INTRODUCTION:

Aesthetics has become a significant aspect of dentistry and clinicians are faced with achieving acceptable gingival aesthetics as well as addressing biologic and functional problems.¹ Melanin pigmentation of the gingiva occurs in all races.² Melanin, a brown pigment, is the most common natural pigment contributing to endogenous pigmentation of gingival. Melanin pigmentation is the result of melanin granules produced by melanoblasts present between epithelial cells at the basal layer of gingival epithelium.³ Gingival hyperpigmentation is seen as a genetic trait in some populations irrespective of age and gender hence it is termed physiologic or racial gingival pigmentation.^2,4 The degree of pigmentation varies from one individual to another which is mainly dictated by the melanoblastic activity.⁵ Melanin pigmentation of gingiva is symmetric and persistent and it does not alter normal gingival architecture.⁶ Melanosis of gingiva is frequently encountered among dark skinned ethnic groups, as well as in medical conditions such as Addison’s syndrome, Peutz- jegher’s syndrome and Von Recklinghausen’s disease (neurofi bromatosis).⁷

Received on 23.12.2014 Modified on 11.01.2015

Research J. Pharm. and Tech. 8(2): Feb. 2015; Page 204-206

DOI: 10.5958/0974-360X.2015.00037.2

In dark skinned and black individuals increased melanin production in the skin and oral mucosa has long been known to be result of genetically determined hyperactivity of their melanocytes. Earlier studies have shown that no significant difference exists in the density of distribution of melanocytes between light skinned, dark skinned and black individuals. However, melanocytes of dark skinned and black individuals are uniformly highly reactive than in light skinned individuals.⁸ Although clinically melanin pigmentation of the gingival does not present any medical problems it can be an esthetic concern for the patient. Demand for cosmetic therapy is made, especially by fair skinned people with moderate or severe gingival pigmentation.⁹ Gingival depigmentation is a periodontal plastic surgical procedure whereby the gingival hyperpigmentation is removed or reduced by various techniques. The first and foremost indication for depigmentation is patient demand for improved esthetics.

Various depigmentation techniques have been employed with similar results. Selection of technique should be based on clinical experiences and individual preferences. One of the first, and still popular technique to be employed is the surgical removal of undesirable pigmentation using scalpels.¹⁰ There is only limited information in the literature on depigmentation using surgical techniques. The procedure essentially involves surgical removal of gingival epithelium along with a layer of the underlying connective tissue and allowing the denuded connective tissue to heal by secondary intention. The new epithelium that forms is devoid of melanin pigmentation.¹⁰ The present case report introduces a simple and effective surgical depigmentation technique that does not require sophisticated instruments or apparatus, yet yields esthetically acceptable results.

Case Report

A 23-year-old male patient complaining of heavily pigmented gums visited department of Periodontics, Institute of Dental Studies and Technologies, Modinagar. On examination, the patient was otherwise healthy but had a deeply pigmented gingiva. Pigmentation was unsightly and hence Surgical gingival de-epithelization can be performed by Scalpel technique.¹¹ The procedure was explained verbally to the patient and the consent was obtained.

In our case we performed the scalpel technique for the lower jaw and the upper jaw. Following the administration of local anaesthetic solution, a partial split thickness flap was raised from the upper and lower anterior region maintaining the normal architecture of gingiva. Bleeding was controlled using pressure pack with sterile gauze. For the upper and lower anterior blade no. 15 was used and the pigmented gingiva was removed. Surgical area was covered with a periodontal pack and post-operative instructions were given. Antibiotic amoxicillin 500mg tds were recommended for 8 days and ibugesic plus Analgesic bd for 3 days was prescribed for the management of pain. After one week, the pack was removed and the surgical area was examined. The healing was uneventful without any post surgical complications. The gingiva appeared pink, healthy and firm giving a normal appearance. The patient was very impressed with such a pleasing aesthetic outcome.

Fig. 1: Pre- operative photograph showing pigmented gingival

Fig. 2: Immediately after surgery of the maxillary anterior region.

Fig. 3: periodontal pack placement after surgery maxillary anterior region

Fig. 4: One month post operative photograph showing

DISCUSSION:

Melanin pigmentation is the result of melanin granules produce by melanoblast interwind between epithelium cells at the basal layer of the epithelium.¹¹

There are wide variations in gingival color in normal healthy persons. Degree of vascularization, the thickness of the keratinized layer and the amount of the pigment containing cells will determine the color of the gingiva.¹² Till date very little literature has been published regarding clinical methods of treatment of pigmented gingiva. The techniques that were tried in the past to treat gingival pigmentation include chemical cauterization,¹³ gingivectomy,¹⁴ scalpel scraping procedure and abrasion of gingiva.¹⁵ The recent techniques of gingival depigmentation in practice are cryotherapy,⁹ free gingival autograft¹⁶ and laser therapy¹⁷ and these have achieved satisfactory results.

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.¹⁸ Cryosurgery is followed by considerable swelling and it is also accompanied by increased soft tissue destruction as the depth of penetration can not be controlled.¹⁹ The CO2 laser causes minimum damage to the periosteum and underlying bone and it has unique characteristics of being able to remove a thin layer of epithelium cleanly. Although healing of laser wound is slower than scalpel wound, laser wound is a sterile inflammatory reaction.

The treated gingiva and mucosa do not need any dressing when it is treated with laser. So re-epithelization will be faster.²⁰ Atsawasuwan et al²¹ have reported four cases of gingival melanin hyperpigmentation using Nd: YAG laser and demonstrated good results; the complications being gingival fenestration and bone exposure. Erbium: YAG laser ablation was reported by Tal et al⁹ to be quite effective and reliable. Among the mentioned techniques, we found the scalpel technique relatively simple and versatile and it required minimum time and effort. No sophisticated and expensive armamentarium was required, only blade was sufficient.

Though the initial result of the depigmentation surgery is highly encouraging, repigmentation is a common problem. The exact mechanism of repigmentation is not known. Different studies shows variation in the timing for early repigmentation. To return to the full clinical baseline repigmentation it takes about 1.5 to 3 years.¹³

This variation may be due to the different techniques performed or due to the patient’s race. Thus, gingival depigmentation procedure, if performed primarily for cosmetic reason, will not be of permanent value, because pigmentation tends to return to baseline values.¹³ In future, even if gingival repigmentation occurs in this patient, the same procedure could be repeated in the same region. Therefore, scalpel surgical technique is highly recommended in consideration of the equipment constraints in developing countries. It is simple, easy to perform, cost effective and above all provides minimum discomfort to the patient and esthetically pleasing results.

This case report described a simple and effective surgical procedure for the treatment of gingival melanin hyperpigmentation resulting in improved esthetics and cosmetic appearance.

REFERENCES:

1. Humagain M, Nayak DG, Uppoor AS. Gingival depigmentation: A case report with review of Literature. J Nepal Dent Assoc. 2009;10:53–6.

2. Dummett, C.O: Oral pigmentation. First symposium of oral pigmentation. J Periodontol 1960;31:356

3. Cicek Y, Ertas U. The normal and pathological pigmentation of oral mucous membrane: a review. J Contemp Dent Pract. 2003:15;4(3):76-86.

4. Dummet CO, Barens G. Oromucosal pigmentation: an updated literary review. J Periodontol. 1971;42(11):726- 36.

5. Perlmutter S, Tal H. Repigmentation of gingival following injury. J periodontal 1986;57:48-50

6. Dummet CO. Oral pigmentation. J periodontal 1960;31:356-60

7. Shafer WG, Hine MK, Levy BM. Text book of oral Pathology. Philadelphia: WB Saunders co; 1984; pp. 89-136

8. Szako G, Gerald SB, Pathak MA and Fitz Patrick TB. Racial differences in the fate of melanosomes in human epidermis. Nature 1969;222:1081

9. Tal H. Landsberg J and Koztovsky A: Cryosurgical depigmentation of the gingiva - a case report. J. Clin Periodontol 1987;14:614-7

10. Roshna T, Nandakumar K. Anterior Esthetic Gingival Depigmentation and Crown Lengthening: Report of a Case. J Contemp Dent Pract 2005;(6)3:139-147

11. Almas K, Sadig W. Surgical treatment of melaninpigmented gingiva; an esthetic approach. Indian J Dent Res. 2002;13(2):70-3

12. TK Pal, KK Kapoor, CC Parel, K Mukharjee. Gingival melanin pigmentation- a study on its removal for esthetics. J Indian Soc of Periodontology, 1994;(Special issue)3:52-54

13. Begamaschi O, Kon S, Doine AI, Ruben MP. Melanin repigmentation after gingivectomy: A fi ve year clinical and transmission Electron Microscopic Study in Humans. Int Journal of Periodontics & Restorative Dentistry, 1993;13(1):85-92

14. Hirschfeld I and Hirschfeld L. Oral pigmentation and method of removing it. Oral Surg Oral Med Oral Path. 1951;4:1012

15. Dummet CO and Bolden TE. Post surgical repigmentation of the gingival. Oral Surg Oral Med Oral Path.1963;16:353

16. Tamizi m, Taheri M. Treatment os severe physiologic gingival pigmentation with free gingival autograft. Quintessence Int. 1996;27(8):555-8

17. Trelles MA. Verkruysse W, JM Segui, and Udaeta A. Treatment of melanotic spots in the gingival by Argon laser. J Oral Maxillofac Surg. 1993;51:759-61

18. Gnanasekhar JD, Al Duwairi YS. Elecrosurgery in Dentistry. Quintessence Int 1998;29:649-54

19. Ishida CE, Ramose Silva M. cryosurgery in oral lesions. Int J. Dermatol 1998;37:283-85

20. Ozbayrak S, Dumly A and Ercalik YS. Treatment of melanin pigmented gingival and oral mucosa by CO2 laser. Oral Surg. Oral Med. Oral Pathol. Endod 2000;90:14-15

21. Atsawasuwan P, Greethong K, Nimmanon V. Treatment of Gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000;71:315-321