Leaf fibromas are pink, fibrous, pedunculated lesions that have been flattened against the palate by a denture. Treatment involves surgical excision followed by construction of a new, close-fitting denture. Leaf fibromas can be a source of anxiety for patients, even when they have been present for many years. The differential diagnosis can include giant cell lesions, phoenician granulomas and malignancy. Therefore it is essential that histopathological examination is carried out to confirm the diagnosis.
Soft tissue pathologies associated with dentures include infections, reactions to the denture materials and mechanical injury. Chronic atrophic candidiasis, also known as denture stomatitis, is a common condition that affects the palatal mucosa of denture wearers. It is often caused by a candidal infection secondary to unsatisfactory dental hygiene and ill-fitting dentures. Xerostomia and some systemic conditions, including HIV (human immunodeficiency virus), will further predispose patients to candidiasis. Allergic reactions to denture material constituents does occur but is considered rare. The burning sensation perceived as an allergic reaction is more commonly caused by mechanical irrition. Traumatic ulcers in denture wearers can be caused by overextensions or uneven occlusal loading. This can be relieved by adjustments to the denture. It has been reported that chronic injury from dentures can predispose patients to oral carcinomas thus emphasising the importance of regular dental reviews for denture wearers.
Ill-fitting or over-extended dentures that have been worn for many years can cause benign hyperplastic fibrous growths or epulides. These are more common with mandibular dentures. These growths are usually firm with little inflammation, and sometimes have ulceration at the base of the epulis where it meets the denture. If the growth occurs as a result of irritation by the border of a denture, it is known as epulis fissuratum, granuloma fissuratum or denture-irritation hyperplasia. These lesions can vary in size and may be erythematous and ulcerated. When the fibrous epulis forms underneath the palate of the denture, it is known as a leaf fibroma.
Leaf fibromas are painless, pink and lobulated epulis flattened against the palate by a denture. They have a pedicle attachment to the underlying mucosa, which can be singular or multiple and are more common in women. Treatment is by conservative surgical removal and construction of new dentures. Long standing leaf fibromas will have a well-developed blood supply and prior to surgical removal consideration should be given to haemostasis. Whilst altering the denture may decrease the size of the lesion, due to the dense nature of the scar tissue, adjustment alone will not cause complete regression.
A 54 year old female patient was referred to the Department of Restorative Dentistry at the University of Manchester Dental Hospital by her General Dental Practitioner. She attended complaining of a "dangly bit" in her palate that had been present for approximately 5 years. The lesion was not painful but interfered with her upper complete denture which she had been wearing for approximately 15 years.
The patient's medical history included depression, hypertension, hyperlipidaemia, arthritis, asthma and rhinitis. She was currently taking a polypharmacy of fluoxetine, felodipine, bendroflumethiazide, simvastatin, naproxen, salbutamol, beclomethasone, loratidine, citirizine, omeprazole and pregabalin. The patient had hayfever, dust allergy and was allergic to septrin.
On examination there was a large, pink, pedunculated soft tissue lesion in the patient's palate, as shown in Figurew 1-3.
Figure 1. Leaf fibroma
Figure 2. Leaf fibroma
Figure 3. Leaf fibroma
The position of the epulis when the denture is in situ (figure 4).
Figure 4. Position of the epulis when the denture is in situ
The lesion was excised and histopathological examination confirmed the clinical diagnosis of a leaf fibroma. A new set of dentures were subsequently constructed by the patient's general dental practitioner.
The histopathology of leaf fibromas includes dense irregular connective tissue fibres, covered by epithelium which is usually hyperplastic. Although classic in appearance, histopathology examination should be carried out to exclude giant cell lesions, phoenician granulomas and malignancy. A case has been reported in the literature of a patient who presented with a lesion resembling a leaf fibroma but on biopsy was shown to be a malignant melanoma. Primary intra oral malignant melanoma is rare but has a poor prognosis compared with presentation on the skin, thus illustrating the importance of confirming the diagnosis. Small leaf fibromas could easily be missed and this case demonstrates how, if left for some time, they can increase in size and become a source of anxiety for patients. There are many presentations of intra oral malignancies, some with a benign appearance, thus a diagnosis of leaf fibroma should always be confirmed.
Authors: Dr Anna Maxwell and Professor Nick Grey
References available from the publisher on request.
This article was first published in the January 2014 issue of Dental Tribune UK