Pregnancy tumor superimposed upon a nevus

PREGNANCY

TUMOR

SUPERIMPOSED

UPON A N-EVUS

Report of a Case Newton E. Allen,

D.D.S., P.A.C.D.,

Selmn, A/n.

P

tumors are thought to be caused by hormonal stimulation during gestat,ion,l-’ and t,hey occur rat.her frequently in women with gingivitis OI pregnancy. They occur on the skin and mucous membrane of the nose, tongm, lips, gingiva, and rectmn7 The oral lesion which is reddish blue in color, tends to decrease in size postpartum and to recw in another Incgnancy. These 1~ and microscopically. sions resemble granuloma pyogenicum, both clinically Recording to Kerr,8 the tumor of pregnancy cannot be distinguished from t.11~ Fabe7 t,hinks that these tumors granuloma pyogenicum by histologic findings. are primarily hemangiomas, usually of the cavernous type, and cannot, be histologically differentiated from them. Rlum’ refers to these lesions as angiclgranulomas. &kin and Nesse,” Fabe,7 and Thorna” have reportecl pregnancy tumors associated with nevi and have supplied evidcncc that ncvi are predisposed 10 tumor formation during gestation. The interesting case reported here involved a large pregnancy tumor snpe~ imposed npon a nevus. The methods employetl for its excision, control o I anticipated excessive bleeding, and rnanagcnwnt of t hc surgical tlefect, canst*tl I)y its removal are presented. REGNANCY

CASE RRl’ORT A 22.year-old Negro woman in thcb fifth month of her second pregnancy was SPW tm Aug. 17, 1954, having been referred by hclr pliysil~ieri for \liaguosis and trt~atmeul of e turn~~l in the right maxillary area. History.-The patient first noticed the mass t,\vo years e;trlier, during the tltirtl <)I fourth month of her first pregnancy. After parturition, the tumor tlr~r~setl in size liut (lid not disappear. It became greatly enlarged during the current preguancy, beginning A large nevus on the right sid(b of the face had existed sint*r ahout the second month. birth. The patient stated that she had never be(u ill in her lifts! an4 the Family history was noncontributory. E:zatination.-The right side of the face was obviously enlarged. A nevus fianunt~s c>overed the external as well as the internal surfaces of the upper lip (Fig. 1) and sprthad over the cheek from the level of the occlusal plane of t,he teeth t,o the lower eyelid. XxAlmost its entire border was outlined t,rrnally, it was reddish brown and slightly elevated. Other than thu dolor an!1 the slight elevation, the grc,ss by a drfinit~e line of demarcation. G57

appearance of the surface was that of normal skin. Palpation, however, I,evealed 1 it to be On the inner surface of the cheek the news was reddic gh and granular. Pu ffy or spongy. It also involved the mucobuccal fold and the labial gingival tissue to the ml:!dian lj inc.

Fig. I.-News

Fig.

2.-Photographs

flammeus

involving

of pregnancy

right

tumor

upper lip and cheek

superimposed

(Aug.

upon news

A large mass extended from the upper right lateral incisor ma xilla and covered the ocolusal surfaces of several teeth (Fig. pri :marily on the buecal side of the arch but involved the palatal It interfered with mastication, it bled easily, and on palpation it

1 7, 1954 )

(ALU:. 17, I 954).

to the t uberosi ty of the 2). The tumor appeared tissues to a lessc:r degree. could be felt tl 3 pulsate.

Volume 13 Number

PREGNANCY

TUMOR

SUPERIMPOSEI~

UPON

,hu’F,T’US

f ; :i ! t

6

The anterior portion of the tumor was bright pink, firm, and lobular. It was apparenti! covered by rather smooth and shiny epithelium, whereas the posterior part was similar iu color and texture to the mucosal covering of the oral surface of the nevus. There was an area of hypertrophicd tissue in the lower right molar region. Revc~l teeth WUC: afYected by advanced caries, and calculus fornmtion was slight. Roentgenographic examination (Fig. 3 ) revealed spacing of t,lu: upper right cuspi~l and first premolar. Some resorption of boric betwern these, trc?h 1, as c~vitl(~nt.

Fig.

8.-Roentgenogram

showing

spacing

of cuspid

and

Arst

premolar

(Aug.

17, 1954).

Except for the orofacial lesions, the patient, whose pregnancy was progressing mally, was in excellent health. The referring physiemn reported that t,he findings physical examination, including laboratory studies, were withiu normal limits.

norof a

Biop6y-On the date of the initial examination, tissue for mieroseopic study was removed under local anesthesia. An attempt was made to obtain a specimen that would comprise a representative section of the tumor mass and the surrounding mucoperiosteum. The tissue was placed in bottle No. 1 containing 10 per cent formalin solution. Profuse bleeding was encountered, and it was necessary to suture a gelatin sponge (Cielfoamj dressing into place to control the hemorrhage. A section of the hypertrophied tissue in the right mandibular molar area was also removed for examination and placed in bottle No. 3. ‘I’ll0 material was submitted to Colonel Joseph I,. Hitrnirr at the* .Atmrd Forces Institutes crt Pathology, and his report, dat,ed Aug. 21, 1954, follows: Two sections of tissue arc examined. The section from the JItiroscopic: tumor mass (1) is characterized by numerous vascular channels of varying sizes. There is some endothelial proliferation with a few scattered chronic inflammatory (aells. The tissue is markedly edematous and is covered by stratified squamous epithelium exhibiting acanthosis and parakeratosis. The other section (2) is covered by hyperplastic stratified squamous epithelium and in one area shows surface The underlying connective tissue is heavily infiltrated by lymphocytes ulcerat.ion. The recognizable fibrous tissue nho~s foci of myxomat,ous and plasma cells. degeneration. Diagnosis:

(1)

Pregnancy

tumor ; (8) hyperplastic

oral mucosa.

T~atment and Counse.--On Aug. 23, 1954, the sutures placed at the time of biopsy were removed and excision of the tumor was scheduled for Aug. 25, 1954. The patient failed to come on that day and was not seen again until Sept. 20, 1954, when she came to On the afternoon of Sept. 22, 1954, she was given a prophymake another appointment. lactic intramuscular injection of 5 mg. of Adrcnosem Salicylat~e. On the following day premeditation consisted of 0.1 gram (1.5 grains 1 of pentoharbital sodium, administered

ALT2!X’

660 orally, and an intramuscular the operation.

injection

OS., O.M. & O.P.

Jung. 19hO

of 5 mg. of Adrenosom

Ralicylate

one hour

before

Local anesthesia was obtained by blocking the posterior superior alveolar, anterior superior alveolar, anterior palatine, and nasopalatine nerves and by infiltrating the tissues surrounding t,he tumor with 2 per cent lidocaine hydrochloride with epinephrine 1:50,000.

Fig.

4.-Gross

Fig.

appearance

of specimen

after

removal

5.

(Sept.

23. 1954).

Fig.

6.

Fig. 5.-Operative fleld immediately after excision of tumor, extraction of two teeth, and reduction of alveolar bone between the cuspid and flrst premolar. Fig. 6.-After gelatin sponge had been placed over the crest of the ridge, loose sutures were attached to the previously undermined mucosa am1 to the palatal soft tissues (Sept. 23, 19 5 4 )

Fig.

7.--Surgical

cement

packed over by removal

the sutures and gelatin sponge of the tumor (Sept. 23, 1954).

protects

the defect

created

An incision started in the mucoperiosteum covering the outer surface of the maxilla in the tuberosity region was carried down to the lrone and extended horizontally in an :*!Iterior direction to a point near the mesial surface of the first molar. It was then ~~ul~v~*~l upward, high into the sulcus, to circumvent the lobular portion of the tumor and tiomnwai~tl The palatal incision was made high II[J, again to the gingival border at the median line. beginning at the posterior end of the buccal incision distal to the second molar and rayThe entire soft tissue mass between the incisioq tending anteriorly to the central incisor. including the residual soft tissue from the in&proximal spaces (Fig. 4), was removed with The alveolar crest was then reduced !P> :I contra-angle, double-end saw type of curette. curettage. Since soft tissue still existed between the cuspid and the first premolar, both :)i which were loose, these teeth were extracted and the intt~rproximal tissues were remo~i~l with rongeur forceps until healthy bone was reached (Fig. 3). In order to cover the exposed bone between the lateral incisor and the second premolar without lowering the muscular attachments excessively, the lmocal mucosa was undermin~tl A piece of dry gelatin spongte to permit its being brought closer to the crest of the ridge. (Gelfoam) was cut, to fit the crest of the ridge, anti the assistant held it in position nit11 dry instruments while silk sutures were attached to the undermined mucosa and the palaM tissuo. The sutures were passed over the gelatin sponge and tied loosely to :ivt)ill soft tension (Fig. 6). Surgical cement, to which had been added tannic acid powder, was rui\nIl to a thick consistency and applied undtxr pressure around the tP(lth and over the surroundiIz soft tissue? (Fig. 7). During t,he entire proccdurc, I Il(>(lding WLS moderxtc.

The patient no bleeding, and Oct. 3, 1954. No and sutures were was eliminated.

was scen on the folloCng day. Silo Ilad txporicrlwtl very iitlk imill, only minimal swelling. She visited the ofh’c*~>on Sept. L!;, S;ctpi. :jn. a~~tf complications were encountered. On Oci. 7. 1954, the surgical dmkng removed and a new dressing was applied. On October 14 lllc ~lWi3in/:

when the patient came t.o the office 011 Chpt. L!X, Be.&ts.-Healing was satisfactory 1954, and healthy tissue covered the defect thal. had been csreatpd by rrmovd of t.he tumor and extraction of the teeth (Fig. 8). She WBS advised tcl rcaturn for periodic nt+s(~r~:\t,lr,n and to contact her dentist for routine dental ca.rp. A questionnaire was sent to the patient, and a reply dated Jan. 15, 1958, rtatod t,hat there had been no recurrence of the lesion, even though she now had a third child.

In the case just reported, a large pregnancy tumor superimposed lipon a nevus was vascular to the extent t’hat palpation revealed it to pulsate.

662

ALLEN

OS., O.M. ti! O.P.

June,1960

Anticipated excessive bleeding was apparently controlled by the prophylactic administration of Adrenosem Salicylate, the use of a local anesthetic solution containing epinephrine, and the application of a surgical cement to which tannic acid powder had been added. To protect the surgical defect without seriously reducing the depth of the buccoalveolar sulcus, a piece of gelatin sponge was placed over the crest of the alveolar ridge and held by passing silk sutures from the buccal mucoSsato the palatal soft tissues and by placing surgical cement over the entire area. Apparently, the gelatin sponge acted as a matrix for the absorption of blood, which resulted in bridging of the ridge with granulation tissue followed by epithelization. The possibility exists, however, that the gelatin sponge merely provided a space under the surgical pack to permit healing by granulation. REFERENCES Pregnancy Tumors, J. Am. Dent. A. 18: 393, 1931. T.: Diagnosis of Common Lesions of the Oral Cavity, J. Oral Surg. 15: Robert B.: 95, 1957. Gingival Condition in Pregnant Women, ORAL SURG., ORAL MED. 3. Gridley, Mohamed 5.:

1. Blum, 2. Shira,

& ORAL PATH. 7: 641, 1954. Gingivitis Gravidarum, OEAL SURG.,ORAL MED. & ORAL PATH. 5: 734, 195'2. 4. Hilming, F.: Pregnancy Gingivitis, Am. J. Orthodontics & Oral Surg. 5. Ziskin, D. E., and Nesse, G. J.:

32: 390, 1946.

Oral Cancer, Philadelphia, 1954, Lea & Febiger, p. 280. J. Roy: * Pregnancy Tumor, ORAL SURG.,ORAL MED. & ORAL PATH. 7: 714, 1954. Granuloma Pyogenicum, ORAL Sum., ORAL MED. & ORAL PATH. 4: 158,1951. 8: Kerr: D: A.: Sturge-Kalischer-Web Syndrome With Pregnancy Tumors, ORAL SURG., 9. Thoma, K. H.: ;. ;ou;g;pa

ORAL MED. & ORAL PATH. 5: 1124, 1952.

410 CHURCH ST.