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Repair of a chronic oronasal defect with an anteriorly based tongue flap: Report of a case
J Oral Maxillofac 46:412-%15,
Surg
1968
Repair of a Chronic Oronasal Defect with an Anteriorly Based Tongue Flap: Report of a Case ANDREW ZEIDMAN, DDS,* ARNIE LOCKSHIN, DMD,* JULIUS BERGER, DDS,t AND BERNARD GOLD, DMD* Introduction
reversed palatal flaps, bone grafts, and metallic implants. I2 The use of tongue flaps has been reserved for cases where the aforementioned procedures have failed. The conservative methods have been reportedly successful when the defect has been less than 1.5 cm.i3
The treatment of intraoral defects with pedicled tongue flaps dates back to 1956, when Klopp and Scherter’ published an article detailing the use of such a flap in the closure of a soft palate defect. Since that time proper flap design and perioperative management have been debated. It is the intent of this article to discuss the prevailing concepts of flap design and perioperative management, the indications for use of such a flap, and to describe a case in which it was successfully used to close a chronic oronasal defect.
Materials and Methods The anatomic basis for tongue flap design was presented by Bracka who described animal studies of the lingual vascular tree.14 The paired lingual arteries course from the base of the tongue anteriorly, along the ventral surface of the tongue, deep to the muscle mass. Proximally, the suprahyoid and dorsalis linguae arteries are given off. The dorsalis linguae arteries course cephalad to supply the dorsum of the tongue, vallecula, epiglottis, tonsil, and adjacent soft palate. 5 This vessel constitutes the primary blood supply to posteriorly based tongue flaps.‘*14 As the lingual artery passes anteriorly, deep to the hyoglossus muscle, it bifurcates into a smaller sublingual artery and a larger deep lingual or ranine artery. I4 The sublingual artery supplies the sublingual gland, the mylohyoid muscle, and adjacent musculature, The deep lingual artery courses anteriorly, deep to the ventral mucosa, giving off numerous branches that ascend towards the dorsum of the tongue.14 The two arterial trees are separated by a median fibrous septum except at the base, where the transverse dorsal branches meet, and at the tip, where the deep lingual branches anastomose. l4 It is these deep lingual or ranine arteries that nourish the anteriorly based tongue flap.234-63’4 It is not always possible to have a choice between anteriorly or posteriorly based flaps because of the region in which the defect lies. If a choice is to be made, however, certain points should be emphasized. According to the vascular studies performed by Bracka, posteriorly based flaps are safer with respect to tilling. l4 However, because of the greater
Indications Tongue flaps have been used to close intraoral defects following tumor surgery,2 severe infection3 trauma, and cleft palate fistulas.3-8 According to DeSanto,’ tongue flaps are also useful after radiation therapy. Posteriorly based flaps are indicated when treating defects of the soft palate, retromolar region, and posterior buccal mucosa.” Anteriorly based flaps are useful in the treatment of defects of the hard palate, anterior buccal mucosa, lips, and the anterior floor of the mouth.” Historically, the treatment of palatal defects has involved using local, conservative treatments such as buccal flaps, palatal flaps, combined buccal and
Received from Kings County Hospital Center and the Downstate Medical Center,i Brooklyn, New York. * Resident in Oral and Maxillofacial Surgery. t Chairman Department of Dentistry. $ Director of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr. Zeidman: New York City Health and Hospitals Corporation, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203. 0 1988 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391188
50.00 + .25
412
ZEIDMAN
413
ET AL.
mobility of flaps based at the tip of the tongue, anteriorly based flaps are more versatile.5 Although most authors recommend nasotracheal intubation for the procedure, Pigott et al. have had
FIGURE 1 (top left).
Appearance
FIGURE 2 (fop right). (mid&
right).
FIGURE 5 (botrom kfi). FIGURE 6 (hotrom
of oronasal communication.
Bony defect after reflection of soft tissue.
FIGURE 3 (middle left). FIGURE 4
success with orotracheal intubation.4 A local anesthetic with a vasoconstrictor should be used on the palate, but no vasoconstrictor should be used on the tongue.5*7*‘3
right).
Intraoperative
view of the anteriorly based tongue flap. The donor site has been closed.
Tongue flap sutured to palatal tissue with 3-O Vicryl sutures. Tongue immediately after return of pedicle. Palate after return of pedicle to the tongue.
414
ANTERIORLY
When using the anteriorly based flap, the base should lie beneath the posterior border of the defect when the tongue is in its neutral position.4 The length of the flap should be sufficient to span the defect and allow for freedom of tongue movement. 4*6Y7,11,13,14 The flap should not impinge upon the main gustatory papillae.” The width of the flap should be equal to the width of the defect plus about 20%.3 Some authors believe that the flap should not cross the midline,5-7,15 and others maintain that crossing the midline does not jeopardize the viability of the flap. 4*‘1,‘4 The main vascular branches course deep to the flap and should not be affected by the surgery. Excellent anastomoses at the tip and base aid bilateral flaps.14 The flap should be thick enough to include several millimeters of muscle to protect the submuBecause of the vascucosal vascular plexus. 4*11,3~14 lar arrangement, the dorsal mucosa blends intimately with the muscle layer, obliterating any surgical cleavage plane. I4 The closure of the donor site is essential to the success of the flap; it should be done in layers to eliminate dead space and ensure hemostasis. Hematoma formation and the infiltration of hemorrhage into the loose stroma of lingual musculature may cause significant edema, thereby jeopardizing flap viability.5.” After removal of the tissue adjacent to the palatal defect, the mucosal edges are everted and sutured to form the nasal mucosal closure of the defect. The flap is then sutured to the palatal mucosa with all edges everted. Suture knots should be tied only after all suturing has been completed.4.6 Some authors recommend postoperative maxillomandibular fixation, ‘r and others feel that wiring the tongue to the maxillary central incisors and/or suturing the tongue to the upper lip provides sufftcient stabilization to protect the flap.‘*r3 With a sufficiently long flap that places little or no tension on the suture line on the palate, stabilization by way of suturing of the tongue to the upper lip is only necessary during the patient’s emergence from general anesthesia.3 Some authors feel that no immobilization is necessary.4,12 Most authors agree that the pedicle can be returned to the donor site in 2 to 3 weeks, under local anesthesia with or without mild sedation. Steinhauser” feels that subsequent thinning of excessive palatal tissue should be done at 4 week intervals, 3 months after the return of the pedicle. Complications of the tongue flap procedure include hematoma formation and sloughing of the loss of graft,5,” epistaxis,4 and the temporary tongue sensation and taste.4 Studies have shown that no remarkable disturbances of speech, articu-
BASED TONGUE FLAP FOR ORONASAL DEFECT
lation, or lingual mobility occur following a reasonable postoperative period.‘r,‘3,‘6~‘7 The only residual defect of the procedure seems to be a slightly narrower tongue. l1 Report of a Case A 39-year-old black man came to the King’s County Hospital Department of Oral and Maxillofacial Surgery in October 1985 with the complaint of a toothache. Routine intraoral examination revealed generalized, severe periodontitis and a 2 cm, round, midline defect in the anterior hard palate (Fig. 1). The patient stated that he had been struck in the face with a brick 4 years earlier. Several teeth had been extracted at that time and maxillomandibular fixation had been placed for unknown fractures. The patient was aware of the oronasal communication and stated that he felt it had been slowly enlarging over the past few years. Although he sought no previous treatment for this condition, he now expressed an interest in having it corrected. The patient was admitted the next day for the extraction of the multiple periodontally involved teeth and for a biopsy of the soft tissue adjacent to the defect. The histologic report indicated only squamous and respiratory mucosa, with chronic inflammation and fibrosis. Further work-up, including CT scan and multiple bacterial and fungal cultures, was negative and a diagnosis of a traumatic defect with oronasal co&unication was made. The patient was readmitted in December 1985, and the
FIGURE 7 (top).
View of tongue 1 year postoperatively.
FIGURE 8 (bottom).
View of palate 1 year postoperatively.
CUESTAS-CARNERO
415
AND BORNANCINI
next day was brought to the operating room. Under gen-
eral anesthesia administered by way of a nasotracheal tube, the soft tissue adjacent to the defect was excised (Fig. 2). The nasal mucosa was visualized, released, and closed primarily. An anteriorly based tongue flap, 3 cm in width, 5 cm in length, and 6 mm in depth including 2 to 3 mm of muscle mass, was raised and the donor site was closed in layers with 3-O chromic gut sutures (Fig. 3). The flap was then sutured to the palatal mucosa, which had been undermined and everted, with 3-O Vicryl sutures (Fig. 4). Additionally, the tongue was sutured to the upper lip with a 1-O black silk sutures during the immediate postoperative period. The postoperative course was uneventful and the patient was discharged on the third day. Approximately 211/2weeks after the initial procedure, the patient had the pedicle returned to the tongue under local anesthesia and light sedation (Figs. 5,6). The patient tolerated the procedure well and was followed closely for 2 months, with effective closure of the defect. The patient was then lost to follow-up and a planned trimming procedure could not be done. However, 1 year postoperatively, the patient returned to our clinic for follow-up and denture construction. The palatal defect had remained closed and it was planned to trim the excess tissue prior to denture
construction
(Figs.
7, 8).
References I. Klopp CT, Schurter M: The surgical treatment of cancer of the soft palate and tonsil. Cancer 9:1239, I956 2. DeSanto LW, Yarington CT Jr: Tongue flaps: Repair of oral and pharyngeal defects after resection of cancer. Otolaryngol Clin North Am 16:343, 1983 3. Smith TS, et al: Repair of a palatal defect using a dorsal pedicle tongue flap. J Oral Maxillofac Surg 40:670, 1982
J Oral Maxillofac 46:415-l20.
4. Pigott RW, et al: Tongue flap repair of cleft palate tistulae. Br J Plast Surg 37:285, 1984 5. Converse: Reconstructive Plastic Surgery, 2nd ed. Philadelphia, WB Saunders. 1977, PD 2701-2705 6. C&eirao S, Lessa S: Tongue flaps and the closing of large fistulas of the hard nalate. Ann Plast Surp. 4: 182. 1979 7. Carlesso J, et al: Hemi-tongue flaps. Plast-Reconstr Surg 66:574, 1980 8. Guerrero-Santos J, Altamirano JT: The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 38:123, 1966 9. DeSanto LW: Lingual flap reconstruction after resection for cancer. Trans Am Acad Ophthamol Otolaryngol 78:135, 1974 IO. Bakamjian VY: Anteriorly and posteriorly based pedicle flaps from the dorsum of the tongue. Proc First Int Conf Surg Face Neck 2: 158, 1972 II. Steinhauser E: Experience with dorsal tongue flaps for closure of defects of the hard palate. J Oral Maxillofac Surg 40~787, 1982 12. Sachs SA, et al: Treatment of a persistant oroantral fistula with a posteriorly based lateral tongue flap. Int J Oral Surg 8:225, 1979 13. Jackson IT: Use of tongue flaps to resurface lip defects and close palatal fistulae in children. Plast Reconstr Surg 49:537, 1972 14. Bracka A: The blood supply of dorsal tongue flaps. Br J Plast Surg 34:379, 1981 15. Hockstein HJ: The closing of large residual palatal and velum clefts using tongue flaps. Zahn Mund Kieferheilkd 65:12. 1977 16. Massengill R, Pickrell K, Mladick R: Lingual flaps: Effect on speech articulation and physiology. Am Otol Rhino1 Laryngol 79:853. 1970 17. Guerrero-Santos J, Fernandez JM: Further experience with tongue flaps in cleft palate repair. Cleft Palate J lO:IY2, 1973 46:OOO-OOO
Surg
1988
Hereditary Generalized Gingival Fibroma tosis Associated with Hypertrichosis: Report of Five Cases in One Family RICARDO CUESTAS-CARNERO, DDS,* AND CARLOS A. BORNANCINI, DDSt Introduction Received from the Oral Surgery Department III, National University of Cordoba. School of Dentistry. Cordoba, Argentina. * Professor. t Assistant Professor. Address correspondence and reprint requests to Dr. CuestasCarnero: Calle General Bustos 401, Cordoba 5000 Argentina.
0 1988 geons
American
0278-2391188
$0.00
Association + .25
of Oral
and
Maxillofacial
Sur-
Gingival fibromatosis is a rare, benign oral disease that is characterized by a slowly progressive, nonhemorrhagic enlargement of the maxillary and mandibular gingivae. This enlargement results from an abnormal increase in the connective tissue elements of the submucosa; sometimes to such a degree that the teeth are completely covered by the
Surg
1968
Repair of a Chronic Oronasal Defect with an Anteriorly Based Tongue Flap: Report of a Case ANDREW ZEIDMAN, DDS,* ARNIE LOCKSHIN, DMD,* JULIUS BERGER, DDS,t AND BERNARD GOLD, DMD* Introduction
reversed palatal flaps, bone grafts, and metallic implants. I2 The use of tongue flaps has been reserved for cases where the aforementioned procedures have failed. The conservative methods have been reportedly successful when the defect has been less than 1.5 cm.i3
The treatment of intraoral defects with pedicled tongue flaps dates back to 1956, when Klopp and Scherter’ published an article detailing the use of such a flap in the closure of a soft palate defect. Since that time proper flap design and perioperative management have been debated. It is the intent of this article to discuss the prevailing concepts of flap design and perioperative management, the indications for use of such a flap, and to describe a case in which it was successfully used to close a chronic oronasal defect.
Materials and Methods The anatomic basis for tongue flap design was presented by Bracka who described animal studies of the lingual vascular tree.14 The paired lingual arteries course from the base of the tongue anteriorly, along the ventral surface of the tongue, deep to the muscle mass. Proximally, the suprahyoid and dorsalis linguae arteries are given off. The dorsalis linguae arteries course cephalad to supply the dorsum of the tongue, vallecula, epiglottis, tonsil, and adjacent soft palate. 5 This vessel constitutes the primary blood supply to posteriorly based tongue flaps.‘*14 As the lingual artery passes anteriorly, deep to the hyoglossus muscle, it bifurcates into a smaller sublingual artery and a larger deep lingual or ranine artery. I4 The sublingual artery supplies the sublingual gland, the mylohyoid muscle, and adjacent musculature, The deep lingual artery courses anteriorly, deep to the ventral mucosa, giving off numerous branches that ascend towards the dorsum of the tongue.14 The two arterial trees are separated by a median fibrous septum except at the base, where the transverse dorsal branches meet, and at the tip, where the deep lingual branches anastomose. l4 It is these deep lingual or ranine arteries that nourish the anteriorly based tongue flap.234-63’4 It is not always possible to have a choice between anteriorly or posteriorly based flaps because of the region in which the defect lies. If a choice is to be made, however, certain points should be emphasized. According to the vascular studies performed by Bracka, posteriorly based flaps are safer with respect to tilling. l4 However, because of the greater
Indications Tongue flaps have been used to close intraoral defects following tumor surgery,2 severe infection3 trauma, and cleft palate fistulas.3-8 According to DeSanto,’ tongue flaps are also useful after radiation therapy. Posteriorly based flaps are indicated when treating defects of the soft palate, retromolar region, and posterior buccal mucosa.” Anteriorly based flaps are useful in the treatment of defects of the hard palate, anterior buccal mucosa, lips, and the anterior floor of the mouth.” Historically, the treatment of palatal defects has involved using local, conservative treatments such as buccal flaps, palatal flaps, combined buccal and
Received from Kings County Hospital Center and the Downstate Medical Center,i Brooklyn, New York. * Resident in Oral and Maxillofacial Surgery. t Chairman Department of Dentistry. $ Director of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr. Zeidman: New York City Health and Hospitals Corporation, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203. 0 1988 American
Association
of Oral and Maxillofacial
Sur-
geons 0278-2391188
50.00 + .25
412
ZEIDMAN
413
ET AL.
mobility of flaps based at the tip of the tongue, anteriorly based flaps are more versatile.5 Although most authors recommend nasotracheal intubation for the procedure, Pigott et al. have had
FIGURE 1 (top left).
Appearance
FIGURE 2 (fop right). (mid&
right).
FIGURE 5 (botrom kfi). FIGURE 6 (hotrom
of oronasal communication.
Bony defect after reflection of soft tissue.
FIGURE 3 (middle left). FIGURE 4
success with orotracheal intubation.4 A local anesthetic with a vasoconstrictor should be used on the palate, but no vasoconstrictor should be used on the tongue.5*7*‘3
right).
Intraoperative
view of the anteriorly based tongue flap. The donor site has been closed.
Tongue flap sutured to palatal tissue with 3-O Vicryl sutures. Tongue immediately after return of pedicle. Palate after return of pedicle to the tongue.
414
ANTERIORLY
When using the anteriorly based flap, the base should lie beneath the posterior border of the defect when the tongue is in its neutral position.4 The length of the flap should be sufficient to span the defect and allow for freedom of tongue movement. 4*6Y7,11,13,14 The flap should not impinge upon the main gustatory papillae.” The width of the flap should be equal to the width of the defect plus about 20%.3 Some authors believe that the flap should not cross the midline,5-7,15 and others maintain that crossing the midline does not jeopardize the viability of the flap. 4*‘1,‘4 The main vascular branches course deep to the flap and should not be affected by the surgery. Excellent anastomoses at the tip and base aid bilateral flaps.14 The flap should be thick enough to include several millimeters of muscle to protect the submuBecause of the vascucosal vascular plexus. 4*11,3~14 lar arrangement, the dorsal mucosa blends intimately with the muscle layer, obliterating any surgical cleavage plane. I4 The closure of the donor site is essential to the success of the flap; it should be done in layers to eliminate dead space and ensure hemostasis. Hematoma formation and the infiltration of hemorrhage into the loose stroma of lingual musculature may cause significant edema, thereby jeopardizing flap viability.5.” After removal of the tissue adjacent to the palatal defect, the mucosal edges are everted and sutured to form the nasal mucosal closure of the defect. The flap is then sutured to the palatal mucosa with all edges everted. Suture knots should be tied only after all suturing has been completed.4.6 Some authors recommend postoperative maxillomandibular fixation, ‘r and others feel that wiring the tongue to the maxillary central incisors and/or suturing the tongue to the upper lip provides sufftcient stabilization to protect the flap.‘*r3 With a sufficiently long flap that places little or no tension on the suture line on the palate, stabilization by way of suturing of the tongue to the upper lip is only necessary during the patient’s emergence from general anesthesia.3 Some authors feel that no immobilization is necessary.4,12 Most authors agree that the pedicle can be returned to the donor site in 2 to 3 weeks, under local anesthesia with or without mild sedation. Steinhauser” feels that subsequent thinning of excessive palatal tissue should be done at 4 week intervals, 3 months after the return of the pedicle. Complications of the tongue flap procedure include hematoma formation and sloughing of the loss of graft,5,” epistaxis,4 and the temporary tongue sensation and taste.4 Studies have shown that no remarkable disturbances of speech, articu-
BASED TONGUE FLAP FOR ORONASAL DEFECT
lation, or lingual mobility occur following a reasonable postoperative period.‘r,‘3,‘6~‘7 The only residual defect of the procedure seems to be a slightly narrower tongue. l1 Report of a Case A 39-year-old black man came to the King’s County Hospital Department of Oral and Maxillofacial Surgery in October 1985 with the complaint of a toothache. Routine intraoral examination revealed generalized, severe periodontitis and a 2 cm, round, midline defect in the anterior hard palate (Fig. 1). The patient stated that he had been struck in the face with a brick 4 years earlier. Several teeth had been extracted at that time and maxillomandibular fixation had been placed for unknown fractures. The patient was aware of the oronasal communication and stated that he felt it had been slowly enlarging over the past few years. Although he sought no previous treatment for this condition, he now expressed an interest in having it corrected. The patient was admitted the next day for the extraction of the multiple periodontally involved teeth and for a biopsy of the soft tissue adjacent to the defect. The histologic report indicated only squamous and respiratory mucosa, with chronic inflammation and fibrosis. Further work-up, including CT scan and multiple bacterial and fungal cultures, was negative and a diagnosis of a traumatic defect with oronasal co&unication was made. The patient was readmitted in December 1985, and the
FIGURE 7 (top).
View of tongue 1 year postoperatively.
FIGURE 8 (bottom).
View of palate 1 year postoperatively.
CUESTAS-CARNERO
415
AND BORNANCINI
next day was brought to the operating room. Under gen-
eral anesthesia administered by way of a nasotracheal tube, the soft tissue adjacent to the defect was excised (Fig. 2). The nasal mucosa was visualized, released, and closed primarily. An anteriorly based tongue flap, 3 cm in width, 5 cm in length, and 6 mm in depth including 2 to 3 mm of muscle mass, was raised and the donor site was closed in layers with 3-O chromic gut sutures (Fig. 3). The flap was then sutured to the palatal mucosa, which had been undermined and everted, with 3-O Vicryl sutures (Fig. 4). Additionally, the tongue was sutured to the upper lip with a 1-O black silk sutures during the immediate postoperative period. The postoperative course was uneventful and the patient was discharged on the third day. Approximately 211/2weeks after the initial procedure, the patient had the pedicle returned to the tongue under local anesthesia and light sedation (Figs. 5,6). The patient tolerated the procedure well and was followed closely for 2 months, with effective closure of the defect. The patient was then lost to follow-up and a planned trimming procedure could not be done. However, 1 year postoperatively, the patient returned to our clinic for follow-up and denture construction. The palatal defect had remained closed and it was planned to trim the excess tissue prior to denture
construction
(Figs.
7, 8).
References I. Klopp CT, Schurter M: The surgical treatment of cancer of the soft palate and tonsil. Cancer 9:1239, I956 2. DeSanto LW, Yarington CT Jr: Tongue flaps: Repair of oral and pharyngeal defects after resection of cancer. Otolaryngol Clin North Am 16:343, 1983 3. Smith TS, et al: Repair of a palatal defect using a dorsal pedicle tongue flap. J Oral Maxillofac Surg 40:670, 1982
J Oral Maxillofac 46:415-l20.
4. Pigott RW, et al: Tongue flap repair of cleft palate tistulae. Br J Plast Surg 37:285, 1984 5. Converse: Reconstructive Plastic Surgery, 2nd ed. Philadelphia, WB Saunders. 1977, PD 2701-2705 6. C&eirao S, Lessa S: Tongue flaps and the closing of large fistulas of the hard nalate. Ann Plast Surp. 4: 182. 1979 7. Carlesso J, et al: Hemi-tongue flaps. Plast-Reconstr Surg 66:574, 1980 8. Guerrero-Santos J, Altamirano JT: The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 38:123, 1966 9. DeSanto LW: Lingual flap reconstruction after resection for cancer. Trans Am Acad Ophthamol Otolaryngol 78:135, 1974 IO. Bakamjian VY: Anteriorly and posteriorly based pedicle flaps from the dorsum of the tongue. Proc First Int Conf Surg Face Neck 2: 158, 1972 II. Steinhauser E: Experience with dorsal tongue flaps for closure of defects of the hard palate. J Oral Maxillofac Surg 40~787, 1982 12. Sachs SA, et al: Treatment of a persistant oroantral fistula with a posteriorly based lateral tongue flap. Int J Oral Surg 8:225, 1979 13. Jackson IT: Use of tongue flaps to resurface lip defects and close palatal fistulae in children. Plast Reconstr Surg 49:537, 1972 14. Bracka A: The blood supply of dorsal tongue flaps. Br J Plast Surg 34:379, 1981 15. Hockstein HJ: The closing of large residual palatal and velum clefts using tongue flaps. Zahn Mund Kieferheilkd 65:12. 1977 16. Massengill R, Pickrell K, Mladick R: Lingual flaps: Effect on speech articulation and physiology. Am Otol Rhino1 Laryngol 79:853. 1970 17. Guerrero-Santos J, Fernandez JM: Further experience with tongue flaps in cleft palate repair. Cleft Palate J lO:IY2, 1973 46:OOO-OOO
Surg
1988
Hereditary Generalized Gingival Fibroma tosis Associated with Hypertrichosis: Report of Five Cases in One Family RICARDO CUESTAS-CARNERO, DDS,* AND CARLOS A. BORNANCINI, DDSt Introduction Received from the Oral Surgery Department III, National University of Cordoba. School of Dentistry. Cordoba, Argentina. * Professor. t Assistant Professor. Address correspondence and reprint requests to Dr. CuestasCarnero: Calle General Bustos 401, Cordoba 5000 Argentina.
0 1988 geons
American
0278-2391188
$0.00
Association + .25
of Oral
and
Maxillofacial
Sur-
Gingival fibromatosis is a rare, benign oral disease that is characterized by a slowly progressive, nonhemorrhagic enlargement of the maxillary and mandibular gingivae. This enlargement results from an abnormal increase in the connective tissue elements of the submucosa; sometimes to such a degree that the teeth are completely covered by the