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Management of traumatic dental injury after

periodontal surgery in patient with hereditary
gingival fibromatosis: case report
Article in Oral health and dental management June 2014
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Aichi Gakuin University

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Management of Traumatic Dental Injury after Periodontal Surgery in

Patient with Hereditary Gingival Fibromatosis: Case Report
Koji Inagaki1,2, Hidehiko Kamei2, Akio Mitani2, Toshihide Noguchi2
Department of Dental Hygiene, Aichi Gakuin University Junior College, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya 464-8650,
Japan. 2Department of Periodontology, School of Dentistry, Aichi Gakuin University, Japan.
1

Abstract

Traumatic Dental Injury (TDI) is often caused by a bruise from a sports-related incident or fall. In individuals with maxillary
protrusion, the risk for TDI may be higher. We treated a patient with Hereditary Gingival Fibromatosis (HGF), a rare genetic disorder
characterized by proliferative fibrous overgrowth of gingival tissue, who subsequently received a TDI after periodontal surgery. A
13-year-old Japanese boy was referred to the Division of Periodontics at Aichi Gakuin University Dental Hospital in March 2005
with the chief complaint of generalized severe gingival overgrowth involving the maxillary and mandibular arches covering nearly
all teeth.
Prior to orthodontic treatment, periodontal surgery was performed under general anesthesia in consideration of mastication, dental
esthetics, and development. However, soon thereafter in August 2007, the protruded maxillary anterior teeth received an injury
while he was playing basketball and the maxillary central incisors showed extrusive luxation. Two weeks after being reset, the
maxillary anterior teeth were splinted with wire and adhesive resin cement, and then the splint was removed following evaluations of
clinical and radiographic showing signs of normal periodontium. The marginal bone height corresponded to that seen in radiographic
findings after the reset and orthodontic treatment was started 1 year later. At the 6-year follow-up examination, the teeth remained
asymptomatic, pulpal response to sensitivity tests was normal, and healing was shown in radiographic images. In the present HGF
case, we speculated that removal of thick gingiva around the teeth, which might have functioned as a mouth guard, increased the
risk for TDI while playing sports. TDI is more likely to occur in patients with exposed protruded misaligned teeth after periodontal
surgery. Therefore, it is important for HGF patients with such protruded maxillary anterior teeth to use a mouth guard when
participating in sports following periodontal surgery to prevent TDI.
Key Words: Traumatic dental injury, Extrusive luxation, Hereditary gingival fibromatosis, Mouth guard

Introduction

as maxillary protrusion and prolonged retention of primary

dentition. Severe gingival overgrowth covers the dental
crowns, which results in aesthetic and functional problems
such as difficulties with mastication and speaking [5].
Here, we report a patient with HGF, a rare isolated genetic
disorder, or part of a syndrome or chromosomal abnormality
that occurs in approximately 1 in 750,000 people and
characterized by proliferative fibrous overgrowth of gingival
tissue [6]. The present patient suffered from extrusive luxation
of the maxillary central incisors from a sports-related injury
after undergoing periodontal surgery, and was successfully
treated and followed for 6 years.

Traumatic Dental Injury (TDI) is considered to be a public

dental health problem because of its frequency and typical
occurrence at young age, as well as cost and treatment that
may continue throughout the life of the patient [1] and is often
caused by an impact from a sports-related incident or fall. In
individuals with maxillary protrusion, the risk for TDI may
be higher [2,3]. TDIs occur with great frequency in preschool
and school age children, and young adults, comprising 5% of
all injuries for which individuals seek treatment [4]. A 12-year
review of published reports showed that 25% of all school
children experience dental trauma and 33% of adults have
experienced trauma to permanent dentition, with the majority
of those injuries occurring before 19 years of age [2]. Luxation
injuries are the most common type of TDI in primary dentition,
whereas crown fractures are more commonly reported in
permanent dentition [2,3]. The teeth most affected by dental
trauma are the maxillary central incisors, while children with
an overjet size >3 mm are 1.78 times more likely to have
TDIs [3]. TDIs present a challenge to clinicians worldwide,
thus proper diagnosis, treatment planning, and follow-up
examinations are critical to assure a favorable outcome.
Gingival enlargement associated with Hereditary Gingival
Fibromatosis (HGF) usually begins at the time of eruption of
permanent dentition, though it can also develop with eruption
of primary dentition, as a slowly progressive and sluggish
localized or generalized hyperplastic gingiva. The common
effects of gingival overgrowth are malposition of teeth such

Case Report

The patient, a 13-year-old Japanese boy, was referred to the

Division of Periodontics at Aichi Gakuin University Dental
Hospital in Nagoya, Japan, on March 2005 with the chief
complaint of severe generalized gingival overgrowth involving
the maxillary and mandibular arches, and covering nearly all
teeth (Figures 1 and 2). At the age of 4 years, his mother first
noticed the condition, which gradually progressed. Family
history and oral examination results showed that not only the
patient, but also his father and sister were affected, revealing
autosomal recessive inheritance (Figure 3). In consideration
of mastication, dental aesthetics, and development, surgery
consisting of gingivectomy, gingivoplasty and flap procedures
was performed under general anesthesia in July 2007 (Figure
4). A specimen of the gingival overgrowth was obtained

Corresponding author: Koji Inagaki, Department of Dental Hygiene, Aichi Gakuin University Junior College, 1-100 Kusumoto-cho,
Chikusa-ku, Nagoya 464-8650, Japan, Tel: 81-52-759-2150; Fax: 81-52-759-2150; e-mail: kojikun@dpc.agu.ac.jp
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OHDM - Vol. 13 - No. 2 - June, 2014

Figure 1. Initial intraoral clinical

appearance of the patient with severe
generalized gingival overgrowth
involving the maxillary and
mandibular arches, which covered
nearly all teeth. Adequate lip closure
could not be attained.

Figure 2. Initial panoramic radiograph

showing impacted permanent teeth.

(75)

II

1: father (46 year-old)

(46)1
Figure 3. Inheritance pattern of family.
The age of each family member is shown
in parentheses. Family history and oral
examination results showed that not
only the patient, but also his father and
sister were affected, revealing autosomal
recessive inheritance. We considered that
the paternal grandfather influenced our
patient, as well as his father and sister. 1:
father, 2: sister, 3: patient.

III
(17)2

(15)

(13)3

2: sister (17 year-old)

3: this case (13 year-old)

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OHDM - Vol. 13 - No. 2 - June, 2014

(Figure 4) and stained with hematoxylin and eosin, which

showed epithelial hyperplasia with prominent papillae
and connective tissue along with an increased amount of
collagenous fibers under low magnification (Figure 5).
Prior to beginning orthodontic treatment, the maxillary
anterior teeth of our patient, which protruded with a 5 mm
overjet, suffered an injury in August 2007 while he was
playing basketball and the maxillary central incisors showed
extrusive luxation. The luxated teeth were partially pushed out

of their sockets and periapical radiograph findings revealed a

radiolucent area around the apex of the roots (Figure 6a, 6b
and 6c). Two weeks after being reset, the maxillary anterior
teeth were splinted with wire and adhesive resin cement
(Super-Bond C&B, Sun Medical Co, Siga, Japan) (Figure 6d
and 6e).
The splint was removed following evaluations of clinical
and radiographic signs showing normal periodontium
(Figures 7 and 8). Marginal bone height corresponded to

Figure 4. Clinical appearance after surgical

procedures consisting of gingivectomy and flap
surgery under general anesthesia performed on
July 2007. Right image shows excised maxillary
gingiva with buccal overgrowth.

Figure 5. Light micrograph findings of gingival overgrowth.

Low magnification view of gingival overgrowth showing
epithelial hyperplasia with prominent papillae and
connective tissue along with an increased amount of
collagenous fibers is shown. (Hematoxylin-eosin, original
magnification x50)
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Figure 6. a, b: Extrusive luxation of the maxillary

central incisors occurred while participating in
basketball on August 2007. c: Radiograph on
August 2007. d: The maxillary anterior teeth were
splinted with wire and adhesive resin cement for
a period of 2 weeks. e: Radiograph 2 week later.
Pretreatment periapical radiograph findings showed a
radiolucent area around the apex of the roots.

Figure 7. Post-splinting views

of maxillary central incisors.
a: after 2 weeks. b: after 2
months. c: after 3 years. d:
after 6 years.
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that seen in radiographic findings after the reset. Orthodontic

treatment was started 1 year later. At the 6-year followup examination, the teeth remained asymptomatic, pulpal
response to sensitivity tests was normal, and radiographic
evidence of healing was demonstrated (Figures 7d and 8).

Figure 8. Post-splinting
radiographic views of maxillary
central incisors. a: Day of extrusive
luxation. b: after 2 months. c: after 1
year. d: after 6 years.

nor duration of splinting are significantly related to healing

outcome, this therapy is considered best practice in order to
maintain repositioned teeth in the correct position, as well
as to provide patient comfort and improve function. On the
other hand, evidence for an association between short-term
splinting and increased likelihood of functional periodontal
healing, acceptable healing, or decreased development of
replacement resorption is inconclusive [11,12].
In our case, the maxillary anterior teeth were splinted with
wire and adhesive resin cement following a reset. At a 6-year
follow-up examination, the teeth remained asymptomatic,
pulpal response to sensitivity tests was normal, and healing
was demonstrated in radiographic images. In our search of
reported cases, none that included long-term follow-up results
of periodontal surgery for HGF were found. The present patient
was followed for 6 years after undergoing a gingivectomy
under general anesthesia and treatment of extrusive luxation
of the maxillary central incisors. To our knowledge, this is
the first report of an HGF patient who underwent periodontal
surgery following TDI, and was successfully treated and
followed for a long period.
Despite efforts to reduce the number of dental traumas,
most current studies indicate that the incidence is unchanged,
and remains at a relatively high level in children and young
adults [13,14]. When reviewing studies related to prevention,
it is clear that the main focus has been on making and
promoting use of mouth guards. The majority of studies
that investigated mouth guards were performed in vitro and
focused on the materials used, as well as how they perform
and protect, and their presented findings support the use and
protective value of mouth guards for reducing sports-related
injuries to the teeth and soft tissues. Dentists are encouraged
to educate patients regarding the risks of oral injury in those
participating in sports, and also fabricate properly fitted
mouth guards and provide appropriate guidance regarding
the various types and their protective properties, costs, and
benefits [15]. As shown in our case, following periodontal
surgery, it is important for HGF patients with protruded teeth
to protect against TDI occurrence by using a mouth guard
when participating in sports activities.

Discussion

HGF is a rare autosomal dominant form of gingival

overgrowth. Affected individuals show a benign, slowly
progressive, non-hemorrhagic, and fibrous enlargement of the
oral masticatory mucosa [7,8]. In our search of reported cases,
none that included long-term follow-up results were found.
The present patient was followed for 6 years after periodontal
surgery and treatment for extrusive luxation of the maxillary
central incisors. It is not easy to visualize excessive overjet
after periodontal surgery in HGF cases. Furthermore, no
known past reports have noted this condition as increasing the
risk of TDI. Therefore, we report the present case of HGF in
a patient who underwent periodontal surgery following TDI,
and was successfully treated and followed for a long period.
TDIs often occur as the result of an accident or sports-related
injury, with the present case typical of the latter. Francisco et
al. [3] reported that the prevalence of dental trauma among
Brazilian schoolchildren was 16.5%. Teeth most affected by
dental trauma are the maxillary central incisors, while boys
run a 2.03-times higher risk of crown fracture than girls and
children with an overjet >3 mm are 1.78 times more likely to
have TDIs. In addition, children with inadequate lip coverage
are 2.18 times more likely to present TDIs than children with
adequate lip coverage [3]. The findings in our case confirmed
all of these factors. In the present patient with HGF, the teeth
affected by dental trauma were the maxillary central incisors,
indicating that excessive overjet with inadequate lip coverage
developed after periodontal surgery for the overgrowth.
Based on the 2011 dental trauma guidelines presented by
the International Association of Dental Traumatology [9,10],
we gently repositioned the teeth into their sockets and used
a flexible splint for stabilization and patient comfort. Such a
procedure can be used for up to 2 weeks, with asymptomatic,
positive response to pulp testing reported. However, false
negative results are possible for up to 3 months. On the other
hand, continuing root development in immature teeth and
intact lamina dura has been reported as favorable outcomes
in similar cases. The present findings support the usefulness
of a short-term non-rigid splint for luxated, avulsed, and rootfractured teeth. Although neither the specific type of splint

Conclusion

In the present HGF case, we speculated that the loss of thick

gingiva around the teeth, which might have functioned like a
mouth guard, increased the risk for TDI when participating
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in sports activities. TDI is more likely to occur in patients

with exposed protruded misaligned teeth after periodontal
surgery. Therefore, it is important for HGF patients with

such protruded maxillary anterior teeth to use a mouth guard

when participating in sports following periodontal surgery to
prevent TDI.

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