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idiopathic gingival fibromatosis ( igf ) is an uncommon , benign , hereditary , slowly progressive , nonhemorrhagic fibrous enlargement of keratinized gingiva .
it usually begins at the time of eruption of permanent teeth , but can develop with the eruption of deciduous dentition and rarely present at birth .
the hyperplastic gingival tissue is pale - pink , firm ; has leathery consistency and presents a characteristic pebbled surface .
the enlarged tissues may partially or totally cover the dental crowns , can cause diastemas , delay or impede tooth eruption and periodontitis . in severe cases , it may lead to mastication and speech impediments or lip closure difficulties .
an 18-year - old male , accompanied by his father reported to the department with the complaint of enlarged gums in upper and lower arches , which caused difficulties in speech , mastication and complete closure of lips , thereby leading to esthetic impairment .
the patient presented with gradual and progressive enlargement of both upper and lower gingival tissues from the age of 6 years .
the patient exhibited no signs of hypertrichosis , mental retardation , epilepsy or intake of medication known to cause gingival overgrowth .
on examination , patient had bilaterally symmetrical face with incompetent lips with the bimaxillary protrusion .
the gingiva was pink in color with melanin pigmentation , and consistency was firm and fibrous .
the enlarged gingiva covered the crowns of all the teeth till the incisal or occlusal third region [ figure 1 ] .
dentition revealed all permanent teeth except mandibular premolar ( 35 ) and an over retained deciduous molar ( 75 ) .
preoperative photographs showing generalized gingival enlargement investigations included orthopantomograph , in which no significant alveolar bone loss was observed [ figure 2 ] .
laboratory investigations which included complete hemogram , thyroid tests ( t3 , t4 , and thyroid stimulating hormone ) , parathyroid test , calcium and alkaline phosphatase levels were made .
all the reports except the levels of alkaline phosphatase ( which was slightly increased ) were within the physiological limits .
panoramic radiograph showing presence of retained deciduous molar in mandibular left region the treatment plan consisted of sextant wise surgical excision of the enlarged gingiva under local anesthesia .
the treatment procedure was explained to the patient and parent , and written consent was obtained .
ledge and wedge procedure was done to remove gingival overgrowth over the palatal aspect of the maxillary posterior region and mandibular posterior region [ figure 3 ] .
intrasurgical photographs histopathology showed parakeratinized stratified epithelium , which was acanthotic at places and elongated rete pegs .
the bulk of connective tissue was composed of dense fibrous connective tissue and numerous fibroblasts .
histologic section shows hyperparakeratinized hyperplastic squamous epithelium with dense fibrocollagenous tissue the patient was recalled every week for 6 weeks when the periodontal pack was removed , and the next sextant was operated upon .
the patient was then placed on a schedule of periodic recall visits for maintenance care .
no recurrence of gingival enlargement was observed 6 months after the surgery [ figure 5 ] .
gingival fibromatosis may occur as an inherited condition known as hereditary gingival fibromatosis , or it may be associated with inflammation , leukemic infiltration , and medications . according to gorlin
igf is most commonly associated with hypertrichosis , also occasionally associated with mental retardation and epilepsy .
it occurs either as an isolated disease or combined with some rare syndromes like zimmerman - laband syndrome ( defects of bone , nail , ear , nose and splenomegaly ) , murray - puretic - drescher syndrome ( multiple dental hyaline tumors ) , rutherford syndrome ( corneal dystrophy ) , cowden syndrome ( multiple hamartomas ) , and cross syndrome ( hypopigmentation with athetosis ) . in the present case ,
the patient exhibited no signs of hypertrichosis , mental retardation and epilepsy or intake of medication known to cause enlargement .
idiopathic gingival fibromatosis affects the attached gingiva as well as gingival margin and interdental papillae .
the cause is unknown , and thus the condition is designated as  idiopathic  .
some cases have a hereditary basis , but the genetic mechanisms involved are not well understood .
a study of several families found the mode of inheritance to be autosomal recessive in some cases and autosomal dominant in others .
histologically , the gingival hyperplasia is mainly due to an increase and thickening of collagen bundles in connective tissue stroma .
igf keratinocytes seem to have an important role in pathogenesis by inducing extracellular matrix accumulation by fibroblasts .
furthermore , it has been reported that increased proliferation and elevated production of extracellular matrix molecules , fibronectin and type i collagen could lead to an increased bulk of gingiva . in the present case , the history revealed that the enlargement started in mixed dentition period .
emerson recommended that the best time for the excision of gingival enlargement is when all the permanent teeth have erupted . among the suggested treatment protocols , ledge and wedge technique along with internal bevel gingivectomy
was selected as it helped in the placement of primary incisions as opposed to the conventional external bevel gingivectomy procedure . moreover
, this procedure does not leave a large external bevel and , therefore , result in less postoperative pain and bleeding .
after surgery , recurrence is expected within a few months after surgery and is most commonly seen in children and teenagers rather than adults .
maintenance of good oral hygiene with professional cleaning and home care maintenance is necessary to prevent the recurrence .
idiopathic gingival fibromatosis ( igf ) is a rare hereditary condition characterized by slowly progressive , nonhemorrhagic , fibrous enlargement of maxillary and mandibular keratinized gingiva caused by increase in submucosal connective tissue elements , mostly associated with some syndrome . 
 this case report describes a case of nonsyndromic generalized igf in an 18-year - old male patient who presented with generalized gingival enlargement . 
 the enlarged tissue was surgically removed by internal bevel gingivectomy and ledge and wedge procedure . 
 the patient was regularly monitored clinically for improvement in his periodontal condition as well as for any recurrence of gingival overgrowth .