INTRAMUSCULAR GINGIVAL LIPOMA: A RARE CASE REPORT

Abstract

Lipomas are most commonly occurring mesenchymal benign tissue tumors in humans but their occurrence intraorally is exceedingly rare (0.5 to 5%). The etiology remains unclear but many theories have been proposed. They are classified according to their location and histological appearance. Gingival lipoma has the least rate of occurrence of all the Intraoral Lipomas (2.0%). Treatment of these lesions remains essentially same, i.e. complete excision of the tissue. Recurrence of the lesion is rare and it does not undergo malignant transformation. Herein we present a case report of an extremely rare subtype of Intraoral Lipoma occurring on gingiva and floor of mouth which was treated with soft tissue diode laser along with brief review of the literature. This paper is an attempt to further the knowledge of this rare disease, highlight their clinical appearance and histological variants while discussing different treatment modalities for the treatment of the same.

Full text

International Journal of Current
Medical and Pharmaceutical
Research
Available Online at http://www.journalcmpr.com
DOI: http://dx.doi.org/10.24327/23956429.ijcmpr20170226
CASE REPORT
INTRAMUSCULAR GINGIVAL LIPOMA: A RARE CASE REPORT
Sachin Mangalekar1, Sagar J Shah1*, Someshwar Golgire2, Amol Karagir3
and Sandeep Patil1
1Department of Periodontics, Bharati Vidyapeeth Deemed University Dental College, Sangli, India
2Department of Oral Pathology, Bharati Vidyapeeth Deemed University Dental College, Sangli, India
3Department of Oral Medicine and radiology, Bharati Vidyapeeth Deemed
University Dental College, Sangli, India
ARTICLE INFO ABSTRACT
Lipomas are most commonly occurring mesenchymal benign tissue tumors in humans but their
occurrence intraorally is exceedingly rare (0.5 to 5%). The etiology remains unclear but many theories
have been proposed. They are classified according to their location and histological appearance.
Gingival lipoma has the least rate of occurrence of all the Intraoral Lipomas (2.0%). Treatment of
these lesions remains essentially same, i.e. complete excision of the tissue. Recurrence of the lesion is
rare and it does not undergo malignant transformation. Herein we present a case report of an
extremely rare subtype of Intraoral Lipoma occurring on gingiva and floor of mouth which was
treated with soft tissue diode laser along with brief review of the literature. This paper is an attempt to
further the knowledge of this rare disease, highlight their clinical appearance and histological variants
while discussing different treatment modalities for the treatment of the same.
Copyright © 2017 Sagar J Shah et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Lipomas are most common benign connective tissue tumors
that origin from mature adipocytes. Oral lipomas were first
described by “Roux” in 1884 and he referred them as yellow
epulis due to the yellowish tint on the lesion clinically [1].
These lesions are rare in oral cavity consisting only about 0.5
to 5% of all the benign tumors [2].
The exact etiology remains unknown but various theories have
been proposed. The "Hypertrophic theory" suggests that
obesity may contribute to the formation of lipoma. The theory
was immediately discarded as it was unable to explain the
occurrence of lesions lacking adipose tissue. The "Metaplastic
theory" advocates that lipomas occur due to aberrant
differentiation of adipocytes. Other factors like trauma,
hormonal imbalance, and chromosomal abnormalities have
also been proposed [3]. Classic lipomas show abnormalities
with 12q13-15 or 6p or 13q whereas spindle cell and
pleomorphic lipomas present with complete or partial loss of
13q and chromosome 16 [4].
These lesions are commonly encountered in 5th to 6th decade of
life [5]. Existing literature suggests that intraoral lipomas have
similar sex predilection to slight female predominance as
compared to lipomas in other parts of the body where the
occurrence is more common in males [1,2]. Buccal mucosa is
most common (38.6%) site followed by tongue (15.2%), lip
(11.8%), floor of the mouth (10.3%), palate (4.5%), retromolar
area (4.5%) and gingiva (2.0%) [6]. In the present case, lipoma
occurred in gingiva and extended up to the floor of the mouth.
The greater incidence of occurrence in the buccal region can
be attributed to the increased fatty tissue in the area in the oral
cavity as compared to any other tissue [1]. The average size of
the tumor ranges from 0.6 cm to 2.6 cm [5]. The lesions are
essentially painless and are slow growing [5]. The patient
usually complains of painless palpable mass, rarely dysphasia
and speech problems are seen with large sublingual lipomas
[7]. The present case report highlights the clinicopathological
features of rare clinical entity, Intramuscular Gingival lipoma
along with different treatment modalities.
Case Report
A 78 year old male patient reported to the Department of
Periodontoics with the chief complaint of an overgrowth in
lower front region since 20 years. The patient complained that
the growth had increased steadily with time. The patient was
diabetic and was on medication for the same since 10 years,
dental and family history was noncontributory. There was no
history of pain, trauma, sinus opening or pus discharge.
Intraoral examination revealed an overgrowth on mandibular
Article History:
Received 20th June, 2017
Received in revised form 3rd
July, 2017
Accepted 27th August, 2017
Published online 28th September, 2017
Key words:
Atypical lipoma, Intraoral,
Diode laser, Gingiva.
ISSN: 2395-6429

International Journal Of Current Medical And Pharmaceutical Research, Vol. 3, Issue, 09, pp.2312-2314, September, 2017
2313
right anterior lingual attached gingiva extending up to floor of
mouth (Figure-1). The overgrowth was about 1.5x2.5 cm in
dimension. The growth was sessile and freely mobile, soft and
fluctuant on palpation. The concerned teeth 41, 42, 43, 44, 45
responded normally to pulp vitality test. Cervical extension of
the lesion was examined by bidigital and bimanual palpation
of the submandibular region, the findings were non
contributory. On radiographic examination, IOPA revealed no
periapical or bony changes (Figure-2).
A differential diagnosis of Ranula, Mucocele, Pyogenic
granuloma, irritational fibroma, and Lipoma was considered
and excisional biopsy was carried out. Considering the age of
the patient it was decided to manage the case conservatively,
complete excision was carried out using a 980 nm soft tissue
diode laser( Figure-3).
Excellent hemostasis was achieved with minimum charring of
tissue (Figure-4). The excised tissue was seen with distinct
tissue capsule (Figure-5). The excised tissue was floating when
immersed in 10% formalin for histopathological investigation,
which is characteristic of Lipoma. The excised specimen was
sent for histopathology and was diagnosed as Intramuscular
Lipoma. Proper oral hygiene maintenance instructions were
given and Chlorhexidine mouthwash 0.2% was prescribed for
oral prophylaxis. Six months follow up showed no recurrence.
Figure 1 Overgrowth associated with 41, 42, 43, 44, 45 on lingual
aspect involving attached gingiva and extending upto floor of mouth
Figure 2 IOPA reveals normal bony architecture eliminating the
possibility of bony involvement of origin.
Figure 3 Soft tissue diode laser being employed for surgical excision of
the tissue.
Figure 4 Note the excellent hemostasis, minimal charring with
conservative excision of the tissue.
Figure 5 Excised tissue speciemen.
Figure 6 Histopathological picture (10x) shows an encapsulated tissue
containing adipocytes traversed by muscle fibers.

International Journal Of Current Medical And Pharmaceutical Research, Vol. 3, Issue, 09, pp.2312-2314, September, 2017
2314
Histopathological studies
Histology slides show tissue showing stratified squamous
epithelium of variable thickness. The connective tissue showed
encapsulated tissue consisting of mature adipocytes. The tumor
cells were seen traversing muscle fibers. Focally thickening of
blood vessels was noted (Figure-6)
DISCUSSION
Lipomas usually occur as solitary tumors but are an infrequent
finding in Cowden's syndrome which shows multiple lipomas
occurring throughout the body due to mutations in the tensin
homolog gene and phosphatase enzyme [8]. Multiple lipomas
are also seen in Dercum's disease, Proteus syndrome, familial
multiple lipomatosis, Pai syndrome [7]. The diagnosis is
essentially made by correlating the clinical features with
histopathological features. The differential diagnosis includes
Fibroma, Lymphangioma, Rhabdomyoma, Neuroma, Dermoid
Cyst, Mucocele, Benign tumor of salivary glands and
Hemangioma. A distinctive pathognomic feature of lipoma is
that it floats without sinking when stored in 10% formalin jar
for histopathological diagnosis; a similar finding was seen in
the present case [9]. Though some of them represent with
distant clinical picture and behavioral characteristics;
histopathological investigation remains the gold standard for
the final diagnosis [3].
Histopathologically, lipomas are classified based on the
histopathological features and growth patterns into various
types: (a) Classic lipomas (49.56%) and Fibrolipomas (20.7%)
are most common and have overlapping histopathological
features. The diagnosis of Fibrolipoma in made when the
mature adipose tissue is interspersed by fascicles of dense
connective tissue in absence of capsule. (b) Intramuscular
lipomas (2.0%) are found in the vicinity of muscle tissue; the
muscle fibers are interspersed in between them and are most
commonly found in tongue and buccal mucosa. (c) Spindle cell
lipoma (1.66%) is a relatively uncommon variant which is
usually seen on the lip. (d) Sialolipoma (1.5%) consist of intra
glandular lipomas consisting of atrophic salivary acini and
ducts, they are commonly seen on the hard palate. (e)
Choronoid lipoma (1.5%) can mimic Liposarcoma and Myxoid
chondrosarcoma, they are confused with aforementioned
lesions due to nests of lymphoblastic like tissue in the
chorondriod matrix. (f) Osseous lipoma (>1%) is rare and
characterized by mature bony or cartilaginous tissue in the
tissue [2, 6, 10].
Irrespective of the histopathological variant, the treatment
essentially remains same, i.e. complete excision of the tissue.
Recurrence is extremely rare [2, 3, 7]. Recurrence is more with
intramuscular lipoma when compared with other variants due
to their infiltrating nature [10,11]. There are no reports of
malignant transformation of intraoral lipoma in existing
literature [2, 7, 11]. Other options for management of lesion
include local injection of lignocaine and triamcinolone
actenoide 1:1 directly into the lesion. They cause fat atrophy
and shrink the size of the tumor. They are best used in lipomas
of 1x1 cm in size and have to be repeated monthly until
desired results are obtained [7].
Soft tissue diode lasers have many advantages when compared
to conventional surgical techniques. They offer shorter
operation time, excellent hemostasis, no sutures, less
requirement of anesthesia, minimal risk of infection, minimal
post operative pain and help in quick healing of the tissue [12].
CONCLUSION
Intraoral lipomas are infrequent clinical finding and its
gingival counterpart is exceedingly rare. Clinicians should be
able to differentiate them from other benign tumors owing to
their distant clinical and behavioral characteristics. Complete
surgical excision should be done to minimize recurrence. Soft
tissue diode lasers have promising results when compared with
conventional surgical techniques and must be routinely
employed in clinical practice.
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