Targeted connective tissue resection with the dual-flap surgical approach in the treatment of drug-induced gingival enlargement: Case study.

Background: Drug-induced gingival enlargement (DIGE) is a common side effect of medications such as anticonvulsants, calcium channel blockers, and immunosuppressants. The treatment of choice for the condition is drug withdrawal or substitution in combination with the nonsurgical phase. In some cases, additional internal or external bevel gingivectomy is needed to achieve periodontal health. Special approaches may be needed in severe DIGE cases superimposed on periodontitis. The aim of this report is to describe the dual-flap internal gingivectomy (DFIG) approach for the simultaneous management of soft and hard tissues via the simultaneous reduction of the connective tissue bulkiness from the superficial flap and preservation of keratinized tissues.

Methods: A generalized Stage IV grade C periodontitis with DIGE was treated.  An initial partial thickness flap was elevated and thinned out to a thickness of 1.0-1.5 mm. Then, a second partial-thickness flap was raised, and a thick band of connective tissue was removed. Proper positioning of the primary flap onto the periosteum was obtained and flap adaptation was achieved with localized gingivoplasty.

Results: Healthy soft tissue was developed with DFIG by debulking the enlarged connective tissues and apical gingival margin positioning with a predictable wide band of keratinized attached gingiva was achieved.    CONCLUSIONS: The DFIG surgical approach provides adequate access for root instrumentation and preserves KT width. The procedure effectively reduces soft tissue thickness and improves soft tissue contours, in DIGE cases superimposed to periodontitis.

Key points: Gingival enlargement is related to excessive production and deposition of collagen in the inner layer of the connective tissue and the surface of the alveolar bone. The dual-flap internal gingivectomy (DFIG) approach allows for targeted excision of the inner layer of the connective tissue from the buccal primary flap while preserving the width of the keratinized tissue. Adequate soft tissue contours and volume are obtained following the DFIG procedure.