ESTHETIC MANAGEMENT OF GINGIVAL

HYPERPIGMENTATION USING LASER AND

SCALPEL TECHNIQUE – CASE SERIES

JIDAM

“An Official Journal of IDA - Madras

Available online

To access & cite this article

Website: jidam.idamadras.com

ABSTRACT

The complaint of darkly pigmented gums is common particularly

in patients having a very high smile line and possess esthetic

problems for them. The degree of gingival pigmentation depends

on melanoblast activity. Various treatment options are in practice

for depigmentation which include scalpel gingivectomy, free

gingival graft surgery, use of chemicals, such as 90% phenol

and 95% alcohol, bur abrasion, electrosurgery, cryosurgery, and

lasers. Among the various techniques, lasers offer a promising

therapeutic option since it is simple, painless, and predictable.

The laser has been recognized as the most effective and reliable

technique having many advantages as compared to other

conventional treatment modalities. It provides a bloodless and

painless surgery.

KEYWORDS:

Scalpel, LASER, depigmentation, esthetics.

JIDAM/Chennai/Volume:7/Issue:4/Pages 157 - 162/Oct-Dec 2020

157

Address for Correspondence:

Dr.K. Sathish Kumar, MDS.,
1674/D, opposite Gov. ITI,
Vengikkal, Thiruvannamalai-606 604.
Mail id: sathishperio94@gmail.com

Received

: 09.06.20

Accepted

: 31.10.20

Published

: 27.12.20

CASE SERIES

Dr. Sathish Kumar K, Dr. Dhivya R, *Dr. Ramakrishnan T, Dr. Priyadurga K, Dr. M.A. Mejalla

Dept. of Periodontology, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu, India.

*Principal, Faculty of Dentistry, Meenakshi Academy of Higher Education and Research, Maduravoyal,

Chennai, Tamilnadu, India.

DOI:1.37841/jidam_2020_V7_I4_05

JIDAM/Chennai/Volume:7/Issue:4/Pages 157 - 162/Oct-Dec 2020

Sathish et al: Gingival depigmentation using Laser and scalpel

158

INTRODUCTION:

The word aesthetic denotes beauty as opposed

to the merely pleasing, indicating that the most

desirable attributes are present. Achieving optimal

oral beauty involves many factors, one of which is

gingival appearance. Harmony of a smile is based on

not only the color of teeth but also depends on the

color of gingival tissues. The objective of gingival

esthetics is to keep healthy good looking gingival

form around teeth that must be restored. A smile also

has additional day-to-day benefits.

When you have

a healthy smile, you are always keen to show it off

in society.

It makes us feel more confident when we

communicate with others, and it also affects how

people around us view us

. It leads to the release of

endorphins that make you feel happier. That eases

the day-to-day stress that you deal with. A healthy

smile can improve the health of not only our mouth

but our body too. It could be an aesthetic problem

for some patients, particularly when it is located in

the anterior labial gingiva, which is associated with a

high smile line and is uneven in appearance.

Gingival

depigmentation can be done by scraping

, free

gingival autografting

, cryosurgery

, electrosurgery

and various types of lasers

CASE REPORT:

CASE 1: A 25-year-old male patient with the chief

complaint of black gums reported to the Department

of Periodontics, Adhiparasakthi Dental College

and Hospital and he also request for the esthetic

treatment of black gums. On clinical examination,

his DOPI score was 3(Heavy clinical pigmentation).

Treatment plan was explained to the patient and

written informed consent was obtained. The patient

and the staff were protected from the laser by wearing

manufacturer’s spectacles. For sites treated with

laser, 20% benzocaine as topical anaesthesia in the

form of gel was applied for 3 minutes in maxillary

anterior region, diode laser in contact mode was used.

The laser ablation was done using a handpiece with

fiber optic filament, 320 μm in diameter set at 0.8 W.

The procedure was performed in a contact mode in

apico-cervical direction on all pigmented areas. No

pain or bleeding complications were observed during

and after the procedure.

CASE 2: A 27-year-old male patient with the chief

complaint of black gums reported to the Department

of Periodontics, Adhiparasakthi Dental College and

Hospital and he also request for the esthetic treatment

of black gums. On clinical examination, his DOPI

score was 3(Heavy pigmentation). Treatment plan

was explained to patient and written informed

consent was obtained. Lignocaine hydrochloride 2%

with 1:100000 adrenaline was administered by the

infiltration technique in the maxillary anterior region.

After 5 minutes, partial dissection and peeling of the

affected area were performed using BP Blade no.15c.

The surgical site was irrigated often with normal

saline while performing the procedure and a wet

gauze pressure pack was given to control bleeding.

POST-OPERATIVE INSTRUCTIONS:

Post-operatively patient is advised to take

Cap. Amoxicillin -500 mg thrice a day and analgesic

Acenac-P twice a day for 3 days was prescribed to

prevent post-operative pain and infection. Following

the procedure, the periodontal pack was given, the

patient was advised to stop brushing in that area for

the next 10 days and the patient also advised to rinse

the mouth with chlorhexidine mouthwash.

POST-OPERATIVE EVALUATION:

Both the patient was apparently normal

immediately after the surgery. Both the patient was

called on the 3rd day when the progressive healing of

the surgical site was seen. The patient did not report

any pain or discomfort on the side treated with the

laser after the procedure. He felt little discomfort

on the side treated with the scalpel but there was no

pain on that side. At a 1-week review appointment,

complete healing of wound on both sides was seen.

At present, i.e. after 6 months, the pigmentation has

recurred in some solitary areas. The patient is still on

follow-up visits.

JIDAM/Chennai/Volume:7/Issue:4/Pages 157 - 162/Oct-Dec 2020

Sathish et al: Gingival depigmentation using Laser and scalpel

161

DISCUSSION:

The color of the healthy gingiva may

vary from pale pink to a deep purplish hue, which

depends on the vascularity of gingiva, thickness of

epithelium, degree of keratinization of epithelium

and the intensity of melanogenesis. A variation in

gingival pigmentation is genetically determined in

their pigment-producing capacity.

The gingiva is the most commonly

affected intraoral tissue, which is responsible for

an unaesthetic appearance. Since the color of the

gingiva can vary, the

homogeneity of color is more

important. Excess deposits of melanin can cause

dark patches on the gingiva this form is known as

gingival hyperpigmentation, particularly at the

base of the interdental papillae. The gingiva is the

commonly affected tissue, which is responsible for

an unpleasant appearance in the oral cavity. Melanin

hyperpigmentation often occurs in the gingiva as a

result of an abnormal deposition of melanin. This

can be caused by a wide range of local and systemic

factors. Some of the local factors are amalgam tattoo,

Pigmented Nevi, Oral melanotic macules, Melanoma

etc., Gingival depigmentation is a procedure used in

periodontal surgery to remove these discolorations.

The first and foremost indication for depigmentation

is patient demand for improved esthetics.

Scalpel technique involves surgical removal

of gingival epithelium along with a layer of the

underlying connective tissue which allows the

denuded connective tissue to heal by secondary

intention. Delicate scarring, exposure of the alveolar

bone at areas where the gingiva is thin may occur

occasionally and repigmentation are the few

disadvantages of the procedure.

In the case of laser depigmentation, the ability

of Melanocytes to absorb the laser is depend on the

laser wavelength, and its ability to penetrate tissue.

Melanocytes has an absorption spectrum range from

351 to 1064 nm. The laser beam has the ability to

destroy the epithelial cells including those at the

basal layer, and hence reduces the repigmentation.

Results of both treatment modalities were stable to

some extent with slight recurrence seen as solitary

units of pigments mainly in the papillary area in both

sites at 3 and 6months

There are many advantages of lasers over surgical

procedures. According to Wigdor et al (1995)

, these

include:

1. Minimize bleeding(high energy beam

photocoagulation),

2. Reduce bacterial infections(sterilizes the area

being worked on),

3. Reduce anxiety in patients,

4. Minimize postoperative swelling and scarring,

5. Painless procedure does not require anesthesia

All these above-mentioned advantages are achieved

in the above case. During the procedure, there was

no bleeding, which is always associated with other

surgical approaches like gingival abrasion technique,

scalpel technique, free gingival autografting, or

gingivectomy are used. Also no postoperative pain

was experienced by the patient and no swelling or

any other signs of infection were noticed, whereas

other alternative procedures have to be accompanied

by the administration of antibiotics and analgesics to

minimize postoperative infection and pain.

DISADVANTAGES OF LASER,

1. Most expensive since the cost of the laser is much

higher,

2. Laser is very delicate to handle

3. Need for Personal protective equipment

4. It is harmful to human beings (hazards for the

direct vision of the beam)

Perlmutter et al. in 1986 conducted a study

the results showed that gingival surgical procedures

performed solely for cosmetic reasons offer no

permanent results

. The spontaneous repigmentation

is due to melanocytes from the normal tissue multiply

and transfer into the depigmented areas.

CONCLUSION:

In conclusion, number of techniques are

available with some advantages and disadvantages.

However, choice of the technique is depend on

individual appearance, clinical expertise and patient

affordability. The present cases revealed that both the

scalpel and diode laser technique used for gingival

depigmentation results in similar outcomes. Recently,

the laser depigmentation technique has been accepted

as the most effective, painless and reliable technique.

The technique used here produced preferred results,

JIDAM/Chennai/Volume:7/Issue:4/Pages 157 - 162/Oct-Dec 2020

Sathish et al: Gingival depigmentation using Laser and scalpel

162

and above all, the patients were pleased with the

outcome, which is the ultimate goal that is carried

out.

FINANCIAL SUPPORT AND

SPONSORSHIP:

Nil

CONFLICTS OF INTEREST:

There are no conflicts of interest.

ACNOWLEDGEMENTS:

I warmly acknowledge my past Professor and

HOD, Dr.T.Ramakrishnan who is now the Principal

of Meenakshi Ammal Dental College.

REFERENCES:

Anderson KM, Behrents RG, McKinney T,

Buschang PH. Tooth shape preferences in

an esthetics smile. Am J Orthod Dentofacial

Orthop. 2005. Oct;128(4):458–65

Ribeiro FV, Caraveller CP et al.Esthetic

treatment of gingival hyperpigmentation with

Nd:YAG laser or scalpel technique: a 6-month

RCT of patient and professional assessment

Lasers Med Sci 2014;29:537-544

Tamizi M, Taheri M. Treatment of severe

physiologic gingival pigmentation with

free gingival autograft. Quintessence Int

1996;27:555-558

Tal H,Landsberg.Cryosurgical depigmentation

of the gingiva.a case report.J Clin Periodontol

1987;4:614-617

Chandna SH, Kedige SD.E valuation of pain

on use of electrosurgery and diode laser in the

management of gingival hyperpigmentation:

a comparative study.J Indian Soc Periodontol

201t5:19:49-55

Low SB, Mott A. Laser technology to manage

periodontal disease: a valid concept? J Evid

– Based Dent Prac 2014; 14(Suppl):154-158

Dr. Harvey A. Wigdor DDS, MS Joseph T.

Walsh Jr. PhD Lasers in dentistry.Lasers in

surgery and medicine 1995:16:103-133

Perlmutter S, Tal H. Repigmentation of

the gingiva following surgical injury. J

Periodontol 1986;57:48-50.