INDIAN DENTAL JOURNAL

Offical Publication of Society of Medical Dental & Public Health

ESTHETIC DEPIGMENTATION OF ANTERIOR GINGIVA: A CASE

REPORT

Cherish Simon1 Sudesh Rege2 Amitabh Varshney3

1MDS (Periodontics), A-2/112, Asmita Jyoti CHS, Malad(W),Mumbai-400095. 2MDS (Prosthodontics) 42, Manchitra, 2nd Koldongri, Sahar road, Andheri (East),

Mumbai 400069. 3Assistant professor, Department of Periodontics & Community Dentistry, Z A Dental college, AMU, Alighar, UP, India.

Address for Correspondence: Dr Amitabh Varshney, Chandra Health Care, Delhi Gate Chauraha, Alighar, UP, India.

E-mail: amitabhvarshney@yahoo.com

ABSTRACT
Excessive gingival pigmentation is a major esthetic concern for many people. Though, it is not a medical problem,
many people complain of dark gums as unesthetic and demand for cosmetic therapy. This problem is aggravated in
patients with a "gummy smile" or excessive gingival display while smiling. Esthetic periodontal plastic surgery is
especially successful in individuals with compromised esthetics. A case is reported here where gingival
depigmentation was done using three different techniques: electrosurgery; scalpel surgery; and surgical abrasion.
The clinical results of the three methods have been compared.

KEYWORDS Gingiva, Aesthetic, Depigmentation

I NTRODUCTION - In today’s aesthetic

conscious world, gingival colour and display rate
is an integral part of an individual’s smile. Fair-
nature and numerous procedures have thus been
introduced with similar results up to date. The
various methods that have been employed for
depigmentation are:
electrosurgery, 7
lasers,
scalpel,5 cryosurgery,6
8,9
deepithelialization
skinned people with moderate or severe gingival
pigmentation frequently request cosmetic treatment technique,10 free gingival grafts,11 etc. Although there
of the black gums. Gingival pigmentation is are many techniques to treat this unaesthetic
considered as an aesthetic, rather than a medical condition the results of most of the techniques have
problem and results from melanin granules, which not been stable for long term.12 This case report
are produced by melanoblasts.1 Melanin pigmentation compares three different depigmentation techniques
of the gingiva is a physiological condition of for removing melanin pigmentation of gingiva: the
endogenous origin and is caused by excessive scalpel method was used on the upper right anterior
melanin deposition by the melanocytes, located in the region, electrocautery technique on the upper left
basal and the suprabasal cell layers of the epithelium. anterior region and the rotary bur was used on the
It generally presents as a diffuse deep purplish lower anterior region.
discoloration or as irregularly shaped brown and light
brown patches.2 Gingival hyperpigmentation is a well CASE DESCRIPTION
documented condition in literature and is frequently
observed in some races such as Asians, Africans and A 25-year-old male who had a chief complaint of
Mediterranean populations.3 It is also known to be unesthetic gingival display in the anterior part of the
caused by various other etiologies including genetic maxillary and mandibular gingiva visited the
factors, tobacco use, prolonged drug use especially Department of Periodontology, Krishnadevaraya
antimalarial drugs & tricyclic antidepressants and college of dental sciences, Bangalore. There was no
systemic conditions such as endocrine disturbances, remarkable medical history, and diffuse melanin
Albright’s syndrome, malignant melanoma, hyperpigmentation was found on the labial surface of
antimalarial therapy, Peutz-jegher’s syndrome, both the maxillary and mandibular arches.(Fig.1)
trauma, hemachromatosis, etc.4 Depigmentation of Patient's gingiva was found to be clinically healthy &
gingiva is a periodontal plastic surgical procedure free from any visible clinical inflammation. All the
and has attracted much interest due to its aesthetic

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 INDIAN DENTAL JOURNAL
Offical Publication of Society of Medical Dental & Public Health

procedures were explained verbally to the patient and and the amount of the pigment containing cells
written informed consent was taken before the determine the colour of the gingiva.13 As the
procedure. awareness of gingival aesthetics is on the rise, a
larger group of people have been requesting to
Scalpel method: The surgical site was anesthetized
undergo depigmentation procedures. A variety of
by local infiltration with 2% lignocaine containing
procedures have been therefore been explored, with
1:80000 adrenaline. A Bard Parker handle with a
almost the same amount of success. The scalpel
No.15 blade were used to remove the entire
method is one of the foremost recommended
pigmented epithelium along with a thin layer of
techniques due to the easy availability of equipments
connective tissue. (Fig.2&3) Electrocautery: A
to carry out this procedure. It is not overtly technique
straight wire electrode tip was used to de-epithelialize
sensitive and has shown to heal faster as compared to
the labial mucosa. Light, gentle ‘paintbrush-like’
other techniques.14 However, the disadvantage of this
strokes were used and the electrode is always kept in
method is the bleeding and the large area of exposed
motion, to prevent a build-up of lateral heat at the tip
lamina propria that has to be probably covered by a
of the electrode. The electrode tip was cautiously
periodontal pack. The electrosurgical method is more
used to avoid injury to the tooth surface or adjacent
technique sensitive and requires an electrosurgical
tissues. (Fig 4 & 5) Abrasion by rotary round bur:
unit that leads to additional costing. This method
A contra-angled hand piece and carbide bur were
cannot be used in poorly shielded cardiac pace
used for abrasion on the other side. Abrasion under
makers, the heat generated by injudicious use can
water spray over an epithelial layer was performed
cause tissue damage and loss of periodontal support
until whitish connective tissue was exposed. All the
when the electrode is used close to bone and also
melanin remnants of the epithelium were completely
treatment causes unpleasant odor. But this technique
removed to prevent the possibility of recurrence.
has the advantage of hemorrhage control and the
(Fig.6&7) After surgery, the denuded connective
subsequent healing discomfort & scar formation is
tissue was covered with a periodontal pack. Patient
minimal.15 Bur abrasion or de-epithelialization using
was instructed to avoid trauma to the treated gingiva
surgical bur has been employed but the depth of de
and avoid acidic and hot food for one week. Post-
epithelialization cannot be precisely controlled in this
surgical antibiotics (Amoxicillin 500mg, thrice daily
technique.16 It is an easy technique that requires
for five days) and Analgesics (ibuprofen, thrice daily
minimal surgical expertise. This case report has
for three days) were prescribed. The patient was
shown all the 3 techniques to provide a remarkable
advised to use chlorhexidine mouthwash 12 hourly
improvement in the aesthetic and cosmetic
for one week. He was reevaluated 10 days and 6
appearance of the gingiva. Some recurrence of
months after the last surgical session. Evaluation
pigmentation has been observed in mandibular labial
included clinical examination and comparative
segment where the carbide bur was used. Insufficient
clinical photographs.
depth of de-epithelialization can be attributed to be,
as the cause of this recurrence. Some pigmentation
also remained on the marginal gingiva and papilla of
RESULTS the maxillary labial segment because the epithelium
No discomfort, teeth sensitivity, pain or bleeding of the papillary edges and free gingival margins were
complications were found intra or postoperatively. not removed perfectly. This was done to avoid the
The patient was satisfied with the significant occurrence of recession.
improvement in color. Tissue deformities, e.g.,
gingival recession and loss of papilla, were not
observed after 6 months because the papillary edges CONCLUSION
and free gingival margins were left untreated.
The depigmentation procedures carried out in this
However, some recurrence can be observed in the
case report have been shown to be successful, cost
mandibular labial segment.(Fig.8)
effective, causing minimal discomfort and the patient
was satisfied with the result. It can be thus concluded
that gingival depigmentation is a reliable procedure
DISCUSSION that can be easily and quickly performed and the
Wide variations have been recorded in the gingival aesthetic result that is obtained from this procedure
colour in normal healthy persons. The degree of has been shown to gratify the patients who are often
vascularization, the thickness of the keratinized layer self conscious of this condition.

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 INDIAN DENTAL JOURNAL
Offical Publication of Society of Medical Dental & Public Health

Fig 1. Pre-operative view Fig.2 Scalpel method Fig.3 Scalpel method

Fig.4 Electrocautery Fig.5 Electrocautery Fig.6 Abrasion by rotary round bur

Fig. Abrasion by rotary round bur Fig 8 – Post operative view

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