel, which lead to complete healing of palatal tissues. Denture-irritation hyperplasia may be managed conservatively or surgically. In early stages of fibrous hyperplasia, nonsurgical treatment with soft-liners is frequently sufficient for elimination or reduction of the hyperplastic tissues.9
Two of the patients in our reported cases were managed with conservative approach (case 2 and 3). Patients were instructed to discontinue the use of denture for some time. Denture faults were corrected and tissue surface was relined with tissue conditioning material (GC Soft Liner). This procedure was repeated for 2-3 times over the span of 15 days till the size of lesion regressed. However, these measures were effective since size of fibrous tissue lesion was small. After complete healing of the tissues, new dentures were fabricated.
Tissue conditioning is a non-invasive treatment that can be solely used to manage clinical cases of small mucosal hyperplastic lesions. However it has limitations in cases with extensive mucosal lesions where there is significant fibrosis and surgical excision of hyperplastic tissue is required in such cases.15,16 In our reported Case 1, the size of lesion was extensive and hence it was surgically excised. These results are similar to a study conducted by Khan WU et al15 in which extensive hyperplastic lesion in the maxillary arch was managed surgically. Surgical techniques include conventional surgical supra-periosteal and advanced techniques eg: cold blade, electro-surgery, lasers or cryosurgery.17 In our case conventional surgical supra- periosteal excision was performed.
CONCLUSION
Denture-induced hyperplasia is a sequelae of wearing complete denture, which commonly occurs due to chronic irritation and ill-fitting dentures. Few cases of epulis fissuratum are presented which were managed by both conservative and surgical approach. Once the lesion is identified patient should be reassured about its benign nature. Instructions regarding meticulous oral and denture hygiene should be provided and patient should be kept on regular recall and follow-up visits to prevent recurrence.

CONFLICT OF INTEREST
None declared

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