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Palatal pyogenic granuloma: An unusual complication following mucogingival surgery for alveolar socket preservation Abstract We report a case of palatal pyogenic granuloma following mucogingival surgery for alveolar socket preservation. A 24-year-old systemically healthy female underwent a pediculated palatal pedicle graft procedure to achieve soft tissue augmentation over a grafted maxillary anterior extraction site. After 1 month, a 15 mm × 20 mm exophytic growth extending from the palatal donor site to distance of 3–4 mm from the extraction socket was observed. After obtaining the subject's consent, local anesthesia was administered and the growth was excised from the base. On histopathological examination, the findings suggestive of pyogenic granuloma were seen. Palatal pyogenic granuloma occurs rarely and the authors were unable to find the reports of pyogenic granuloma originating in the vicinity of a surgical wound after a pediculated connective tissue mucogingival procedure. Healing plays a vital role in mucogingival procedures, and thus, it is very important to know about the complications affecting this important cascade of events. Failing to consider potential sources of irritation or trauma at the surgical site may lead to considerable morbidity even in sites that may heal without any untoward complications. INTRODUCTION Subepithelial connective tissue grafts (CTGs) have been frequently used to augment and correct soft tissue ridge defects in sites requiring implant placement.[12] Many modifications of the CTG procedure exist and one such procedure is the pediculated CTG.[1] The modified rotated palatal pedicle connective tissue flap is a more predictable technique for soft tissue coverage and augmentation as it retains its vascular supply with the palatal bone, allows for transposition over grafted sites, and preserves gingival scallop to improve esthetic outcomes.[12] Commonly reported complications associated with mucogingival procedures include pain, swelling, and bleeding.[12] In a CTG procedure, complications associated with the palatal donor site can arise because of incomplete primary closure of the epithelial flap or sloughing of the overlying tissue.[2] However, altered healing patterns may lead to unconventional complications of the surgical site in the form of granulomatous gingival cysts.[345] Pyogenic granuloma is the most common among oral tumor-like growths. Although terminology implies a benign neoplasm, most of fibromas represent reactive focal fibrous hyperplasias due to trauma or local irritation. The term “focal fibrous hyperplasia,” although describes the clinical appearance and pathogenesis of this entity more accurately, is not commonly used. In response to various stimuli such as low-grade local irritation, traumatic injury, hormonal factors, or certain kinds of drugs lead to pyogenic granuloma.[6] This lesion is universally accepted that it is formed as a result of an exaggerated localized connective tissue reaction to a minor injury or any underlying irritation. Calculus, poor oral hygiene, nonspecific infection, over hanging restorations, cheek biting, etc., are the irritating factors. The underlying fibrovascular connective tissue becomes hyperplastic because of the irritation factors, and there is proliferation of granulation tissue which leads to the formation of a pyogenic granuloma.[6] Pyogenic granuloma is a reactive or reparative response to factors, such as local irritation, hormones, food impaction, periodontitis, or toothbrush trauma.[78] The intriguing additions to the situations in which pyogenic granuloma can develop are guided tissue regeneration procedure, allogeneic bone marrow transplantation, and primary tooth injuries.[345] Pyogenic granulomas may form secondarily in nonturbulent, austere environments such as postsurgical wounds.[123] The development of pyogenic granuloma after surgical procedures may be due to the overproduction of angiogenic growth factors and capillary overgrowth in an healing wound coupled with an irritating or an inflammatory stimulus.[1] In a study, periapical granuloma was observed when an implant was placed into a healed mandibular ridge several months after extraction of the tooth.[7] There was vigorous revascularization after periodontal surgery[89] and thought that an imbalance between angiogenic promoters and inhibitors might potentially lead to a capillary overgrowth.[9] Andersen et al.[2] described intense inflammation, swelling, and altered healing following mucogingival surgery in a subject with Crohn's disease. Fowler et al.[3] reported a case of pyogenic granuloma 5 weeks after guided tissue regenerative surgery in which a nonresorbable membrane and allograft were used. Gefrerer et al.[10] conducted a study about recurrence of pyogenic granuloma around dental implants and found that lack of attached gingiva and simultaneous exposure of implant threads might lead to pathologic hyperplasia. The reparative response in a surgical wound may be disturbed by a multitude of local factors, leading to diverse wound-healing pathologies.[11] This case report describes a case of pyogenic granuloma arising from the donor site of a pediculated palatal pedicle graft, 1 month after surgery. This manuscript also discusses the typical management of pyogenic granuloma and the expected outcomes when it occurs in unusual sites or situations. CASE REPORT A 24-year-old systemically healthy female subject came with the complaint of mobile upper right central incisor [Figure 1a]. Clinical examination revealed an endodontic-periodontic lesion in relation to 11 and the tooth was Grade II mobile. Since it was an esthetic region, extraction with an appropriate technique to achieve soft tissue augmentation over a grafted maxillary anterior extraction site was planned. Figure 1 Grade II mobile 11 (a) was extracted (b) and a pediculated connective tissue was elevated (c), tucked into the buccal pouch (d) and secured with the help of sutures (e). Primary closure was obtained at the donor site as well (f) After premedication, local anesthesia was secured and an atraumatic extraction was performed carefully preserving the remaining hard and soft periodontal tissues [Figure 1b]. Following extraction, intraoral measurements were taken to harvest a pediculated CTG to cover the extraction socket. The length of the required pediculated connective tissue was calculated by the sum of three pre-recorded measurements 1. The buccolingual width of the extraction site 2. The distance between the palatal edge of the extraction site and the base of the pedicle (usually 4mm), and 3. An extra 3 mm to “tuck” the flap into the buccal gingival tissue. The width of the pedicle was determined by measuring the mesiodistal dimension of the extraction site and adding 1 mm to account for graft shrinkage. An “L-”shaped incision was given distal to the lateral incisor that extended to the mesial side of first molar. The margin of the incision was maintained at a distance of 4–5 mm from the free gingival margin to prevent marginal tissue recession at the donor site. The base of the incision was maintained at a distance of 3–4 mm from the extraction socket. A partial thickness dissection was done to facilitate harvesting the underlying connective tissue. The connective tissue was elevated with the underlying periosteum and was attached at the base close to the socket [Figure 1c]. The isthmus between the socket and the base of the pedicle was undermined using an Orban's knife. The extraction socket was packed with bone graft (Sil-Oss®, AzureBio, Spain) and the pediculated connective tissue was tucked into the buccal pouch [Figure 1d] and secured with the help of sutures [Figure 1e]. Primary closure was obtained at the donor site as well [Figure 1f]. Appropriate postsurgical protocols were followed. The patient reported to the clinic after 1 month with a complaint of dysphagia and intermittent bleeding. On examination, a 15 mm × 20 mm exophytic growth extending from the palatal donor site to distance of 3–4 mm from the extraction socket was observed [Figure 2a]. While it appeared sessile, on manipulation, the growth was pediculated at the palatal donor site and resulted in the displacement of the “epithelial door” that essentially covers the surgical site in CTG procedures [Figure 2b]. The growth was creamish-brown and soft and exhibited a slightly nodular surface that bled easily on slight touch. The recipient site appeared normal and no extravasation or exposure of the graft material was seen. Figure 2 After 1 month, a 15 mm × 20 mm exophytic growth extending from the palatal donor site to distance of 3–4 mm from the extraction socket was observed (a). The growth was pediculated at the palatal donor site and resulted in the displacement of the "epithelial door" that essentially covers the surgical site in connective tissue graft procedures (b). Surgical excision of the growth was planned and the growth was excised from the base (c). The growth appeared to have originated mostly from the donor site and from an isthmus of connective tissue graft near the extraction socket (d). The wound margins were approximated with a suture (e). Two weeks post-excision, the sites exhibited uneventful healing (f) After obtaining the subject's consent, surgical excision of the growth was planned and scheduled. Local anesthesia was administered and the growth was excised from the base [Figure 2c]. The growth appeared to have originated mostly from the donor site and from an isthmus of CTG near the extraction socket [Figure 2d]. Necrotized epithelial tags were excised, debris were flushed out under irrigation, and the flaps were loosely closed [Figure 2e]. Two weeks post-excision, the sites exhibited uneventful healing [Figure 2f]. On histopathological examination [Figure 3], thin parakeratinized stratified squamous epithelium and underlying connective tissue with haphazardly arranged dense collagen fibers with numerous blood vessels lined by endothelial cell proliferation wer seen. In deeper sections, glands are evident in focal areas. Chronic inflammatory cells were also noted. These findings were suggestive of pyogenic granuloma. Figure 3 On histopathological examination, thin parakeratinized stratified squamous epithelium and underlying connective tissue with haphazardly arranged dense collagen fibers with numerous blood vessels lined by endothelial cell proliferation were seen. Chronic inflammatory cells were also noted. These findings were suggestive of pyogenic granuloma DISCUSSION The rotated palatal pedicle connective tissue flap is an effective means of achieving graft containment, primary closure, and soft tissue augmentation in a single surgical procedure. This technique can be used to preserve ridge contours for delayed implant placement and for site development for traditional fixed prostheses.[12] The incidence of complications after CTGs is relatively low. In their study, Harris et al.[9] reported that there were no pain reported in 81.4% of the patients, no bleeding in 97.0% of the patients, no infection in 99.2% of the patients, and no swelling in 94.6% of the patients after CTG procedure. Pyogenic granuloma is considered as an impaired wound-healing process,[12] and known environmental factors such as irritation, trauma, or altered healing around a “difficult wound” may lead its development from the skin and the mucous membranes.[9101112] In the present case, the overgrowth was observed on the palatal donor site; we theorize that loosening of suture might have taken place and subsequent masticatory movements and food interference might have led to alteration in subsequent wound healing, leading to a overgrowth of the connective tissue. This fits into the concept and theory that pyogenic granuloma develops as a response to irritation or trauma and is usually localized to a site.[3451112] Anitua and Pinas[13] conducted a study and found that pyogenic granuloma caused accumulation of dental plaque and improper prosthetic design. The improper prosthetic design with flanges was found to be difficult to maintain good oral hygiene might predispose the development of pyogenic granuloma around dental implants. In the present study, while it appeared sessile, on manipulation, the growth was pediculated at the palatal donor site and resulted in the displacement of the “epithelial door” that essentially covers the surgical site in CTG procedures. Clinically, pyogenic granuloma manifests as a small, red erythematous papule on a pedunculated or sessile base.[3451112] The growth appeared to have originated mostly from the donor site and from an isthmus of CTG near the extraction socket. The vascularization of the CTG is a dynamic event and originates from the periodontal plexus, the supraperiosteal plexus, and the overlying flap.[89] Pyogenic granuloma has predilection to develop in sites with high vascularity;[89] 75% of all cases are seen in the free gingiva; and the lips, tongue, and buccal mucosa are the next common sites.[6] Although seen on the palate in this report, interestingly, pyogenic granuloma occurs rarely in the hard and the soft palate.[3589] However, surgical manipulation and the exposure of vascular rich pedicle into the oral cavity coupled with alterations during subsequent wound healing might have led to the development of the lesion. Histopathology was suggestive of a pyogenic granuloma with the specimen showing a high vascularity with extreme endothelial proliferations and vascular spaces that resembled granulation tissue.[89] The lesion was subsequently removed by surgical excision and the healing was uneventful. Fowler et al.[3] managed a case of pyogenic granuloma associated with a routine guided tissue regenerative surgery by wide surgical excision with no signs of recurrence. Aguilo[5] reported a case of pyogenic granuloma subsequent to injury of a primary tooth which was subsequently managed with excisional biopsy as well. Excisional biopsy tends to lead to subsequent mucogingival defects,[3412] and mucogingival surgery either done concurrently during biopsy or as a separate standalone procedure at a later date may restore healthy gingival architecture.[12] The recipient site appeared normal and no extravasation or exposure of the graft material was seen during the healing period. Pyogenic granuloma heals well after excision and does not show a negative influence on surgical outcomes such as root coverage, hard tissue regeneration, or implant stability.[235] CONCLUSION We report a case of palatal pyogenic granuloma following mucogingival surgery for alveolar socket preservation. This case report highlights that the importance of monitoring wound healing[7] and the importance of a comprehensive examination for early identification of signs and/or symptoms related to surgical complications cannot be overemphasized. Palatal pyogenic granuloma occurs rarely,[57911] and the authors were unable to find reports of pyogenic granuloma originating in the vicinity of a surgical wound after a pediculated connective tissue mucogingival procedure. Healing plays a vital role in mucogingival procedures, and thus, it is very important to know about the complications affecting it. Failing to consider potential sources of irritation or trauma at the surgical site may lead to considerable morbidity even in sites that may heal without any untoward complications. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.