Hyperplastic reaction of normal connective tissue graft harvested from the palate

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Posted on By Howard Gluckman In Failures

This case was treated with normal connective tissue harvested from a pouch in the palate. A few years later the patient presented with this extreme hyperplastic reaction of the tissue and a severely unaesthetic complication. The patient had already had laser therapy to reduce the tissue but it just came back. What would your treatment approach to this be and what is the cause of this type of problem and has anyone seen anything like this I have not, although we now have a second case in the last few months.


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21 Comments

Howie; Wow, I think a few things going on here at the same time possibly? 1. Hyperplastic reaction of grafted tissue (from palate I have not seen something quite like that) 2. Impingement of biologic width with restorations (cause of chronic inflammation and color change around restorations). or 3. Allergy to Restorative Materials?? My suggested solution would be Internal bevel and repositioned flap with crown length to accommodate the existing crown margins. Tough situation, keep us posted. regards Mo


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Given that the reactions are only around the restorations and not generalized, the first things that I would look at is a) infringement on the biologic width and b) retained cement. Both can be addressed by laying a flap and taking a look. Keep us posted. Definitely curious to find out.


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Biological width violation. I would open flap , crown lengthening and curretage the tissue from periosteum. Never had this reaction and I am not sure of outcome. Regards, Gregory


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Definitely has all of those but the craziest part is the massive hyperplasia. I have never seen anything like it. How would you handle this.


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My humble suggestion-regain biologic width and then use high speed diamond to recontour soft tissue Looking at canines the soft tissue height is very forgiving Do you have original photos prior to tx Why was tx done initially?


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She has already had laser recontouring of the gingiva to thin it out and it has just rebounded.


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Sir violation of biological width and secondary irritation factor like mouth breathing should be ruled out. Radiograph with proper angle and probing will help in identifying crown margin in relation with bone level. I had encountered similar case, but it was not grafted case. Upper anterior case showing enlargement after crowns given by restorative dentist. Patient was not aware of mouth breathing. As far as treatment is concerned, posted by many experts, flap elevation and restoration of biologic width. Please post the follow up sir.


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I would agree with mouth breathing for a hyper plastic response of the marginal gingiva but not for the area which has had the graft. The important factor here is the patients lip rises over the graft area and gets stuck so it is a huge cosmetic concern for her. There is no doubt the biological width as well as mouth breathing are a factor in the marginal gingival response. But how do we eliminate the excess tissue when the laser has already failed and lead to regrowth.


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What about labial reposition?


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she is not unhappy with the hyper mobile lip but she is concerned about the lip sliding over the tissue bulk and getting stuck there and if dry she has to physically help the lip over the gum with her hands


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Dear Howie,
This kind of complication is frustrating...
Mostly we see this kind of complications with tuberosity. Ricci and his team have found out that it can be because of gen expression for collagen maturation and that graft thickness should not exceed 3 mm. I am sure you are familiar with this data, since you recently published a paper to this topic.
Could it be because of residual epithelium on the graft? Studies show that it`s never removed completely if de- epithelization is done after graft harvesting. I dont`t know...just trying to find out..
And to the treatment: in one out of 8 my keloid cases I haven`t reduced outer layer with laser or whatever, but exceeded the tissue from inside and it is stabile (18 months now).
Keep us posted
Thank you for sharing
Snjezana


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Thanks Snazzie. WE have discussed this issue and the Ricci paper is for tuberosity graft. This is weird as it is normal sub epithelial connective tissue unique the Ricci or our paper. This is weird so no epithelium as it is pure CT. I have never seen keloid like this and we have a second case now as well


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Supraperiosteal flap, tissue thinning, biological width issue, temporary crowns, reevaluate and then permenant the best of luck


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So this is what we did. We raised a flap crown lengthened where necessary and removed all the inner tissue which is the inducing agent for the hyper plastic tissue. 3 months post op we have now done some laser adjustment before she goes to Mark Bowes for final crowns.


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3 months without laser adjustments


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slight adjustment of the gingival margin. using waterlase


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I do not like how papilla looks. I'm afraid it will come back.


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Howie; I think this is an excellent and biological based approach and would expect an excellent result BUT, she appears somewhat "VME" Vertical Maxillary Excess and possibly Lip incompetent so mouth breathing will continue to play a role especially with subgingival margin location. Thanks for always sharing. Mo


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She has a short lip. Botox.


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I agree. She has a hyper mobile lip. I’m not sure where we will go. Ortho is not an option for her already did 4 urs in brackets. Surgery is out as far as the orthognathics go. And I have not had long term success with lip repositioning. So we will see where we go


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Hu-Friedy
Omnia