Bevel: Case Report

Pyogenic Granuloma in the Aesthetic Region after Installation of Implant Supported Denture: Report of two Cases and Literature Review

Emerson Filipe de Carvalho Nogueira, Luciano Barreto Silva, Bruno Jos Carvalho Macdo Neres, Thiago Nunes de Siqueira Pedrosa, Gerhilde Callou Sampaio, Jos Ricardo de Holanda Vasconcellos

Abstract

The purpose of this paper is to present two clinical cases of pyogenic granuloma in the buccal cavity that developed in the aesthetic region after the installation implant supported denture, as well as perform a critical review on granulomas in dental implants. The first case presented an exophytic, reddish, asymptomatic lesion in the cervical region, 21 days after extraction of the fractured element 11 and implant with immediate prosthesis installation. In the second case, the fractured element 12 was extracted, the implant was installed and the prosthesis was placed after 5 months. This element developed lesion with similar characteristics to the first case, but with 2 months of rehabilitation. The cause of lesion development in both cases was related to local trauma due to mobility and instability of the provisional prostheses. Both cases were treated with prosthesis removal, cleaning and sanitizing of the region with a solution of chlorhexidine 0.2%, repositioning and stabilization of the prostheses, which resulted in complete regression of the lesions, achieved in around 30 days without the need of any surgical intervention. Correct diagnosis, knowledge of possible etiologies and its location are important factors in the planning of patients with pyogenic granuloma. Patients rehabilitated with dental implants are subject to development of this lesion, and the lack of knowledge of the characteristics of the reactive lesions may lead to unnecessary biopsies and development of important aesthetic defects.

 

Keywords: Dental Implants; Gingival Diseases; Pyogenic Granuloma; Prostheses and Implants.

 

Emerson Filipe de Carvalho Nogueira, Luciano Barreto Silva, Bruno Jos Carvalho Macdo Neres, Thiago Nunes de Siqueira Pedrosa, Gerhilde Callou Sampaio, Jos Ricardo de Holanda Vasconcellos. Pyogenic Granuloma in the Aesthetic Region after Installation of Implant Supported Denture: Report of two Cases and Literature Review. International Journal of Oral & Maxillofacial Pathology; 2019:10(2):13-17. International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved.

 


Introduction

Gingival reactive lesions such as pyogenic granuloma (PG) have frequent occurrence around the natural dentition, however, its association with dental implants is not common. The causes of PG in relation to dental implants are not clear mainly due to few published cases.15 The tooth-related PG is a result of the tissue response to small lesions or chronic low grade irritation.6,7 Clinically, oral PG is characterized as a soft mass of smooth or lobulated appearance that may be sessile or pedunculated and frequently has ulceration. The lesion grows rapidly for a few weeks and the color varies from pink purple to red and bleeding may occur spontaneously or after minor trauma.5 The incidence is relatively common and represents 3.81% to 7% of all biopsies collected from the oral cavity.7,8

 

The most frequent intraoral location is the gingiva (60-70%), but lesions on the lips (14%), tongue (9%), buccal mucosa (7%) and palate (2%) may occur.9,10 Possible treatment methods are excision, curettage, cryotherapy, sclerotherapy, chemical and electrical cauterization and the use of lasers with carbon dioxide (CO2) or argon. Conservative local excision is the most recommended form of treatment and recurrence rates after excision range from 0% to 16%.11 This is the first paper in the scientific literature that describes PG lesions associated with titanium dental implants in aesthetically region treated conservatively based on their clinical characteristics.

 

Case Report 1:

A 25-year-old male patient went to the odontological office after facial trauma during sports activity, he had a displacement of the fixed unitary prosthesis and fracture of the radicular cervical third of the element 11. In the emergency room, the prosthesis was repositioned, restrained, and computed tomography of the maxilla was requested for a better diagnosis and elaboration of the treatment plan. The image examination showed a periapical hypodense image in element 11 with complete impairment of the vestibular cortical, which was suggestive of periapical cyst associated with vestibular bone loss of this element. The rehabilitation planning consisted of the atraumatic extraction of the root rest followed by implant and immediate prosthesis.

 

The patient underwent local anesthesia with the use of 4% articaine with epinephrine 1: 200,000, and the element was removed atraumatically with the use of a dental extractor (Neodent, Curitiba, Brazil). After extraction, the alveolus was prepared with surgical drills followed by the installation of the implant Acqua Drive Conemorse 4.3 x 13 mm (Neodent, Curitiba, Brazil). With a locking of 40N, the screwed immediate temporary prosthesis was selected, leaving it in infraocclusion and without contact with an antagonist during mandibular movements. On the 7th postoperative day, the patient returned to the outpatient clinic with no complaints and no signs of infection, but on the 21st day he complained of asymptomatic volume increase in the cervical region of the marginal gingiva and inserted in the rehabilitated element. In the physical examination, reddish, granular, non-bleeding exophysial lesion with approximately 8 mm in its greatest diameter was observed, as well as the discrete mobility of the provisional prosthesis. (Figure 1A) The scan showed a gingival sulcus with 9 mm depth, and the radiographic examination did not detect any alteration. (Figure 1B)

 

With these characteristics, the diagnostic hypothesis given was of pyogenic granuloma caused by local trauma due to loosening of the prosthetic screw. Thus, the provisional prosthesis was removed, the region was hygienized with chlorhexidine 0.2%, and repositioning and retention with prosthetic screw were performed. In order to provide greater stability, a palatal containment with steel wire and resin were also placed. The patient was monitored weekly and it was observed a complete regression of the lesion 30 days after correction of the stability of the provisional prosthesis. Three months after the installation of the implant, the definitive prosthesis was made and the rehabilitation completed. The patient has been followed for 6 months without recurrence of the lesion. (Figure 2)

 

Case Report 2:

A 55-year-old female patient, without systemic disease, who makes no use medications, except for calcium and iron supplements due to stomach reduction surgery, sought dental care after coronary fracture of the right upper lateral incisor. Rehabilitation planning consisted of the removal of the remaining tooth, followed by alveolar filling with biomaterial for bone grafting (Geistlich Bio-Oss). After 6 months, the implant installation site was prepared following the sequence of surgical drills for the installation of the 3.5 x 11.5 mm Morse Indexed Dental Implant, Master Flash Hard (Conexo, So Paulo, Brazil), in which was obtained a lock with a torque of 35 N, followed by installation of the cover scrow, suture of the gingival tissues, installation of temporary adhesive prosthesis associated with the surrounding teeth and free of occlusal contact with the inferior opposing teeth. She returned for postoperative evaluation after 7 days without complaints or signs of infection.

 

The reopening was performed 5 months after surgery, with a mucoperiosteal flap displacement with pedicle grafting of connective tissue to increase the gingival profile inserted in the vestibular region, installation of a transgingival healer and usage continuation of the temporary adhesive prosthesis attached to the surrounding teeth, whose healer was removed 3 months later and the installation of screwed provisional prosthesis.

 

Two months after the last step, an exophytic volume increase, sessile and softened in gingival tissue, with a bright and bleeding after touch surface was present, corroborating with the clinical characteristics of pyogenic granuloma associated with the cervical region of the prosthesis, which after a detailed clinical examination, had limited mobility because of a loosening of the fixation screw. (Figure 3A) Afterwards, the removal of the provisional prosthesis, a thorough clinical evaluation of the gingival emergency profile in conjunction with the implant embouchure surface and radiographic tracking with a guttapercha stick to verify the origin of the lesion were performed. Radiographic evaluation suggested that the origin was in the soft tissues associated with the peri-implant region. (Figure 3B)

 

A cleaning with 0.2% chlorhexidine solution was performed in the gingival emergency profile, disinfection followed by a new polishing of the acrylic of the provisional prosthesis and its reinstallation. The patient was tracked weekly, and after 15 days, the stability of the provisional prosthesis and reduction of the lesion were visible. After 30 days, the gradual return of the normality characteristics of the peri-implant tissues was visible. (Figure 4) Two months later, rehabilitation was completed with the installation of the definitive prosthesis, and 8 months of recurrence free follow-up.

 

figura 1

Figure 1: A) Pyogenic granuloma affecting the marginal gingiva after provisional prosthesis. B) Radiographic examination.

 

Figura 2

Figure 2: Clinical situation after 30 days follow-up period showed regression of the lesion.

 

Figura 3

Figure 3. A) Clinical aspect of the lesion in gingival tissue. B) Image examination demonstrating guttapercha screening.

 

figura 4

Figure 4. Reduction of lesion and return to normal characteristics of peri-implant tissues.

Discussion

PG is an example of inflammatory hyperplasia that may occur in the oral cavity. Although its name implies infection, this condition has no relation to the infection clinically or histopathologically. The exact cause is not clearly identified; however, it can be connected to trauma, poor oral hygiene, low grade irritation and dental plaque. Since pyogenic granuloma is a reactive lesion, it tends to regress after removal of the stimulating factor.1

 

The rarity of PG associated with dental implants is evidenced by the few cases described in the literature, demonstrating the lack of data in this topic.1,2,4,5,1215 A search in the PubMed database using the terms "pyogenic granuloma", "dental implants" revealed only 8 papers available about GP cases after dental implants by 2018. (Table 1)

 

Among researchers, there are those who believe that its development is related to infectious factors such as foreign bodies, bacterial presence in the walls of blood vessels that nourish the granuloma and also hormonal imbalance.16 Although pyogenic granulomas have been associated with hormonal imbalance that modifies the behavior of an inflamed gingiva, it is also associated with bacterial plaque and the effects of its toxins on periodontal tissues, mainly because the normal periodontium is also vulnerable to the same conditions, even though inflammation is not present.

 

PGs can in fact be treated with different techniques, or even a combination of them. Oral and topical beta-blocker treatment has been described by some authors as the first choice treatment when they affect children, mainly due to minimal adverse effects. Complete surgical removal of the lesion for histopathological examination is also indicated in most cases, but may cause aesthetic problems, especially when involving the upper incisors due to their position in the maxilla. In the cases described in this paper, surgical approaches could cause great aesthetic defects during the healing process, therefore, removal of the possible cause and chemical control with the use of chlorhexidine was the chosen treatment.

 

Reactive lesions tend to respond positively to conservative treatment, and the clinical situation 30 days later showed that it was appropriate in both cases. Another fact to be mentioned is that, in both situations, loosening of the fixation screw seems to have been the main responsible for gingival inflammation, more specifically due to the fact that the loose screws increase plaque deposition while causing displacement of the gingival tissue. The association of low grade trauma in addition to microorganisms in an environment where constantly under stress contributes to inflammation and therefore is the main point to be corrected. Again, the close relationship of PG and dental plaques is in line with the work of Kerr,16 who states that foreign bodies and bacterial presence in the walls of blood vessels play important roles in the development of this lesion.


 

Author

Year

No. of cases reported

Outcome

Treatment

Olmedo et al 2

2010

1

No relapses

Surgical excision

Dojcinovic et al 1

2010

1

No relapses

Surgical excision

Etoz et al 3

2013

1

No relapses

Surgical excision

Kang et al 5

2014

1

No relapses

Surgery excision

Kaya et al 4

2015

1

No relapses

Surgical excision

Anitua et al 13

2015

10

No relapses

Surgical excision

Truschnegg et al 14

2016

1

No relapses

Surgical excision

Gefrerer et al 15

2016

1

No relapses

Surgical excision

Present Case

2018

2

No relapses

Conservative treatment

Table 1: Reported Cases on occurrence of pyogenic granuloma in relation to dental implant.

 


In general, lesions that do not regress within 14 days are treated with complete surgical excision in most cases. However, in both cases reported in this paper, radical treatment with total removal of the lesion could cause a considerable aesthetic defect, which would probably require free flaps or grafts, in addition to a surgical approach, costs to the patient and finally gingival aesthetics scar.

 

In summary, the results of the approaches described in this paper corroborate the clinical sense that any factor that contributes to the accumulation of dental plaque around and within the gingival tissues plays an essential role in the development of PG, and that plaque control and stabilization of the prosthesis may, in fact, be the necessary clinical procedures that contribute to its regression.

 

Conclusion

Based on the data obtained in this study and others in the literature, we can conclude that PG in association with dental implants and their respective prosthesis, seem to respond to the same stimulus that triggers this lesion related to natural teeth. They should be included in the differential diagnosis of soft mass growth around dental implants.

 

Author Affiliations

1.Dr.Emerson Filipe de Carvalho Nogueira, Oral and Maxillofacial Department, 2.Dr.Luciano Barreto Silva, Oral Pathology Department, 3.Dr.Bruno Jos Carvalho Macdo Neres, Oral and Maxillofacial Department, 4.Dr.Thiago Nunes de Siqueira Pedrosa, Federal University of Pernambuco, 5.Dr.Gerhilde Callou Sampaio, Professor of the Oral Pathology Department, 6.Dr.Jos Ricardo de Holanda Vasconcellos, Professor of the Oral and Maxillofacial Department, Dental School of Pernambuco, University of Pernambuco, Camaragibe, Pernambuco, Brazil.

 

References

1.     Dojcinovic I, Richter M, Lombardi T. Occurrence of a pyogenic granuloma in relation to a dental implant. J Oral Maxillofac Surg. 2010;68:18746.

2.     Olmedo DG, Paparella ML, Brandizzi D, Cabrini RL. Reactive lesions of peri-implant mucosa associated with titanium dental implants: a report of 2 cases. Int J Oral Maxillofac Surg. 2010;39;5037.

3.     Etz O, Soylu E, Kili K, et al. A Reactive Lesion (Pyogenic Granuloma) Associated With Dental Implant: A Case Report. J Oral Implantol 2013;39:7336.

4.     Kaya A, Ugurlu F, Basel B, Sener CB. Oral Pyogenic Granuloma Associated With a Dental Implant Treated With an Er:YAG Laser: A Case Report. J. Oral Implantol 2015;41:7203.

5.     Kang YH, Byun JH, Choi MJ, et al. Co-development of pyogenic granuloma and capillary hemangioma on the alveolar ridge associated with a dental implant: a case report. J. Med. Case Rep. 2014;8:192.

6.     Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48:16775.

7.     Al-Khateeb T, Ababneh K. Oral Pyogenic Granuloma in Jordanians: A Retrospective Analysis of 108 Cases. J Oral Maxillofac Surg. 2003;61:12858.

8.     Epivatianos A, Antoniades D, Zaraboukas T, et al. Pyogenic granuloma of the oral cavity: Comparative study of its clinicopathological and immunohistochemical features. Pathol Int. 2005;55:3917.

9.     Gordn-Nez MA, de Vasconcelos Carvalho M, Benevenuto TG, et al. Oral pyogenic granuloma: A retrospective analysis of 293 cases in a Brazilian population. J Oral Maxillofac Surg. 2010;68:21858.

10.   Saravana GHL. Oral pyogenic granuloma: A review of 137 cases. Br J Oral Maxillofac Surg. 2009;47:3189.

11.   Gonzlez S, Vibhagool C, Falo LD Jr, et al. Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol. 1996;35:42831.

12.   Etz OA, Soylu E, Kili K, et al. A Reactive Lesion (Pyogenic Granuloma) Associated With Dental Implant: A Case Report. J Oral Implantol. 2013:39:7336.

13.   Anitua E, Pinas L. Pyogenic granuloma in relation to dental implants: Clinical and histopathological findings. J Clin Exp Dent. 2015;7:44750.

14.   Truschnegg A, Acham S, Kqiku L, Beham A, Jakse N. CO2 Laser Excision of a Pyogenic Granuloma Associated with Dental Implants: A Case Report and Review of the Literature. Photomed. Laser Surg. 2016;34:4089.

15.   Gefrerer L, Popowski W, Perek JN, Wojtowicz A. Recurrent Pyogenic Granuloma Around Dental Implants: A Rare Case Report. Int J Periodontics Restorative Dent. 2016;36:57381.

16.  Kerr DA. Granuloma pyogenicum. Oral Surg. Oral Med. Oral Pathol. 1951;4:15876.

 

Corresponding Author

Dr.Emerson Filipe de Carvalho Nogueira

Rua Conde de Iraj, 544, Torre, Recife-PE

Ph: 55-81-995458234

E-mail: emerson_filipe@hotmail.com


 

 

 

 

 

Source of Support: Nil, Conflict of Interest: None Declared.

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