Surgical elimination of inflammatory fibrous hyperplasia associated with combination syndrome: a two-year follow-up case report

Abstract

Inflammatory fibrous hyperplasia (IFH), also known as epulis fissuratum, is a reactive mucosal overgrowth caused by chronic denture-related irritation. This report describes a 58-year-old woman with a painful fibrous enlargement in the maxillary anterior vestibule associated with the long-term use of an ill-fitting complete denture. The lesion was excised using a scalpel, with simultaneous vestibuloplasty performed to increase vestibular depth and improve denture stability. Histopathological examination confirmed the diagnosis of IFH. Following soft tissue healing, a new maxillary complete denture was fabricated, and border adjustments were performed during follow-up. At the two-year follow-up, the surgical site remained stable, with preserved vestibular depth and no evidence of recurrence. This case highlights the importance of combined surgical and prosthetic management in achieving long-term tissue stability.

Introduction

Inflammatory fibrous hyperplasia (IFH), also known as epulis fissuratum (EF) or denture-induced hyperplasia, is a benign reactive overgrowth of oral fibrous connective tissue that develops in response to chronic low-grade trauma caused by the flanges of ill-fitting removable prostheses [1]. Clinically, the lesion most commonly occurs in the anterior maxillary vestibule and presents as a raised, nodular or pedunculated fold of hyperplastic tissue adjacent to the denture border [2].

Combination syndrome, first described by Kelly, occurs in patients wearing a maxillary complete denture opposed by mandibular anterior teeth without posterior support [3]. The characteristic pattern of bone resorption and soft tissue changes associated with this syndrome may predispose patients to the development of hypermobile anterior maxillary ridge and IFH [4, 5].

Various surgical and non-surgical approaches have been described for the treatment of IFH and the management of associated soft tissue deformities. Reported treatment modalities include conventional scalpel excision, laser surgery, electrocautery, tissue conditioning, prosthetic refabrication, and the use of a free gingival graft following the removal of hypermobile mucosal folds [6–10]. The management of IFH should be individualized according to the clinical characteristics of the lesion and should include elimination of etiological factors, and adequate long-term follow-up. In this context, additional case reports with extended follow-up may contribute to a better understanding of the long-term stability of different surgical approaches [11].

This case report presents a patient with IFH associated with combination syndrome and maxillary complete denture use who was treated with surgical excision and simultaneous vestibuloplasty, with stable clinical outcomes observed over a two-year follow-up period.

Case report

A 58-year-old woman presented to the Department of Periodontology with a chief complaint of mucosal enlargement in the anterior maxilla and mild-to-moderate pain that increased while wearing her maxillary complete denture. Her medical history included type 2 diabetes mellitus, hypertension, and intracranial artery stenosis, which were managed with sitagliptin/metformin, perindopril, and aspirin. The patient had natural anterior teeth and a fixed partial denture in the mandibular anterior region, with no posterior teeth, and had been wearing a maxillary complete denture for ~13 years. Her history revealed that the mucosal enlargement had first been noticed seven years earlier and had initially been managed by her prosthodontist with tissue conditioning. However, as the mucosal enlargement persisted and the pain progressively worsened, she was referred to our clinic for further evaluation. Written informed consent for treatment and the acquisition of clinical images was obtained from the patient prior to treatment.

Clinical examination revealed a nodular, fibrotic, pedunculated, and mobile mucosal enlargement measuring 8 × 5 mm in the anterior maxillary vestibule, with a vestibular depth of 4 mm (Figs 1 and 2). The clinical findings were consistent with denture-induced fibrous hyperplasia. The patient had an edentulous maxilla opposed by mandibular anterior teeth, with an associated hypermobile anterior maxillary ridge. These findings were compatible with combination syndrome. Panoramic radiography was obtained for baseline assessment (Fig. 3).

Given the fibrotic and pedunculated nature of the lesion and its association with chronic denture-related trauma, epulis fissuratum was considered the leading diagnosis. Irritation fibroma and pyogenic granuloma were considered as differential diagnoses. Since a neoplastic process could not be excluded on clinical grounds alone, an excisional biopsy was performed for histopathological evaluation.

Under local anesthesia, the lesion was excised using a scalpel and submitted for histopathological evaluation. To improve prosthetic stability, the mobile mucosa was repositioned apically and sutured, thereby increasing the depth of the maxillary vestibule (Fig. 4).

Histopathological examination of the excised tissue revealed hyperplastic keratinized squamous epithelium overlying a collagenized stroma with dilated capillaries and a nonspecific chronic inflammatory infiltrate (Fig. 5). These findings confirmed the diagnosis of inflammatory fibrous hyperplasia.

At one-week follow-up, healing was uneventful. After clinical soft tissue healing at one month, a new maxillary complete denture was fabricated (Figs 6 and 7). At the six-month follow-up, the mucosa had healed favourably with good esthetic and functional outcomes (Fig. 8). Denture borders were adjusted as required during the follow-up. At the two-year follow-up, there was no clinical evidence of recurrence; the mucosa appeared healthy, and the vestibular depth achieved through vestibuloplasty remained stable at 6 mm (Fig. 9). During the follow-up period, written informed consent for publication of this case report and the accompanying clinical images was obtained from the patient. The patient reported continued satisfaction with the function and comfort of the denture.

Discussion

Inflammatory fibrous hyperplasia is a reactive lesion that develops as a consequence of persistent mechanical irritation, most commonly caused by an ill-fitting removable prosthesis. In the present case, the lesion was located in the anterior maxillary vestibule and associated with long-term denture use, which is consistent with the typical clinical presentation described in the literature [11, 12]. The patient had been wearing a maxillary complete denture for more than 10 years, and the long duration of the lesion further supports the role of repeated low-grade trauma in its etiology.

Although the clinical appearance was highly suggestive of IFH, an excisional biopsy was performed because reactive and neoplastic lesions may exhibit overlapping clinical features [13]. Histopathological examination remains important, particularly for long-standing lesions, to establish a definitive diagnosis and exclude other pathologies. In this case, the presence of hyperplastic keratinized squamous epithelium, collagenized connective tissue, dilated capillaries, and chronic inflammatory infiltrate supported the diagnosis of inflammatory fibrous hyperplasia.

Several non-surgical and surgical techniques have been described for the treatment of IFH; however, no standardized management protocol has been established. The treatment approach should therefore be individualized according to lesion size, tissue characteristics, prosthetic requirements, and patient-related factors. Laser excision has been reported to be an effective treatment modality for EF [14]. Nevertheless, scalpel excision was preferred in the present case because of the nodular and fibrotic character of the lesion and the need to obtain an intact specimen without thermal artefacts, thereby allowing optimal histopathological evaluation.

The favourable healing observed at six months and the absence of recurrence at two years suggest that simultaneous correction of the soft tissue deformity and elimination of local traumatic factors may contribute to stable clinical outcomes. Long-term maintenance, prosthetic adjustment or renewal when indicated, and regular follow-up remain essential to minimize the risk of recurrence and preserve function.

Conclusion

Surgical excision combined with vestibuloplasty provided favourable functional and clinical outcomes, with no recurrence observed during the two-year follow-up. Accurate diagnosis, elimination of chronic trauma, and long-term monitoring remain essential for stable treatment outcomes.

Acknowledgements

Six-month follow-up of this case was previously presented as a poster at EuroPerio11, 2025, Vienna, Austria.

Author contributions

Cansu Can Yasar: Diagnosis, surgical treatment, and management of the patient; conceptualization, data interpretation, and writing the original draft, critical reviewing and editing, and supervision of the study; Kamar Albaba: Clinical investigation, assistance with surgical and postoperative patient care, data curation, visualization, literature review; Ganime Coban: Histopathological investigation and interpretation, preparation and evaluation of histopathological images, editing. All authors approved the final version, and agreed to be accountable for all aspects of the work.

Conflicts of interest

The authors declare that they have no conflict of interest.

Funding

This work was supported by Bezmialem Vakif University through conference participation funding for presentation at Europerio11.

Data availability

The data that support the findings of this case report are available from the corresponding author upon reasonable request.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying clinical images.

References