Case Studies




Pyogenic granuloma secondary to biological width issues

A 50 year old female presented with an area on the upper right that constantly bled and was tender.   It swells and goes down with aggressive home care.   The crown on #4 has been present for about one year.   Scaling and root planing resolved the issue for a short amount of time but the lesion eventually came back.


I considered a couple of different things when diagnosing and treating this case.   The most obvious item is the granulamatous lesion present between #4 and #5, see Figure 1.   Closer examination reveals an erythematous and cyanotic type lesion around the crown on #4 as well as the crown on #2.   Compare the tissue color and texture to the natural tissue response around tooth #6 which has nice pink, firm tissues, with no signs of inflammation.  The tissue around the crown is the opposite.


The radiograph examination shows a close approximation of the crown margin to the bone height, see Figure 2.   Assume the radiograph is parallel and place a probe or measuring device on the radiograph, it would read approximately 2 millimeters from the osseous crest.   We know from literature that the biologic width needs to be 3 to 4 mm from the crown margin to the bone crest.   If the biological width is encroached, an inflammatory response occurs similar to bacteria induced periodontal disease.


The crown was placed subgingival to get beyond the restorative margin of the previous restoration; similar to the restoration on #5, but the gingival fibers were encroached.   Initially there was no reaction to the crown, but an inflammatory response began.   Once this inflammatory response is activated, various results can occur.  In this case a pyogenic granuloma formed.   A pyogenic granuloma is a common tumor-like growth found in the oral cavity.   It is thought to represent an exuberant tissue response to traumatic local irritation.   Pyogenic granulomas are highly vascular in nature and bleed easily because of this feature.   Normally a "stalk" of vessels "feed" the tumor.   These feeding vessels need to be identified and cauterized before complete resolution of the tumor occurs.  (Neville textbook)


Treatment for this area was crown lengthening and removal of the pyogenic granuloma.   The procedure was done with a Biolase Waterlase, where both soft tissue and hard tissue were removed to facilitate healing.   A periodontal dressing (Coe-pak) was placed to aid with protection of the wound during healing.   The area will heal uneventfully with a new biologic width and normal healthy tissues.


To treat or not treat a sulcus based on the number?  I get this question a lot when talking with people about treatment planning periodontal issues.   Probing depths are used as a guide to tell us the extent of a pocket and its relationship to its surrounding landmarks.   We can extrapolate that it relates to bone loss and it does on some cases.   The problem is relying only on the number and not confirming it with other findings.


One of the most overlooked indicators is tissue color and texture around an area of concern, as well as how it compares with the rest of the mouth.   If the tissues are pink and firm throughout the majority of the mouth and yet one area appears deep red or bluish-purple, then it is an isolated issue, not to be ignored.


Bleeding on probing is another indicator we know but forget to use.   Of course, with a heavy hand any area can bleed.   "Slight provocation" is the phrase used when checking for bleeding on probing.   When light probing elicits a bleeding response it means the capillary system within the sulcus is inflamed and has increased in response to a local infiltration.   If you have to push to make something bleed, then a wound has been created and it is not a true problem area.


In Figures 3 and 4, the distal of #30 has a 5 mm probing depth.   The tissues are pink and firm with no bleeding.   The dentist treated the area with scaling and root planing and multiple rounds of Arestin.   The patient’s home care is immaculate and she has done well taking care of it.   The problem is no matter how much scaling or antimicrobials placed in the pocket, the “number” or probing depth will never resolve.


Look closer at the radiograph.  It shows a discrepancy of the crown margin height.   The distal of #30 crown is about 2 mm more subgingival than the mesial of #31.   This height difference shows up in the pocket measurement.   Remember there has to be a biologic width associated with restorative dentistry.   If the 3 to 4 mm of biologic width is not present, the body will make it that way with an uncontrolled inflammatory process.


In this case, the pocket is stable.   Do not forget about it, watch it closely.   Because of the deeper restorative margin it has the potential to become pathogenic and develop recurrent decay.   If this pocket begins to break down and bleed, then crown lengthening should be performed to reestablish appropriate biological width.


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