Facial appearance depends on several oral and extraoral factors. The gingiva is an important intraoral tissue which when affected particularly by pigmentation is. Gingival Depigmentation. shArmilA VermA*, meerA Gohil**, VAnDAnA rAthwA†. AbstrAct. A smile expresses a feeling of joy, success, sensuality, affection and. ser than liquid nitrogen in case of gingival depigmentation. That’s why two alternative methods are used: laser ablation with an Er:YAG laser and cryosurgical.
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Melanin pigmentation often occurs in the gingiva as a result of an abnormal deposition of melanin, due to which the gums may appear black, but the principles, techniques, and management of the problems associated with gingival melanin pigmentation are still not fully established.
YAG laser, semiconductor diode laser, and CO 2 laser have been employed for removal of melanin hyper pigmentation.
The following case series describes three different surgical depigmentation techniques: Better results of depigmentation were achieved with diode laser than conventional scalpel and with rotary abrasion with respect to esthetics.
The results point out that lasers are an effective and a safe means to removal of hyperpigmentation from the gingiva. Healing was uneventful and no repigmentation occurred. Etiological factors are varied which include drugs, heavy metals, genetics, endocrine disturbances, syndromes as Albright’s syndrome, Peutz Jegher’s syndrome, and also in inflammation. Adverse habits such as smoking can also stimulate melanin pigmentation and the intensity of pigmentation is related to the duration of smoking and the number of cigarettes consumed.
The pigmentation is mostly localized at the anterior labial gingiva, affecting females more than males. Melanin, a nonhemoglobin-derived brown pigment, is the most common of the endogenous pigments and is produced by melanocytes present in the basal layer of the epithelium. Gingival hyperpigmentation is caused by excessive deposition of melanin located in the basal and suprabasal cell layers of the epithelium. Melanin pigmentation is the result of melanin granules produced by melanoblasts intertwined between epithelial cells at the basal layer of the gingival epithelium.
The degree of pigmentation varies from one person to another and depends on variety of factors especially the melanoblastic activity. Gingival depigmentation can be considered a periodontal plastic procedure whereby the gingival hyperpigmentation is removed by various techniques and the technique selection should primarily be based on clinical experiences and individual preferences with primary indication of demand for improved esthetics.
Different techniques for depigmentation include: The present case series describes three simple and effective surgical depigmentation techniques – The scalpel technique, rotary abrasive technique, and a diode laser surgery — for gingival depigmentation, which have produced good results with patient satisfaction. The use of a rotary abrasive was planned to perform the depigmentation.
The entire procedure was explained to the patient and written consent was obtained. A complete medical, family history, and blood investigations were carried out to rule out any contraindication for surgery.
Local anesthesia was infiltrated in the maxillary anterior region from premolar to premolar Lignocaine with adrenaline in the ratio 1: A high speed hand piece with an acrylic rotary abrasive was used to remove the pigmented layer [ Figure 2 ]. Pressure was applied with sterile gauze soaked in local anesthetic agent to control hemorrhage during the procedure.
After removing the entire pigmented epithelium along with a thin layer of connective tissue with the acrylic rotary abrasive, the exposed surface was irrigated with saline. While using the rotary tool, minimal pressure was applied with feather light brushing strokes and without holding it in one place.
Care was taken to see that all remnants of the pigment layer were removed [ Figure 3 ].
The surgical area was covered with a periodontal dressing [ Figure 4 ]. Post-surgical antibiotics Amoxicillin mg, three times daily for 5 days and Analgesics ibuprofen with paracetamol, three times daily for 3 days were prescribed.
The patient was advised to use chlorhexidine mouthwash 12 hourly for 1 week. The patient was reviewed at the end of 1 week to be satisfactory [ Figure 5 ].
The patient had no complaints of postoperative pain or sensitivity. At the end of 3 months, the gingiva appeared healthy and no deligmentation was seen [ Figure 6 ]. The depimgentation process was proceeding normally and patient did depitmentation report any discomfort. A year-old male patient complaining of heavily pigmented gums visited the Department of Periodontics, Army College of Dental Sciences, Secunderabad.
He complained of dark gums [ Figure 7 ] and requested for any cosmetic treatment which would eventually enhance the aesthetics on smiling. His medical history was non-contributory. The hyperpigmentation was esthetically displeasing and laser-assisted depigmentation of the gingiva in the anterior region from canine to canine in the maxilla was planned.
Topical anesthetic gel was applied to ginigval surgical field.
Special eye glasses were worn by the patient and the staff to fulfill with the FDA laser safety rules. The properly initiated tip of the diode laser unit Deplgmentation, AMD laser technologies, USA; wavelength nm angled at an external bevel of 45 degrees and at energy settings of 0. After removal of the overlying epithelial tissue, power setting was increased to 2 W to attain rapid ablation for removing the pigments present deep deepigmentation the basement membrane and minimize the hemorrhage from the connective tissue [ Figure 9 ].
During the procedure, any tissue tags left out after laser ablation were wiped with sterile gauze soaked in saline every min and depigmejtation inspection was done to confirm no pigmented areas were left out The surgical area was covered with a periodontal dressing [ Figure 10 ]. The patient was prescribed analgesics for use when required and was discharged with necessary post-operative instructions. The patient was reviewed at 1 week and the post-operative healing was uneventful [ Figure 11 ].
The patient was recalled after 1 month and 3 deigmentation for evaluation depigmentarion any repigmentation [ Figure 12 ]. There was no incidence of any repigmentation. Her oral examination revealed that she had deeply pigmented gingiva from right first premolar to left first premolar. The depigmentation procedure with scalpel was planned accordingly. After administration of local anesthetic, a Bard Parker handle with a No.
The entire pigmented epithelium along with a thin layer of connective tissue with scalpel was removed. The exposed surface was irrigated with saline the surgical area was covered with a periodontal dressing [ Figure 16 ].
Pink esthetics in periodontics – Gingival depigmentation: A case series
Post-surgical instructions were given to the patient along with antibiotics Depigmentagion mg, three times daily for 5 days and anti-inflammatory analgesics Ibuprofen and Paracetamol three times daily for 3 days. The patient was advised to 0.
The patient was reviewed at the end of 1 week. The healing process was proceeding normally and it was quite uneventful on the surgical area. The patient was asked to continue the chlorhexidine mouth wash for another week. At the end of 1 month, re-epithelization was complete and healing was found to be satisfactory [ Figure 17 ]. The patient had no gingivao of post-operative pain or sensitivity. The gingiva appeared healthy and no repigmentation was observed at the end of 1 and 3 months [ Figure 18 ].
The degree of melanin pigmentation was determined by melanin pigmentation index yingival Figure 19 ] based on the following scoring system:. Solitary unit s of pigmentation in papillary gingiva without extension between neighboring solitary units.
Formation of continuous ribbon extending depigmeentation neighboring solitary units. The visual analog scale VAS was used to evaluate the subjective pain level experienced by the patient.
Pink esthetics in periodontics – Gingival depigmentation: A case series
The patient was asked to mark the severity of the pain. The distance of this point, in centimeters, from the left end of the scale was recorded and used as the VAS score: Wound healing was evaluated based on the following scores: Tissue defect or necrosis. Because the patient was under anesthesia, evaluation of pain was done 1 day postoperatively. Healing was uneventful in 1 st week with pink color comparable to nearby non-treated area, resulting in depig,entation significant improvement in esthetic appearance.
Patient’s acceptance of the procedure was good and results were excellent as perceived by the patient. Compared to scalpel blade and rotary abrasion depigmentation, diode laser showed delayed healing [ Table 1 ].
At giingival VAS evaluation sites operated on with scalpel blade and bur abrasion, the patient complained of moderate pain, but at the site treated with diode laser, only slight or no pain was recorded. However, the pain had reduced considerably 1 week after the surgery [ Table 2 ].
Gingival depigmentation: A split mouth comparative study between scalpel and cryosurgery
The MPI score also showed that there was no recurrence of pigmentation at 3 months. Melanin pigmentation is frequently caused by melanin deposition by active melanocytes located mainly in the basal layer of the oral epithelium. Physiologic pigmentation is probably genetically determined, but as Dummet[ 6 ] suggested, the degree of pigmentation is partially related to mechanical, chemical, and physical stimulation.
Different treatment modalities have been used for this aim. There are increasing demands for cosmetic rehabilitation for gingival melanin pigmentation. Several modalities have been suggested for gingival depigmentation, varying from scalpel, electrosurgery, and cryosurgery to lasers. Abrasion technique using a large round diamond bur in a high speed handpiece with depigmentatipn irrigation also has been used but difficulty remains in controlling the depth of de-epithelization and obtaining an adequate access.
The semiconductor diode laser is emitted in continuous- wave or gated-pulsed modes, and is usually operated in a contact method using a flexible fiber optic delivery system. Laser light at to nm is poorly absorbed in water, but highly absorbed in hemoglobin and other pigments.
Since the diode basically does not interact with deigmentation hard tissues, the laser is an excellent soft tissue surgical laser, indicated for cutting and coagulating gingiva and oral mucosa, and for soft tissue curettage or sulcular debridement. The usage is quite similar to electrocauterization. Tissue penetration of a diode laser is less than that of the Nd: YAG laser, while the rate of heat generation is higher.
The advantages of diode lasers are the smaller size of the units as well as the lower financial costs. Diode laser did not produce any deleterious effect on the root surface. Thus, it is generally deligmentation that diode laser surgery can be performed safely in close proximity to dental hard tissue.
The healing period of scalpel wounds is shorter than with diode laser. However, scalpel surgery causes unpleasant bleeding during and after the operation and it is necessary to cover the exposed lamina propria with a periodontal pack for 7 to 10 days. The diode laser causes minimal damage to the periosteum and bone under the gingiva being treated, and it has the unique property of being able to remove a thin layer of epithelium cleanly.
Although healing of laser wounds is slower than healing depigmentatin scalpel wounds, a sterile inflammatory reaction occurs after laser use. They found an extraordinarily high reduction of bacteria.
The use of scalpel technique for the depigmentation is the most economical as compared to other techniques, which require more advanced armamentarium. However, scalpel surgery causes unpleasant bleeding during and after the operation, and it is necessary to cover the surgical site with periodontal dressing for 7 to 10 days.
Electrosurgery has its own limitations in that its repeated and prolonged use induces heat accumulation and undesired tissue destruction. The need and demand for esthetics requires the removal of unsightly pigmented gingival areas to create a pleasant and confident smile, gigival altogether may alter the personality of an individual.
This could depigmentahion easily attained by using any of the methods described above. The application of diode laser appears to be a safe and effective alternative procedure for the treatment of gingival melanin pigmentation.