1.

Epulis fissuratum
Epulis fissuratum (also termed inflammatory fibrous hyperplasia, denture-induced fibrous inflammatory hyperplasia denture injury tumor, denture epulis, denture induced granuloma, and granuloma fissuratum) is a benign hyperplasia of fibrous connective tissue which develops as a reactive lesion to chronic mechanical irritation produced by the flange of a poorly fitting denture. More simply, epulis fissuratum is where excess folds of firm tissue form inside the mouth, as a result of rubbing on the edge of dentures that does not fit well. It is a harmless condition and does not represent oral cancer. Treatment is by simple surgical removal of the lesion, and also by adjustment of the denture or provision of a new denture.

Classification
Epulis (literally, 'on the gingiva') is a general term for any gingival or alveolar tumor (i.e. lump). This term describes only the location of a lump and has no implication on the histologic appearance of a lesion. Epulis is also sometimes used synonymously with epulis fissuratum,[1] however other conditions are classified as epulides, e.g. giant cell epulis (peripheral giant cell granuloma), ossifying fibroid epulis (peripheral ossifying fibroma), and congenital epulis.[1]

Signs and symptoms

The lesion is usually painless.The usual appearance is of two excess tissue folds in alveolar vestibule/buccal sulcus, with the flange of the denture fitting in between the two folds.[1] It may occur in either the maxillary or mandibular sulci,[1] although the latter is more usual. Anterior locations are more common than posterior. Less commonly there may be a single fold, and the lesion may appear on the lingual surface of the mandibular alveolar ridge. The swelling is firm to pakpation and fibrous, with a smooth, pink surface. The surface may also show ulceration or erythema. The size of the lesion varies from less than 1 cm to involving the entire length of the sulcus.

Causes
The cause is usually pressure from the flange of a denture which causes chronic irritation and a hyperplastic response in the soft tissues.[5] Women during pregnancy can also present with an epulis, which will resolve after birth. Fibroepithelial polyps, pedunculated lesions of the palate beneath an upper denture, are associated with this condition. A cobble-stone appearance similar to an epulis fissuratum in a patient without dentures can be diagnostic of Crohn's disease.[7] Epulis fissuratum can also appear around dental implants.

Histology-

The hyperplastic mass of tissue is composed of an excessive bulk of fibrous connective tissue covered by a layer of stratified squamous epithelium which may be of normal thickness or show acanthosis. Pseudoepitheliomatous hyperplasia is often found. Hyperkeratosis is frequently present. Connective tissue is composed mainly of coarse bundles of collagen fibers with few fibroblast or blood vessels unless there is an active inflammatory reaction present. Often mucopolyssacaride keratin dystrophy also known as plasma pooling is seen in surface epithelium of inflammatory fibrous dysplasia.it consists of homogenous eosinophilic pools of materials in the superficial spinous layer of the epithelium. Bone formation is sometimes seen in a fibrous epulis and sometimes called as peripheral ossifying fibroma although it has no relation with the ossifying fibroma of the bone and is not a fibroma.

Treatment
Treatment is by surgical excision (complete removal) of the fibrous tissue overgrowth and addressing the causative factor to prevent recurrence of the lesion.

Epidemiology
This condition occurs in association with denture wearing, and so those affected tend to be middle aged or older adults. 66-75% are estimated to occur in women.[1] Epulis fissuratum is the third most common reactive lesion that occurs in the mouth, after peripheral giant cell granuloma and pyogenic granuloma.[9]

2. Giant cell fibroma

Introduction The giant cell fibroma is a subtype of irritation fibroma, i.e. it is a localized inflammatory fibrous hyperplasia, but it differs significantly from routine fibromas in that its stroma contains scattered fibroblasts with very large, usually angular (stellate), but not hyperchromatic nuclei. Clinical Features This type of fibroma can be seen at any age and on any oral mucosal surface, but it has a predilection for gingival, lateral tongue and tip of tongue locations. It seldom becomes more than 0.5 cm. in greatest diameter and often are comprised of two or

three lobules, or may have a few small papules on the surface. Most lesions are pedunculated but sessile examples are not unusual. The surface is almost never ulcerated, unless acutely traumatized, and the color is that of the surrounding normal mucosa. Occasional patients will have multiple lesions but they are seldom numerous.

Pathology and Differential Diagnosis The lesion is characterized by a diffuse, somewhat immature, rather avascular collagenic stroma with small bipolar and slightly stellate fibroblasts scattered throughout in moderate numbers. Occasional fibroblasts will be quite large and angular, and may have more than one nucleus . These pathognomonic cells are never hyperchromatic, as they would be if they were truly dysplastic fibroblasts, and they often have a smudged appearance. They are most numerous in the zone immediately beneath the covering epithelium. The epithelium is usually normal but may have elongated and narrow rete ridges. At the inferior margin the lesional fibrosis blends into the normal underlying fibrovascular tissues, with no capsule or pseudocapsule. Occasional lymphocytes may be seen beneath the epithelium or around capillaries.

Treatment and Prognosis The giant cell fibroma is treated by conservative surgical removal but is more likely to recur with this treatment than a more routine irritation fibroma, even when that fibroma is much larger. If left alone, the giant cell fibroma will not enlarge indefinitely, but will reach its maximum size within a few months and remain unchanged thereafter, unless acute trauma produces edema or areas of granulation tissue proliferation.