I had a case somewhat similar to what you are describing, but not in the esthetic zone.

I had a patient with a big lesion on the buccal keratinized gingiva of tooth 30. I did an excisional biopsy and the resultant defect was pretty large. All KG in that area was removed with the biopsy, so I did a simultaneous free gingival graft.

Everything healed just fine and the esthetics were functionality were very nice. The biopsy came back as a Peripheral Ossifying Fibroma. 6 months later, the lesion recurred in the same exact spot. This was interesting because the tissue from the FGG ended up being converted to the POF. This time, I re-biopsied the area with wider margins. Both biopsies were taken down to bone.

I did an extensive PUBMED search on this and here is what I came up with. If the lesion recurs after this second attempt with much wider margins, the cells responsible for causing the POF are likely located in the PDL of the associated tooth. If so, the tooth needs to be extracted if you do not the lesion to recur.

Now we are getting into some uncharted territory. What happens if you take out the tooth and the lesion still recurs? Now you have taken out this patient's tooth for nothing. The patient is not going to be happy about this. Quite a dilemma.

At this point, the lesion has not recurred after the second biopsy. I did speak to the patient about the situation I just laid out here. If it recurs, we are just going to leave the lesion and monitor.

This reminds me of a case I did some years ago. This patient was referred by a general dentist that had removed the lesion twice with a laser. The lesion returned each time. The patient presented with what appeared to be a fibroma (confirmed later) that was 4mm x 5mm and raised 3mm involving the marginal attached gingiva on the facial of #8, This young lady (16 years old) showed all the way to the mucosa when she smiled, and she really liked to smile.

The lesion had been "removed" by the dentist and his laser by lasing the outer surface till level and that was that. Recurrence was predictable. Clearly the lesion needed to be removed all the way to the bone. So I resected it entirely leaving a notable defect as you might imagine. There really was no other way to approach this case. Then I placed a connective tissue graft, at the same visit. Again, there simply was no other way to approach this. After all, bone was exposed. To have allowed this to heal without grafting would have created a defect much more difficult to repair and for no reason.

The result in the end was excellent and it was an easy way to be a hero in a nice lady's eyes! (and her mother too..!)

So, I would agree that grafting at the time of excisional biopsy is a very important consideration. With the caveat that the type of lesion is also important to assess when approaching any case, as noted in one of the examples presented in other posts.

Michael