Discussion
CE is also known as CE of the newborn [
4], congenital granular cell tumor [
4], congenital granular cell lesion [
4], gingival granular cell tumor of the new born [
1] and Neumann's tumor [
2]. CE is usually diagnosed at birth; although, if the lesion is large, it may be diagnosed
in utero by 3D ultrasound and magnetic resonance imaging (MRI) examinations [
5,
6]. The lesion has a site predilection for the maxillary alveolar process, lateral to the midline in the region of the primary canine and lateral incisor [
4]. It has a 9:1 sex predilection for females [
4]. Clinically, it presents as a nodular sessile or pedunculated mass with a smooth normal colored surface [
4]. Usually, patients present with a single lesion, although there have been case reports of multiple lesions [
7,
8] and one case report of a patient with involvement of the alveolar ridge as well as the tongue [
9]. The lesion may be large enough to make it difficult for the child to feed and/or may cause airway obstruction [
8]. Clinical differential diagnoses for CE include hemangioma, fibroma, rhabdomyoma, rhabdomyoscarcoma, lymphangioma, osteogenic and chondrogenic sarcomas, teratoma and granular cell tumor [
5,
10].
The traditional management of the lesion has been complete surgical excision under either general anesthesia [
11] or local anesthesia [
12] within hours [
8] to days [
11,
13] after birth. There is one case report of excision of CE using carbon dioxide laser under general anesthesia in a two-day-old infant [
13] and another report on the use of erbium, chromium: yttrium-scandium-gallium-garnet (Er, Cr: YSGG) laser to remove a CE lesion [
14]. CE is not known to recur after surgical excision even when the removal has been incomplete. The dentition in the region of lesion usually remains unaffected [
15,
16]. However, there has been a case reported of hypoplastic maxillary primary left incisor, cuspid, and first molar in the region where a 2.5 cm large CE was surgically removed 11 days after birth [
17]. Mucoperiostial flaps were raised during the surgical procedure and the authors speculate that the surgery may have disrupted development of these three primary teeth [
17].
Histopathologically, CE comprises of large round cells with granular eosinophilic cytoplasm in a fibrous connective tissue stroma. The overlying surface epithelium exhibits atrophy of the rete ridges [
4]. There exists much controversy and uncertainty over the histogenesis of CE [
18]. The origin of the lesion has been theorized from various tissue components including odontogenic epithelium, mesenchymal cells as well as neurogenic cells [
18].
CE is usually an isolated finding and it has not been found to be pathognomic of any other medical condition or syndrome. However, a thorough review of case reports of CE revealed CE occurring in infants with polydactyly [
10], goiter [
19], Triple X syndrome [
10], polyhydraminos [
20,
21], maxillary hypoplasia [
21] and neurofibromatosis [
22].
Recent advances in pre-natal imaging have enabled assessment of fetal swallowing and airway patency with the use of 3D ultrasound [
8,
23]. This enables the physician to plan for a multi-disciplinary team to be present at the time of delivery of the child. This team usually comprises of the obstetrician, obstetric anesthesiologist, pediatric anesthesiologist, neonatologist, otolaryngologist, neonatal nurse and pathologist [
5,
8]. The option of
ex utero intra-partum treatment may be planned in cases with obstructive lesions diagnosed in the fetus in the pre-natal period [
8,
23]. Follow-up of fetuses with CE diagnosed in the pre-natal period with 3D ultrasound has also revealed that this lesion exhibits maximum growth in the end of the third trimester; it has been speculated that hormonal influences towards the end of pregnancy influence this rapid growth of the lesion [
10].
Of the more than 200 cases of CE of the new born reported in the English literature, there have been eight case reports [
14‐
16,
24‐
27] that have documented spontaneous regression (Table
1). There have been recommendations in the literature to assume an expectant, non-surgical approach in cases of CE where there is no interference with feeding or respiration [
15]. In such cases, regular monitoring of the lesion for regression has been advocated as an acceptable clinical approach [
15,
16,
25]. The reasoning is that the CE has an inherent tendency to involute without exhibiting post-natal growth [
12]. In the management of an infant with this lesion, the risks arising from the use of general anesthesia must be weighed in making a treatment decision.
Table 1
Reports of cases of congenital epulis managed conservatively
O'Brien & Pielou 1971[ 24] | Case 1: male | NS | Maxillary right alveolar process | 1 surgically excised, 1 not excised | 13 months | Non-resected lesion resolved, dentition unaffected |
| Case 2: female | NS | Mandibular left posterior alveolar process | 1 surgically excised, 1 not excised | 12 months | Non-resected lesion disappeared |
| Female | 1 cm | Mandibular right anterior alveolar process | Nonsurgical management | 5 years | Residual swelling; dentition unaffected |
| Female | 1.5 cm | Right maxillary alveolar process | Nonsurgical management | 12 months | Lesion size 3-4 mm; dentition unaffected |
| Female | 8 × 4 × 4 mm | Anterior mandibular ridge | Nonsurgical management | NS | NS |
| Female | 1.4 × 1.2 × 1.2 cm | Right maxillary alveolar process | Nonsurgical management | 10 months | Lesion regressed in 8 months |
| Female | 1 × 0.6 cm | Left maxillary aanterior alveolar process | Nonsurgical management | 12 months | Complete regression at 12 months; dentition unaffected |
| NS | NS | Right maxillary alveolar process | Nonsurgical management | 1 year | Complete regression, dentition unaffected |
Ritwik 2009 (current case report) | Female | 1.5 cm | Right maxillary alveolar process | Nonsurgical management | 16 months | Residual 2 mm swelling, dentition unaffected |
Our patient presented with a relatively small lesion (1.5 cm in its greatest dimension) on the maxillary alveolar process, which was not causing any problems with feeding or respiration. With radiographic and urinary investigations we ruled out neuroectodermal tumor of infancy which also has a maxillary anterior site predilection [
3]. Parental compliance was excellent for all follow-up appointments. This case demonstrates the ability of the CE of the new born to spontaneously regress. The biologic behavior of the lesion in our patient can be compared to that reported by Welbury [
15] and Jenkins [
25]. In their case reports, the CE lesions regressed over a period of 12 months, but a residual lesion persisted in the original site. The size of the lesion in our patient was comparable to that reported in all other eight cases of CE which were managed conservatively [
4,
15,
16,
24‐
27]
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
PR examined and treated the patient. RBB provided oral and maxillofacial pathology consultation. RJM provided pediatric dentistry consultation. All authors have read and approved the final manuscript.