|Year : 2017 | Volume
| Issue : 2 | Page : 61-64
Esthetic correction for gingival pigmentation using scalpel/electrocautery/lasers: A report of three cases with review of literature
Ramanarayana Boyapati1, Siva Sai Prasad Reddy Dandu1, Prathiba Gojja1, Kotya Naik Maloth2, Shyam Sunder Salavadi1
1 Department of Periodontics, Mamata Dental College and Hospital, Khammam, Telangana, India
2 Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Khammam, Telangana, India
|Date of Web Publication||29-Dec-2017|
Dr. Ramanarayana Boyapati
Department of Periodontics, Mamata Dental College and Hospital, Khammam - 507 002, Telangana
Source of Support: None, Conflict of Interest: None
Esthetics has become a major concern in the modern era, though hyperpigmented of gingiva is not a medical problem, many people consider it as unesthetic. Gingival melanin pigmentation occurs in all races without any sex and gender predilection in variable amount caused by melanin granules. The degree of pigmentation varies from individual to individual based on various etiological factors. The gingival hyperpigmentation is removed or reduced by various techniques such as scalpel, electrosurgery, cryosurgery, lasers, and abrasion with diamond bur. The present study compares the management of three cases with scalpel, electrocautery, and laser techniques.
Keywords: Cryosurgery, electrocautery, gingiva, lasers, melanin, physiologic, pigmentation
|How to cite this article:|
Boyapati R, Dandu SS, Gojja P, Maloth KN, Salavadi SS. Esthetic correction for gingival pigmentation using scalpel/electrocautery/lasers: A report of three cases with review of literature. J Dent Lasers 2017;11:61-4
|How to cite this URL:|
Boyapati R, Dandu SS, Gojja P, Maloth KN, Salavadi SS. Esthetic correction for gingival pigmentation using scalpel/electrocautery/lasers: A report of three cases with review of literature. J Dent Lasers [serial online] 2017 [cited 2019 May 26];11:61-4. Available from: http://www.jdentlasers.org/text.asp?2017/11/2/61/221996
| Introduction|| |
Esthetics has become an important aspect of dentistry in present-day life and oral clinicians are more concerned to face the challenging esthetics, along with addressing the biological and functional problems. One such common esthetic problem complained by patients is pigmentation of gingiva. Gingival pigmentation has been defined as the discoloration of the gingiva due to lesions associated with extrinsic and intrinsic factors. Most pigmentation is caused by five primary pigments, such as melanin, melanoid, oxyhemoglobin, reduced hemoglobin, and carotene. Melanin pigmentation is the most commonly noticed pigment in oral cavity, affecting gingiva most common. Melanin pigmentation presents neither itself as a medical problem nor a disease entity, but only as a major esthetic concern for people. Gingival melanin pigmentation occurs in all races without sex and gender predilection. The typical clinical representation of gingival pigmentation is symmetric and persistent without altering the normal gingival architecture., Along with this primary factors, they are also associated with genetic factors, tobacco use, systemic disorders (endocrine disturbance, McCune–Albright syndrome, malignant melanoma, Peutz–Jeghers syndrome, hemochromatosis, Addison's disease, and von Recklinghausen's disease), antimalarial drugs, heavy metals (silver, bismuth, mercury, and lead), zidovudine, amalgam tattoo, nevus, melanoacanthoma, and Kaposi's sarcoma. Gingival hyperpigmentation is seen as a genetic trait in some populations irrespective of gender and sex and is more appropriately termed physiologic or racial gingival pigmentation, more aggravated in patients with a “gummy smile.”
All the exogenous and endogenous etiological factors result in oral pigmentation and give a unesthetic appearance. To improve the esthetics, various depigmentation methods are followed –surgical methods such as scalpel technique, cryosurgery, electrosurgery, gingivectomy with free gingival autografting, acellular dermal matrix allografts, abrasion with diamond bur, and various types of lasers (neodymium: aluminum–yttrium–garnet (Nd: YAG), erbium: YAG, and carbon dioxide lasers). Chemical agents such as 90% phenol and 95% alcohol are used in combination. Here, we conducted a comparative study on esthetic correction for gingival pigmentation using scalpel, electrocautery, and laser techniques with 3-month follow-up.
| Case Reports|| |
A 24-year-old male patient visited the department of periodontics with the chief complaint of black-colored gums. History revealed that it was present since childhood suggestive of physiological melanin pigmentation [Figure 1]a. The patient was systemically healthy without any habits. The patient's oral hygiene was good. The patient was explained about the treatment options available and the possibility of repigmentation after certain period, and written consent was obtained.
|Figure 1: Case 1 – preoperative view showing melanin pigmentation in upper labial gingiva (a); immediate postoperative view (b); Perio Pack placed (c); 3-month postoperative view (d)|
Click here to view
Local infiltration of lignocaine was administered in the maxillary anterior region from premolar to premolar. A conventional technique was used, where a Bard-Parker handle with a #15 blade was used to remove the pigmented layer [Figure 1]b. Pressure was applied with sterile gauze soaked in local anesthetic agent to control hemorrhage during the procedure. The surgical area was covered with a periodontal dressing, after removal of the entire pigmented epithelium along with layer of connective tissue using scalpel [Figure 1]c.
Postoperative instructions were given to the patient; antibiotics (capsule amoxicillin 500 mg, thrice daily for 5 days) and analgesics (ibuprofen with paracetamol thrice daily for 3 days) were prescribed. The patient was reviewed at the end of 1 week. The healing process was normal and the patient did not notice any discomfort, except pain experienced for 3 days postoperatively. At the end of 1 month, reepithelialization was completed and healing was found to be satisfactory. At the end of 3 months, the gingiva appeared healthy and no further repigmentation was seen [Figure 1]d. The patient was very impressed with such a pleasing esthetic outcome. Depigmentation was not carried out for mandibular anterior region because they were of no esthetic concern for the patient.
An 18-year-old female had a chief complaint of black-colored gums since childhood suggestive of physiological melanin pigmentation. The depigmentation procedure was performed with electrocautery; a loop electrode is used for deepithelizing the gingiva. It is used in a light brushing strokes and tip is kept in motion all the time. Keeping tip in one place could lead to excessive heat build-up and leads to destruction of tissues [Figure 2]a and [Figure 2]b.
|Figure 2: Case 2 – preoperative view (a); immediate postoperative view (b); 3-month postoperative view (c)|
Click here to view
Finally, a Perio Pack is placed to prevent foreign irritants, thermal stimuli, and infection followed by oral hygiene instructions. The Perio Pack was removed after 1 week and healing process was normal. No pain or bleeding complications were found. Three-month postoperative visit showed well-epithelized gingiva which was pink and healthy [Figure 2]c.
A 21-year-old female complained of dark gums since childhood suggestive of physiological melanin pigmentation. The depigmentation procedure was performed with laser technique, after administration of adequate local anesthesia, a fiberoptic laser tip kept in contact with the pigmented area and laser was emitted in a gated pulsed mode and operated between the wavelengths of 800 nm and 980 nm. Depigmentation was performed with paint brushing strokes in a horizontal direction to remove the epithelial lining. The area to be depigmented was wiped with gauze soaked in saline solution and the same procedure was repeated till no pigments remained. Following the procedure, no periodontal pack was given and no antibiotics were administered. The wound healed well after 1 week, without any complications. Three-month postoperative visit showed well-epithelized gingiva which was pink and healthy [Figure 3]a, [Figure 3]b, [Figure 3]c.
|Figure 3: Case 3 – preoperative view (a); immediate postoperative view (b); 3-month postoperative view (c)|
Click here to view
| Results|| |
Although all the above-treated three cases showed proper healing without any recurrence of pigmentation during a follow-up of 3 months, the procedure in Cases 1 and 2 was invasive with mild postoperative complications such as pain, bleeding, and required periodontal dressing, compared to laser technique, a noninvasive procedure in case 3, without any postoperative complications.
| Discussion|| |
Melanin is a brown pigment and is the most common natural pigment contributing the endogenous pigmentation of gingiva and the severity of pigmentation varies from one individual to another, based on melanoblastic activity. The patients with pigmented gingival tissue forces to seek cosmetic treatment many at times. Different treatment modalities have been used for this purpose. The selection of a technique for depigmentation of the gingiva should be based on clinical experience, individual preferences, and patient's affordability.
In the present study, we selected various depigmentation methods such as scalpel, electrocautery, and laser techniques for esthetic correction.
Scalpel surgical method
Although it is old technique and has various drawbacks such as patients fear toward this technique, hemorrhage, secondary infections, required more postoperative care compared to other techniques, being economical it is still considered as a popular technique and followed mostly for removal of severe depigmentation. In Case 1 performed with scalpel method, the healing process was normal, and the patient did not notice any discomfort, except pain experienced for 3 days postoperatively. At the end of 1 month, reepithelialization was completed and healing was found to be satisfactory.
Electrosurgery requires more expertise and technical skills than scalpel surgery. Prolonged or repeated application of electric current to tissue induces heat accumulation and undesired tissue destruction. In Case 2 performed with electrosurgery method, the healing process was normal. At the end of 1 month, reepithelialization was completed and healing was found to be satisfactory.
It is a noninvasive method and patient-friendly, most commonly used, and popular technique in present-day life. It causes minimum damage to the periosteum and underlying bone and mucosa. Laser beam even destroys the epithelial cells including those at the basal layer and that reduces repigmentation. Thus, repigmentation was minimum with the use of laser than any other techniques.
It has more advantages compared to other two techniques such as easy handling, hemostasis, lesser operative time, decontamination and sterilization effects are good, and elimination of using periodontal dressing is possible using laser. The only drawback of this technique is expensive and technique sensitive. In Case 3 performed with laser technique, the healing process was normal and the patient did not notice any discomfort. At the end of 1 month, reepithelialization was completed and healing was found to be satisfactory.
| Conclusion|| |
Gingival hyperpigmentation results in unesthetic appearance and this can be treated by various depigmentation methods. The limitation of using old methods such as scalpel surgery, electrosurgery and gingival abrasion with bur are invasive procedures with more time consuming, painful, required periodontal dressing and postoperative complications, whereas newer techniques such as cryosurgery and lasers show better results and faster outputs with less postoperative complications. Based on our results, we concluded that all the procedures we followed for depigmentation procedures showed good results; out of the three techniques, lasers can be considered more superior than other techniques, due to its patient-friendly and being noninvasive.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of the oral cavity: Review, differential diagnosis, and case presentations. J Can Dent Assoc 2004;70:682-3.
Steigmann S. Treatment of melanin-pigmented gingiva and oral mucosa by CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:14-5.
Patil KP, Joshi V, Waghmode V, Kanakdande V. Gingival depigmentation: A split mouth comparative study between scalpel and cryosurgery. Contemp Clin Dent 2015;6:S97-S101.
Shafer WG, Hine MK, Levy BM. Text Book of Oral Pathology. Philadelphia: WB Saunders Co.; 1984. p. 89-136.
Hedin CA, Larsson A. The ultrastructure of the gingival epithelium in smokers' melanosis. J Periodontal Res 1984;19:177-90.
Dummett CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971;42:726-36.
Meyerson MA, Cohen PR, Hymes SR. Lingual hyperpigmentation associated with minocycline therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:180-4.
Roshna T, Nandakumar K. Anterior esthetic gingival depigmentation and crown lengthening: Report of a case. J Contemp Dent Pract 2005;6:139-47.
Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.
Ozbayrak S, Dumlu A, Ercalik-Yalcinkaya S. Treatment of melanin-pigmented gingiva and oral mucosa by CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:14-5.
Kaarthikeyan G, Jayakumar ND, Padmalatha O, Varghese S, Kapoor R. Pain assessment using a visual analog scale in patients undergoing gingival depigmentation by scalpel and 970 nm diode laser surgery. J Laser Dent 2012;20:20-3.
Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000;71:315-21.
Ishikawa I, Aoki A, Takasaki AA. Potential applications of Erbium: YAG laser in periodontics. J Periodontal Res 2004;39:275-85.
[Figure 1], [Figure 2], [Figure 3]