the congenital granular cell tumour of the newborn , also known as congenital epulis or neumann 's tumor , is rare . this lesion behaves in a benign manner and no recurrent or metastatic lesions have been reported . we are reporting a 2-day - old female neonate , who came to our unit with a well defined , solitary , firm mass arising from the maxillary anterior region measuring about 3.5 cms in diameter and causing difficulty in breast feeding but no hindrance to the airway . we have presented the clinical features and the different modalities of its treatment to spread awareness among clinicians for better management of similar tumors . congenital granular cell tumor ( cgct ) , first described by neumann in 1871 , is a benign soft tissue lesion of the neonate that almost always arises from the alveolar mucosa . they are seen 3 times more frequently in the maxillary alveolus than in the mandibular alveolus ( 2 , 3 ) . females are affected from 8 to 10 times more frequently than males , perhaps indicating a hormonal component in its development ( 4,5 ) . the typical location is the alveolar ridge of the maxilla near the canine , but the mandibular region can also be involved . usually , it is presented as a single lesion ; however , multiple lesions have been reported in some cases ( 6,7 ) . this lesion is seen as a mass protruding from the mouth of a newborn and it may interfere with feeding and respiration . the recommended treatment plan involves prompt surgical resection of the mass under ga or la , since spontaneous regression is rare . some authors have also advocated gingivoperiosteoplasty with excision for primary alveolar reconstruction in cases of defects in the alveolar ridge . it helps in achieving proper alignment and promotes normal tooth development ( 9).this case report intends to document the clinical presentation and its management of the neumann 's tumor in the maxillary arch of a 2-day - old female neonate . an otherwise healthy 2-day - old neonate was referred to our oral and maxillofacial surgery unit from the neonatal icu of our hospital for diagnosis and treatment of a large mass protruding from her mouth . the mother was fit and well gravida 2 para 1 , with no remarkable medical history to note . the baby was born at term plus eight days weighing 2.85 kg , pink and breathing spontaneously ( apgar : 910 ) . as the mother was from a remote rural area , she did not have access to any antenatal ultrasonogram . at birth , a firm pedunculated mass , there was a solitary , firm , pedunculated mass , measuring about 3.5cms in diameter . it was arising from the upper alveolar ridge over the right lateral and central incisor area ( figure 1 ) . pre - op view of 5 day neonate 's congenital granular cell tumor she was scheduled for surgery on the 5 day after birth . monopolar electrocautery was used , and there was very minimal blood loss ( figure 2 ) . in postexcision , any kind of alveolar defect was not noted ( figure 3 ) . the child was breastfeeding 48 hours after surgery , and she was discharged the following day . histopathology revealed focal ulceration with underlying stroma demonstrating large sheets of closely packed , polygonal cells with round , regular nuclei and inconspicuous nucleoli . it also showed abundant granular cytoplasm consistent with the diagnosis of congenital epulis , or congenital granular cell tumor ( figure 4 ) . excised congenital granular cell tumor post - op view of the 5 day neonate after excision congenital granular cell tumor with cautery histopathology of excised congenital granular cell tumor congenital epulis , also known as granular cell tumour of the gingiva , congenital granular cell myoblastoma , or newmann 's tumour , following the first published case ( 1 ) , is encountered exclusively in newborns . congenital epulis differs from other granular cell tumours encountered in adults by its exclusive origin from the neonatal gingiva , the scattered presence of odontogenic epithelium , the more elaborate vasculature and the lack of interstitial cells with angulate bodies ( 10 , 11 ) different entity from other gcts . the tumor usually arises at the future site of the maxillary canine or the lateral incisors , but the unerupted teeth are not involved . it has been described as arising from the mandibular gingiva as well as from several other locations simultaneously . the reported size varies from several millimeters to 7.5 cm ( 8) . the clinical presentation consists of a lobular or ovoid , sessile or pedunculated swelling covered by a smooth mucosal surface , usually in the maxilla . the differential diagnosis of a large mass in the fetal or neonatal oral cavity should include such congenital malformations as encephalocoele , dermoid cysts orteratoma and benign and malignant neoplasms including hemangioma , lymphatic malformations , melanotic or pigmented neurectodermal tumours of infancy and rhadomyosarcoma ( 10 ) . the treatment of choice is surgical excision to be performed as soon as possible ( 12 ) . there are reports of lesion removal without the use of anesthesia . however , this kind of procedure is not justified since these surgical interventions are elective . the cgct removal under local anesthesia is also an alternative ( 7,8,11 ) when intubation is not possible or in cases of small lesions . there is also the possibility of removal during the delivery in cases where the lesion was detected during pregnancy ( 12 ) . this approach may eliminate additional procedures such as anesthesia and intubation , and it provides the newborn with a free airway and an unobstructed oral cavity immediately after birth ( 7 ) . recurrence after removal is not seen , infact recurrence is not seen even after incomplete excision ( 13 ) . excision of these masses can leave a notch in the alveolus that may result in an incomplete dental arch . gingivoperioseptoplasty is performed early to correct it so that it can restore physiological continuity across the premaxilla and allow osteogenic hematoma formation between the anterior maxillary cleft . it is thought that the union of the mucoperiosteum across an alveolar and anterior hard palate defect creates a periosteal tunnel conducive to bone formation and normal tooth eruption along the cleft region ( 9,14 ) . in conclusion , neumann 's tumor or congenital epulis is a very imposing tumor of the oral cavity in neonates . the tumor is often misdiagnosed before surgery because of its rarity and lack of awareness among clinicians ( 15 ) . neumann 's tumors rarely cause compromise in the airway , but most of them do hamper breast feeding . it does not harm the future dentition .
backgroundthe congenital granular cell tumour of the newborn , also known as congenital epulis or neumann 's tumor , is rare . 
 it occurs on the gingiva of the anterior alveolar ridge of the jaws . 
 this lesion behaves in a benign manner and no recurrent or metastatic lesions have been reported.case reportwe are reporting a 2-day - old female neonate , who came to our unit with a well defined , solitary , firm mass arising from the maxillary anterior region measuring about 3.5 cms in diameter and causing difficulty in breast feeding but no hindrance to the airway . 
 the mass was surgically excised under general anesthesia . 
 postoperative wound healing was uneventful.conclusionwe have shared our experience in handling this rare type of tumor . 
 we have presented the clinical features and the different modalities of its treatment to spread awareness among clinicians for better management of similar tumors .