Denture Induced Inflammatory Fibrous Hyperplasia (Denture epulis) with Combination Syndrome - A Case Report

INTRODUCTION

Epulis fissuratum¹ (Denture induced inflammatory fibrous hyperplasia) is a term related to ill-fitting denture. This condition is of great concern to the patient as it leads to pain, discomfort and loss of function. Ellsworth Kelly in 1972 was the first person to use the term 'Combination Syndrome² . He described 5 signs or symptoms that commonly occurred in this situation. They include anterior maxillary ridge resorption, papillary hyperplasia in the hard palate, maxillary tuberosity hypertrophy, extrusion of the mandibular anterior teeth, and bone loss under the partial denture base.

Shen and Gongloff³ investigated the prevalence of the combination syndrome in patients who use complete maxillary dentures and found the above changes most consequential to denture using occurred in 24% of patients who had natural mandibular anterior teeth opposing complete maxillary dentures. This prevalence was five times greater than in patients who use maxillary and mandibular complete dentures. The rate did not significantly differ between patients who use or do not use a mandibular RPD. Their study also stated that 5% of their subjects with an edentulous mandible developed combination syndrome. Those patients who had even one mandibular molar present did not show the combination syndrome. Prosthodontist try overcoming this Combination syndrome by careful treatment planning, using preventive, therapeutic and functional treatment modalities which may require a multi-disciplinary approach involving surgical intervention such as planned extractions followed by immediate dentures, vestibuloplasty, excision of flabby tissue followed by metallic denture base prosthesis, implant supported fixed prosthesis, implant supported over dentures etc⁴ . Even conventional prosthodontic techniques with special consideration for flabby tissues, over denture prosthesis and removable cast partial denture may be used.

CASE REPORT

A 45 year old female patient reported to the dental clinic with a history of loose maxillary removable acrylic partial denture since four years. Intra oral examination revealed a symptomless, pedunculated mass, firm in consistency measuring around 3 x2 cm in size involving the anterior maxillary sulcus extending from canine to canine region and on palpation the dental alveolus was soft with the resorbed anterior maxilla (fig 1). Patient dental history revealed that she had undergone extraction of eight anterior teeth four years back and was wearing acrylic removable partial denture. The loose maxillary denture was coming in contact with the lower natural anterior teeth on occlusion (fig 2) .Her medical history revealed that she was no- diabetic and nonhypertensive. A provisional diagnosis of Denture induced fibrous hyperplasia with combination syndrome was arrived at. Blood investigations revealed normal haemoglobin, bleeding and clotting time. Planned surgical excision of the lesion was carried out under local anaesthesia with adrenaline using number 15 BP blade and 3-0 suture needle and suture material .Primary closure with good approximation of the tissue till haemostasis was achieved (fig 3). The excised specimen was sent for histopathological examination in a sterile container with 10% formalin (fig 4). A simple and conventional technique of complete denture design with dental reliners in anterior maxillary region was advocated in this patient with total extraction of the remaining teeth.

Histopathological findings: The gross specimen measured 3x1.5 cm and was firm in consistency. Histopathological examination showed some areas of atrophic as well as hyperplastic stratified squamous epithelium covering dense bundles of connective tissue fibres with plump fibroblasts and few blood vessels (fig 6 and 7). Areas of dense chronic inflammatory cells close to the epithelium were also noted.

DISCUSSION

Epulis fissuratum^1,5 is a common sequel of wearing ill-fitting removable dentures with natural permanent anterior teeth and missing lower posterior teeth .The growth is commonly seen in combination syndrome patients characterized by anterior maxillary ridge resorption, papillary hyperplasia in the hard palate, maxillary tuberosity hypertrophy, extrusion of the mandibular anterior teeth, and bone loss under the partial denture base. Various synonyms^1,6 for this condition include- Denture induced inflammatory fibrous hyperplasia, redundant tissue, Denture injury tumor, Denture Epulis. Epulis fissuratum has a strong female^{6 ,7,9} predominance over males and is seen in age group of 30-60 years.⁴ In a study of 583 cases, 64% were found in females .⁶ In majority of cases, 4 lesions are seen in maxilla than in mandible .Anterior portion of jaws⁶ are affected much more often than posterior area. The lesions may be single or numerous, composed of flaps of hyper plastic tissue .Clinically it is characterized by the development of elongated rolls of tissue in the mucolabial or mucobuccal fold area into which the irritating denture flange conveniently fits. Basic etiology of this condition is chronic injury from thin, over extended denture flanges of unstable dentures¹ . Inflammation though variable is seen in the bottom of deep fissures. In some cases ulceration is not uncommon. 40% of these patients reported a duration of 6 months to two years. Redundant tissue is usually firm and fibrous, although some lesions appear erythematous and ulcerated. It can vary in size from 1 cm to massive lesions that involve most of the length of the vestibule. The lesion has such a characteristic clinical appearance that differential diagnosis is not a problem.

Histologically, the excessive tissue is composed of cellular, inflamed fibrous connective tissue. The overlying epithelium is frequently hyperkeratotic and demonstrates irregular h y p e r p l a s i a o f r e t e ri d g e s. I n f e w c a s e s pseudoepitheliomatous hyperplasia can be seen.A variable chronic inflammatory infilterate is present; sometimes, it may include eosinophils or show lymphoid follicles. If minor salivary glands are included in the specimen, then they usually show chronic sialadenitis. In rare instances, the formation of osseous or chondromatous metaplasia as a reactive phenomenon may be noticed. Care should be taken by the pathologist not to mistake the irregular nature of bone and cartilage for a sarcoma⁶ . 

Treatment of epulis fissuratum depends on the severity of condition at the time of diagnosis. It can be treated with surgical excision, conservative methods or a combination of both⁸ . In most cases, inflammatory fibrous hyperplasia are surgically excised either by conventional methods or by laser^10,11. 

Thirteen patients who had worn a maxillary conventional denture and mandibular osseointegrated implant-supported overdenture for at least 3 years were evaluated and the findings of this study support the view that the combination of prostheses can result in perceived loosening of the maxillary denture, loss of posterior occlusion, increased anterior occlusal pressure, and anterior maxillary bone loss, similar to the effects seen in Combination Syndrome(CS). It is therefore important to ensure that where an implant-supported mandibular overdenture is planned for the edentulous patient, some form of stabilisation of the maxillary arch is also considered¹² . Dental implant rehabilitation challenges conventional treatment with bone-anchoring techniques to provide improved retention and stability for implant-retained and supported prostheses. The necessity of a multidisciplinary approach for early prevention and treatment of this complex condition is emphasized.

Based on pathogenesis of this syndrome, four possible treatment modalities can be conceptually applied to attenuate or correct a traumatic anterior hyperfunction and treat CS. They are: (1) a properly designed removable mandibular partial denture around stable, mildly super-erupted anterior teeth opposed by a complete maxillary denture with even distribution of occlusal stresses over hard/soft tissues and careful maintenance through the follow-up care with a goal to preserve posterior occlusion. In some cases, mandibular anterior teeth may need to be treated with root canal and have their clinical crowns shortened to place opposing maxillary incisors in a proper position; (2) an extraction of anterior mandibular teeth with/without alveoloplasty and construction of functional complete upper and lower dentures with a stable posterior occlusion with punctilious follow-up care and maintenance protocol; (3) an implant treatment of existing dentition with or without extraction of teeth to re-establish solid posterior occlusion with an implantassisted or supported maxillary or mandibular prostheses; (4) using advanced maxillary bone grafting techniques to rebuild the maxillary anterior alveolar ridge in concert with one of the previous three options. The first two treatment modalities are conventional pre-implant symptomatic restorative techniques. The last two seem to be a causative physiologic surgical-prosthetic rehabilitation of the stomatognathic system that can prevent continuous bone deterioration and related signs and symptoms in CS patients.¹³

Prior to or at the implant surgical phase, the hypertrophy of posterior maxilla and overgrowth of maxillary tuberosities can be corrected with an alveoloplasty and maxillary endosseous implants can be placed in a better vertical relationship. If subantral augmentation (sinus lift) is needed, this can also be done with a direct (Tatum) or indirect (Summers) method. CS patients of extensive three dimensional maxillary bone loss have guided dental clinicians and surgeons towards the development of many innovative surgical and prosthetic techniques of correction of maxillary bone atrophy combined with immediate or delayed placement of dental implants.

Reconstructive approaches for the compromised maxillary bone include vertical alveolar distraction osteogenesis, horizontal distraction in combination with bilateral sinus lift/bone grafting procedure, maxillary ridge-splitting techniques followed by immediate dental implants, autogenous iliac crest and calvarial bone grafting, reconstruction of the resorbed edentulous maxilla with autogenous rib grafts, tibial grafting for maxillary bone loss, treatment of severe maxillary atrophy with vascularized free fibula flap in combination with dental implants, interpositional bone grafting with LeFort I osteotomy, orthognathic surgery with or without onlay bone grafting, use of the osseoinductive effect of bone morphogenic protein within endosseous dental implants placed in the maxilla, zygomatic implants with or without sinus lift/bone graft, pterygomaxillary implants combined with zygomatic and conventional implants, the Marius implant bridge for the surgical prosthetic rehabilitation of the resorbed completely edentulous maxilla with 6 implants, ''all-on-4'' maxillary edentulous rehabilitation with 4 strategically placed and immediately loaded implants, combination of short implants and osteotome technique for the posterior maxilla, use of transitional implants and bone grafting before placement of definitive implants, optimal use of the anatomic features of the maxillary arch with tilted implants, use of transmandibular implant and Tatum custom ramus frame implant in CS patients, and others. Both implant-retained and implant-supported prostheses have become an increasingly popular and successful prosthetic rehabilitation for partially and fully edentulous maxilla¹³ .

Those patients who have not developed signs of the combination syndrome and whose mandibular anterior teeth are well preserved and not overerupted may be treated conservatively with a mandibular removable partial denture. A properly designed removable partial denture that distributes occlusal stresses over hard and soft tissues minimizes the risk of developing the combination syndrome. Nevertheless, the overdenture seems to provide a more predictable prognosis, especially for patients who already have the combination syndrome or whose mandibular anterior teeth are structurally or periodontally compromised or overerupted. The treatment modality is determined by the apparent potential of the patient to develop the combination syndrome and by the condition of the remaining mandibular anterior teeth¹⁴. In our case, hyperplastic tissues in the maxilla was surgically excised and no recurrence was seen after a thorough follow up of 1year with a conventional complete denture using soft liners in the anterior maxilla.

CONCLUSION

Denture induced fibrous hyperplasia or denture epulis in combination syndrome patients is a relatively common condition easy to diagnose and treat. The recurrence of the lesion is not seen when it is treated with proper surgical techniques or lasers .The rehabilitation of the patient with special importance to the flabby tissue using multidisciplinary approach results in non- recurrence of the growth. However reassuring the patient regarding the harmless nature of the the growth is a must.