Case #37 Discussion

Summary: A patient, who has not visited a dentist in 15 years since his maxillary denture has been constructed, seeks treatment because of a soft tissue enlargement in the maxillary mucolabial fold area.  The lesion has been present for several years and is larger now than when it was first noticed.  The lesion is exophytic, 2.5 x 1.0 cm, firm to palpation, has a smooth but fissured surface, and is fixed to the surface mucosa and to underlying structures.  The flange of the denture fits into the fissure or depression in the lesion.  The lesion is nontender, with the exception of a depressed area in the lesion which is slightly erythematous and tender to palpation.  The lesion does not blanch upon palpation except in the small erythematous area.  Lesions to Exclude from the Differential Diagnosis: This lesion is described as a soft tissue enlargement.  Reactive soft tissue enlargements can be excluded from differential diagnosis because the lesion has been present for several years and is progressively enlarging.  Also, the lesion is not painful, except for occasional soreness associated with the denture. Within the category of tumors, malignant tumors can be excluded because the lesion is very slowly growing and essentially asymptomatic.  Soft tissue cysts are eliminated because they are fluid filled and have “hydraulic” properties, meaning that they are compressible and expand in all directions uniformly.  Cysts do not have a surface with a depression or fissure. From the category of benign tumors, epithelial lesions and salivary gland tumors can be excluded.  Epithelial lesions can be excluded because these have a white, rough surface.  Salivary gland tumors can be excluded because the lesion appears to be arising from the alveolar ridge mucosa.  Salivary gland tumors may arise from the mucolabial fold, but they would displace the denture rather than grow around the flange of the denture. Within the category of benign mesenchymal tumors, the following are excluded.  Irritation fibroma, lipoma, peripheral ossifying fibroma, leiomyoma, neurofibroma, schwannoma, and granular cell tumor can be excluded because they would displace the denture rather than grow around the flange.  The vascular lesions, including pyogenic granuloma, peripheral giant cell granuloma and hemangioma can be excluded because these are vascular in appearance and blanch upon pressure.   Lymphangioma is excluded because it is present from childhood and is compressible.   Neuroma can be excluded because it is typically painful to palpation.  Congenital epulis can be excluded because these lesions are congenital or appear early in life.       Definitive Diagnosis: The definitive diagnosis is epulis fissuratum (also called inflammatory fibrous hyperplasia).  It is the only lesion that surrounds the flange of a denture rather than displacing the denture.  It is often easy to make this diagnosis immediately based on the shape, location, and appearance of the lesion.  Epulis fissuratum represents an overgrowth of fibrous connective tissue due to a poorly fitting denture flange traumatizing the surrounding mucosa.  Thus, the basic pathologic process of epulis fissuratum is a reactive lesion, but we classify it as a tumor because it is persisent and progressive. Management: The patient should have a new denture constructed, however, before this is done, surgical excision of the lesion should be accomplished for microscopic diagnosis and so that the new denture can be accurately constructed.  Final Diagnosis: epulis fissuratum (inflammatory fibrous hyperplasia)