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Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

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Benign Epulis in the Anterior Maxilla: Surgical Management and Esthetic Outcome – A Case Series of Three Cases

Melak Tlili*, Wafa El Kholti, Marouane El Machrouhi, Jamila Kissa

Department of Periodontology, Faculty of Dental Medicine, Hassan II University of Casablanca, Casablanca, Morocco

Abstract: Background: Epulis is a benign, tumor-like gingival lesion encompassing several histopathological subtypes. Although non-neoplastic, these lesions may recur, particularly in the presence of persistent local irritants or following incomplete surgical excision. Accurate diagnosis, appropriate oral hygiene preparation, and complete removal are essential to ensure long-term stability. Case presentation: This case series describes three female patients presenting with recurrent benign epulis in the anterior maxilla, each with a history of previous excision performed elsewhere. Case 1: An ossifying epulis that developed during pregnancy was treated using a papilla-preserving excision technique, with uneventful healing and no recurrence at 6 months. Case 2: A fibrous epulis with mild inflammation recurred one month after conservative excision, requiring a second, more extensive surgical intervention including papilla removal. Case 3: A large fibrous epulis associated with poorly adapted prosthetic crowns was managed by complete excision combined with prosthetic correction, with no recurrence observed at 3 months. Discussion: Epulis lesions (fibrous, ossifying, or inflammatory) represent both esthetic and functional challenges, particularly in the anterior maxilla. Recurrence is commonly associated with persistent local irritants such as plaque, calculus, or prosthetic trauma, as well as incomplete excision. Successful management requires elimination of etiological factors, complete and well-planned surgical excision, and adaptation of the technique to esthetic considerations. Conclusion: This case series highlights the clinical variability of recurrent benign epulis and underscores the importance of comprehensive management, including initial oral preparation, complete excision, histopathological confirmation, and structured follow-up to achieve stable and esthetically satisfactory outcomes.

Keywords: Epulis, Gingival lesions, Fibrous epulis, Ossifying epulis, Recurrence

Received March 01, 2026; Revised April 01, 2026; Accepted April 08, 2026

Citation: Melak Tlili, Wafa El Kholti, Marouane El Machrouhi, Jamila Kissa, Benign Epulis in the Anterior Maxilla: Surgical Management and Esthetic Outcome – A Case Series of Three Cases. International Journal of Dental Sciences and Research, 14 (1). 1-5. January 2026. doi:10.12691/ijdsr-14-1-1

1. Introduction

Epulis refers to a group of benign, tumor-like reactive overgrowths arising from the gingival connective tissue rather than true neoplasms [1,2]. Several histopathological subtypes exist, including fibrous epulis, peripheral ossifying fibroma, inflammatory fibrous epulis, and peripheral giant cell granuloma [3]. These lesions are commonly triggered by chronic irritation such as plaque accumulation, calculus, traumatic occlusion, or poorly adapted prosthetic restorations [5].

Despite their benign nature, epulis lesions may clinically mimic other gingival proliferations, including pyogenic granuloma or, less frequently, true neoplastic processes, reinforcing the need for histopathological confirmation [8]. Standard management involves complete surgical excision preceded by oral hygiene optimization to reduce inflammation, improve surgical visibility, and lower recurrence risk. Recurrence rates vary widely, ranging from 8% to 20%, and may reach 30% depending on the subtype and completeness of excision [9].

Recurrence in esthetically demanding regions such as the anterior maxilla presents additional clinical challenges. The aim of this paper is to report three cases of recurrent benign epulis with distinct clinical and histopathological features and to discuss their management, differential diagnoses, and esthetic considerations.

2. Materials and Methods

This retrospective case series was conducted in the Department of Periodontology, Faculty of Dental Medicine, Hassan II University of Casablanca, Morocco.

The study was carried out between September 2024 and November 2025.

The study was conducted in accordance with the principles of the Declaration of Helsinki [12] and followed international recommendations for biomedical research and publication ethics [13,14]. According to institutional regulations for retrospective case series, formal ethical committee approval was not required. All patients provided written informed consent for treatment and for the use of their clinical data and images for publication purposes.

The study included three female patients presenting with recurrent benign gingival lesions clinically diagnosed as epulis, all located in the anterior maxilla. Each patient had a history of previous surgical excision performed in another institution, followed by recurrence.

All patients underwent a comprehensive clinical examination, including periodontal assessment and intraoral evaluation. Radiographic examination was performed using periapical radiographs to assess possible bone involvement.

Prior to surgical intervention, all patients received initial periodontal therapy consisting of oral hygiene instructions, motivation, and scaling and root planing in order to reduce local inflammation and improve surgical conditions.

Surgical treatment was performed under local anesthesia and consisted of complete excision of the lesion. The surgical approach was adapted to each case according to lesion size, location, recurrence status, and esthetic considerations. In some cases, interdental papilla preservation was performed, whereas in others, a more extensive excision including papilla removal and superficial bone curettage was necessary to minimize the risk of recurrence.

All excised specimens were submitted for histopathological examination to confirm the diagnosis.

Inclusion criteria:

(1) recurrent gingival lesion clinically compatible with epulis,

(2) localization in the anterior maxilla,

(3) availability of complete clinical, radiographic, and follow-up data.

Exclusion criteria:

(1) lesions of non-gingival origin,

(2) absence of histopathological confirmation,

(3) incomplete clinical records.

3. Case Series

3.1. Case 1

A 34-year-old systemically healthy female presented with a recurrent gingival lesion in the anterior maxilla. The initial lesion had developed during pregnancy and had been previously excised in another institution.

Clinical examination revealed a sessile, firm, erythematous mass measuring approximately 1 × 0.8 cm, located between the maxillary right central and lateral incisors (Figure 1A). The lesion was mildly tender on palpation. Periapical radiographic examination showed no evidence of underlying bone involvement (Figure 1B).

Prior to surgery, comprehensive periodontal preparation was performed, including reinforcement of oral hygiene measures and scaling.

Surgical excision was performed under local anesthesia using 2% lidocaine with epinephrine (1:100,000). An internal bevel incision was made using a #15C blade to allow precise removal of the lesion while preserving the interdental papilla. The lesion was excised down to the periosteum, and the underlying tissue was carefully curetted using Gracey curettes to ensure complete removal of any residual pathological tissue. The surgical site was thoroughly irrigated with sterile saline solution. Hemostasis was achieved, and interrupted sutures (4-0 silk) were placed to stabilize the gingival margins and promote optimal esthetic healing (Figure 1C).

Histopathological analysis revealed fibrous connective tissue containing foci of ossification and a mild lymphoplasmacytic inflammatory infiltrate, with no signs of malignancy (Figure 1D).

At the 6-month follow-up, complete healing was observed, with satisfactory esthetic integration and no evidence of recurrence (Figure 1E).

Figure 1. Case 1 – Ossifying epulis (teeth 11–12)

3.2. Case 2

A 36-year-old systemically healthy female presented with recurrent gingival nodules following a previous surgical excision performed elsewhere.

Clinical examination revealed three sessile, firm, erythematous nodules measuring 0.6 cm, 1 cm, and 1.5 cm, located between the maxillary central incisors (Figure 2A). The lesions were tender on palpation. Periapical radiography demonstrated a mild intrabony defect on the mesial aspect of the maxillary right central incisor (tooth 11) (Figure 2B).

Following periodontal preparation similar to Case 1, an initial conservative surgical excision was performed.

The first surgical procedure was carried out under local anesthesia using 2% lidocaine with epinephrine (1:100,000). A conservative excision was performed using a #15 blade, aiming to remove the visible fibrous tissue while preserving the interdental papilla. The lesions were excised using a scalpel, followed by careful curettage of the surrounding soft tissue with Gracey curettes. The surgical site was irrigated with sterile saline solution, and hemostasis was achieved. No bone curettage was performed at this stage (Figure 2C).

However, recurrence was noted one month later, presenting as a new erythematous swelling in the same region (Figure 2D).

A second, more extensive surgical intervention was therefore planned after three months.

The second surgical procedure was performed under local anesthesia using 2% lidocaine with epinephrine (1:100,000). A wider excision was carried out using a #15C blade, including complete removal of the interdental papilla. The lesion was excised down to the periosteum, followed by superficial bone curettage using Lucas curettes to eliminate any residual pathological tissue. The surgical site was thoroughly irrigated with sterile saline solution. Hemostasis was achieved, and interrupted sutures (4-0 silk) were placed to stabilize the soft tissues (Figure 2E).

Figure 2. Case 2 – Recurrent fibrous epulis (teeth 11–21)

Although this approach resulted in a slight esthetic compromise, it allowed for improved long-term stability.

Histopathological examination revealed stratified squamous epithelium with papillomatosis and acanthosis, partially ulcerated in some areas, overlying a collagen-rich, vascularized fibrous connective tissue with lymphoplasmacytic inflammatory infiltrate. No evidence of malignancy was observed (Figure 2F).

At the 3-month follow-up, complete healing was achieved, with stable gingival architecture and no signs of recurrence (Figure 2G).

3.3. Case 3

A 60-year-old female patient with controlled hypertension presented with a large recurrent gingival lesion in the anterior maxilla.

Clinical examination revealed a pedunculated, firm, pink mass located between the maxillary right lateral incisor and canine. The lesion was lobulated and divided into three components measuring 1.8 cm, 2 cm, and 2.2 cm (Figure 3A). The adjacent teeth were restored with poorly adapted prosthetic crowns, which were identified as a contributing factor to chronic irritation (Figure 3B).

Figure 3. Case 3 – Fibrous epulis (teeth 12–13)

Following initial periodontal preparation, complete surgical excision was performed.

Surgical excision was carried out under local anesthesia using 2% lidocaine with epinephrine (1:100,000). Given the size and lobulated nature of the lesion, a wide excision was performed using a #15 blade, extending to the base of the lesion down to the periosteum. The lesion was carefully dissected and removed in its entirety. Thorough curettage of the underlying tissue was performed using surgical curettes (Gracey and Lucas curettes) to ensure complete elimination of any residual pathological tissue. The surgical site was irrigated with sterile saline solution, and hemostasis was achieved. Interrupted sutures (4-0 silk) were placed to stabilize the soft tissues and promote optimal healing (Figure 3C).

Given the presence of poorly adapted prosthetic crowns, the patient was subsequently referred for prosthetic rehabilitation in order to eliminate the etiological factor.

Histopathological analysis showed hyperplastic stratified squamous epithelium without atypia, overlying dense fibrous connective tissue with mild lymphoplasmacytic infiltrate and vascular congestion, consistent with fibrous epulis (Figure 3D).

At the 3-month follow-up, satisfactory healing was observed, with no evidence of recurrence (Figure 3E).

4. Discussion

Epulis represents one of the most common reactive gingival lesions and encompasses a spectrum of clinicopathological entities. Large cohort studies demonstrate that focal fibrous hyperplasia is the most frequent subtype, followed by peripheral ossifying fibroma, pyogenic granuloma, and peripheral giant cell granuloma [4]. These lesions exhibit a marked female predominance and typically occur in the third and fourth decades of life, with the anterior maxilla being a frequent site [2,3]. These epidemiological findings are consistent with the present case series.

4.1. Pathogenesis and Contributing Factors

Epulis is considered a reactive hyperplastic response rather than a true neoplasm. Chronic low-grade irritation resulting from plaque accumulation, calculus deposits, traumatic occlusion, or poorly adapted prosthetic restorations plays a central role in its development [5]. Hormonal fluctuations, particularly those associated with pregnancy, may further modulate the inflammatory response, contributing to lesion formation or recurrence [6].

Histopathologically, fibroblastic proliferation may be associated with varying degrees of inflammation, ossification, or calcification, depending on the subtype [6], as observed in the present cases.

4.2. Importance of Pre-surgical Preparation

All three patients underwent comprehensive oral hygiene preparation prior to surgery. This step reduces inflammation, enhances surgical visibility, minimizes intraoperative bleeding, and improves postoperative healing. Evidence suggests that adequate plaque control and periodontal debridement significantly reduce recurrence rates in reactive gingival lesions [11].

4.3. Surgical Management and Comparison Between Cases

Surgical excision remains the treatment of choice for all epulis subtypes. However, in esthetically demanding regions such as the anterior maxilla, the clinician must balance complete lesion removal with preservation of soft tissue architecture.

A comparison of the three cases highlights the importance of tailoring the surgical approach according to lesion characteristics and etiological factors. In Case 1, conservative excision with papilla preservation resulted in favorable healing without recurrence, likely due to the absence of persistent local irritants and adequate lesion removal.

In contrast, Case 2 demonstrated early recurrence following an initial conservative excision, suggesting incomplete removal and persistence of etiological factors. A second, more radical intervention including papilla removal and bone curettage was necessary to achieve a stable outcome.

In Case 3, the presence of poorly adapted prosthetic crowns constituted a major contributing factor. Successful management was achieved through complete excision combined with elimination of the prosthetic irritant.

These findings emphasize that complete excision down to the periosteum, combined with elimination of local irritants, is essential to minimize recurrence risk, particularly in recurrent or extensive lesions [11].

4.4. Recurrence and Prognosis

Reported recurrence rates range from 8% to 20% and may reach up to 30% in peripheral ossifying fibroma [9]. Major causes include incomplete initial excision, persistence of local irritants, and anatomical difficulty in accessing the lesion base [9,11].

The present case series illustrates the multifactorial nature of recurrence. The early relapse observed in Case 2 highlights the limitations of conservative management in recurrent lesions, whereas the absence of recurrence in Cases 1 and 3 underscores the importance of adequate surgical margins and elimination of etiological factors.

4.5. Multidisciplinary Management and Follow-up

Optimal management extends beyond surgical excision. A comprehensive approach including periodontal therapy, elimination of local irritants such as defective prosthetic restorations, reinforcement of oral hygiene practices, and regular supportive periodontal care is essential.

Most recurrences occur within the first 12 months following treatment, emphasizing the importance of close monitoring.

Recurrent benign epulis in the anterior maxilla therefore requires a structured and multidisciplinary approach to ensure predictable long-term success. Favorable outcomes depend on meticulous oral hygiene preparation, complete surgical removal of the lesion and its base, elimination of local irritants, histopathological confirmation, and structured follow-up to detect early recurrence.

Overall, this case series highlights the importance of individualized surgical planning based on lesion characteristics and etiological factors.

5. Conclusion

Within the limitations of this case series, recurrent benign epulis in the anterior maxilla requires a comprehensive and individualized management approach.

Successful outcomes depend on thorough elimination of etiological factors, meticulous pre-surgical periodontal preparation, and complete surgical excision of the lesion down to its base. Particular attention should be given to the choice of surgical technique, especially in esthetically demanding areas, where a balance between radical excision and soft tissue preservation is required.

The comparison of the three cases highlights that recurrence is multifactorial and strongly associated with incomplete excision and persistence of local irritants. In contrast, favorable outcomes were achieved when both surgical and etiological factors were adequately addressed.

Histopathological confirmation remains essential to establish a definitive diagnosis, while structured postoperative follow-up is crucial for early detection of recurrence.

A multidisciplinary approach integrating periodontal, surgical, and prosthetic management is therefore fundamental to achieving stable and esthetically satisfactory long-term outcomes.

Ethical Approval

This study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients for treatment, photography, and publication of anonymized clinical data.

Conflict of Interest

The authors declare no conflicts of interest.

References

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