Surgical Esthetic Correction For Gingival Pigmentation Case Series

195 Journal of Interdisciplinary Dentistry / Sep-Dec 2012 / Vol-2 / Issue-3
INTRODUCTION
P
igmentation is a discoloration of the oral
mucosa or gingiva due to the wide variety
of lesions and conditions. The pigments are not only
the most beautiful, but also some of the most vital
substances in the body. The pigments of biological
origin are frequently striking and of brilliant color.
Pi gmented l esi ons ar e commonl y f ound i n
the mouth. Such lesions r epr esent a variety
of clinical entities, ranging fr om physiologic
changes (e.g., racial pigmentation) to manifestations
of systemic illnesses (e.g., Addisons disease) and
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DOI:
10.4103/2229-5194.113259
Surgical esthetic correction for gingival
pigmentation: Case series
Shilpi S. Shah
Department of Periodontology and Implantology, Ahmedabad Dental College and Hospital, Ahmedabad,
Gujarat, India
Address for correspondence: Dr. Shilpi S. Shah, E-mail: smilecostsnothing@gmail.com
ABSTRACT
Gingival pigmentation is a major concern for a large number of patients visiting the dentist. The patients with excessive gingival
display and pigmentation are more concerned esthetically. Most pigmentation is caused by five primary pigments out of which
melanin shows the maximum incidence rate. Melanin hyper pigmentation usually does not present as a medical problem, but
patients may complain about their unesthetic black gums. The gingiva is the most frequently pigmented intraoral tissue, with
the highest rate observed in the area of the incisors Esthetic periodontal plastic surgery is a boon in patients having dark
gums and gummy smile. This article offers a retrospective case series of gingival depigmentation by epithelial excision
using scalpel. Out of the several techniques employed for depigmentation, the surgical technique using scalpel is still the first
and most popular technique. Experience of 4 years is put forward with critical analysis of the surgical technique including
the various advantages and disadvantages. This is a case report representing a simple surgical technique of de-epithelization
which has been successfully used to treat gingival hyperpigmentation caused by excessive melanin deposition and highlights the
relevance of an esthetically pleasing smile especially in smile conscious individuals.
malignant neoplasms (e.g., melanoma and Kaposis
sarcoma).
[1]
The color of healthy gingiva is variable, ranging from
a pale pink to a deep bluish purple hue. Between
these limits of normalcy are a large number of
pigmentation mosaics which depend primarily
upon the intensity of melanogenesis, depth of
epithelial cornification, and arrangement of gingival
vascularity. Moreover, color variation may not be
uniform and may exist as unilateral, bilateral mottled,
macular, or blotched, and may involve gingival
papillae alone or extend throughout the gingiva on
to other soft tissues.
[2,3]
Most pigmentation is caused by five primary pigments.
These include: Melanin, melanoid, oxyhemoglobin,
reduced hemoglobin, carotene, bilirubin, and iron.
[4-6]
Mel ani n pi gmentati on of the gi ngi va (not a
medical problem) is a cause of embarrassment in
smile-conscious individuals. Demand for cosmetic
Key words: Esthetic gums, gummy smile, pigmentation
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY
Gingival hyper pigmentation is a very common esthetic complaint reported by patients in various fields of dentistry.
Through this case series the dentists can ascertain the various types of techniques mentioned in the following article for
treating pigmented gums with pleasing esthetics &acceptable patients satisfaction
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Shah: Surgical esthetic correction for gingival pigmentation
therapy is made, especially by fair-skinned people with
moderate or severe gingival pigmentation,
[3]
mostly
in patients with a high smile line (gummy smile).
A periodontal plastic surgical procedure called the
gingival depigmentation is performed whereby the
gingival hyperpigmentation is removed or reduced
by various techniques. This case series presents
48 cases of gingival hyperpigmentation where gingival
depigmentation procedure was per for med either
through slicing or scraping technique, with satisfactory
clinical outcomes. The surgical technique used in the
present study is the first but still popular method with
an advantage of being a simple chair side procedure
with least and cost-effective armamentarium normally
available in almost all dental operatories, yielding
esthetically acceptable results along with patient
satisfaction.
MATERIALS AND METHODS
The cases were reviewed retrospectively from July 2004
to June 2007. A total of 48 patients (27 male, 21 female)
with a chief complaint of black gums were selected
in this study and treated by surgical depigmentation
procedure over a period of 3 years (2004-2007). Total
number of sites operated was 57. None of the patients
were medically compromised, smokers, or having any
psychiatric disorder as the patient compliance might
be poor (excluded from the study). The youngest was
15 years old and the oldest was 40 years old [Table 1].
The complaints were mainly observed in patients
who were esthetically bothered by black gums shown
during smiling or talking, patients with gummy smiles,
and fair-skinned patients. Dark-skinned patients and
patients without gum display (having pigmentation)
were excluded from the study. The patients with
Dummett-Gupta Oral Pigmentation Index scores 2 and
3 were included in the study.
Dummett-Gupta Oral Pigmentation Index scoring criteria
given by Dummett in 1964 are as follows:
0: No clinical pigmentation (pink gingiva)
1: Mild clinical pigmentation (mild light brown color)
2: Moderate clinical pigmentation (medium brown or
mixed pink and brown color)
3: Heavy clinical pigmentation (deep brown or bluish
black color)
All patients were treated surgically by slicing technique/
scraping technique using scalpel under local anesthesia
by the author only. The selection of slicing or scraping is
done by the width of the keratinized gingiva available.
Either of the two techniques showed similar result with the
sole purpose of removing the melanin hyperpigmented
areas from the gingiva. The cases were followed up to a
Table 1: Results of 57 surgical depigmentation
procedures in 48 patients
Case Age
(years)
Sex Operated site
(FDI notation)
Total follow-up
(months)
Recurrence
1. 27 F 13-23 18 No
2. 32 M 14-24 15 No
3. 16 F 13-23 20 No
4. 21 F 13-23 24 No
33-43
5. 37 M 14-24 16 No
6. 35 F 15-25 11 No
7. 20 F 16-26 12 No
8. 24 M 14-24 13 No
9. 26 F 13-23 17 No
10. 32 M 15-25 18 No
35-45
11. 19 M 14-24 20 No
12. 18 F 13-23 18 No
13. 22 M 14-24 18 No
14. 28 F 13-23 24 No
15. 34 F 16-26 30 No
35-45
16. 26 M 15-25 18 No
17. 25 F 15-25 18 No
35-45
18. 30 M 14-24 12 No
19. 33 M 13-23 12 No
20. 39 M 13-23 12 No
33-43
21. 27 F 15-25 14 No
22. 22 F 14-24 15 No
23. 18 F 14-24 18 No
34-44
24. 16 M 13-23 18 No
33-43
25. 34 F 15-25 20 No
35-45
26. 15 M 16-26 22 No
27. 40 M 14-24 23 No
28. 38 F 13-23 18 No
29. 21 M 13-23 20 No
33-43
30. 25 F 14-24 13 No
31. 27 M 15-25 15 No
32. 23 M 16-26 17 No
33. 29 M 13-23 13 No
34. 31 M 14-24 12 No
35. 16 F 14-24 10 No
36. 36 F 14-24 18 No
37. 17 F 13-23 20 No
38. 33 M 16-26 24 No
39. 22 M 14-24 10 No
40. 21 M 13-23 12 No
41. 18 F 13-23 13 No
42. 38 M 14-24 08 No
43. 19 M 16-26 14 No
44. 40 F 15-25 10 No
45. 31 M 14-24 07 No
46. 24 M 14-24 08 No
47. 26 M 13-23 10 No
48. 17 M 13-23 12 No
maximum of 30 months and minimum of 7 months for
analyzing the efficiency of the procedure.
Figure 1: Preoperative photograph showing gingival pigmentation
with markings
Figure 2: Slicing of the pigmented area done using a scalpel
Figure 3: Sliced pigmented section removed
Figure 4: 10 days postoperative photograph
Figure 5: 30 months postoperative photograph
Surgical technique
Scalpel surgical technique or slicing technique
The area of melanin hyper pigmentation (area of interest)
was marked by two vertical and horizontal lines for
demarcating it from the uninvolved area. This procedure
of outlining the area was strictly performed by asking the
patient to smile, so as to know the exact extension of
the unesthetic looking gums. For marking the extensions,
an indelible pencil or back of the surgical blade can
be used [Figure 1]. After following complete aseptic
precautions, surgical technique was performed. Standard
skin preparation was carried out by 10% povidone
iodine solution and temporary draping was done. Local
infiltration was done using local anesthetic solution
Lignox
(2% lignocaine with 1:200,000 adrenaline).

To retract the lips, either a check retractor was used or
the help of an assistant was taken. Petroleum jelly was
applied over the lips. Special care was taken to prevent
injury to the lips. No. 15 or no. 11 surgical grade blade
on a bard parker handle was used. The procedure was
performed either through scraping epithelium with
underlying pigmented layer (in attached gingival area) or
through slicing the pigmented epithelial layer from the
underlying connective tissue, i.e., raising partial thickness
flap and excising the flap from its base denuding the
connective tissue epithelial excision [Figure 2]. A uniform
layer of the epithelium was sliced from the underlying
connective tissue to prevent nicks, cuts, and underlying
alveolar bone exposure. Special care was taken in
the free gingival margin area as improper epithelial
excision might lead to gingival recession in that area.
The raw surface was thoroughly irrigated with saline
and povidone iodine (1:1) to remove any loose tissue
tags [Figure 3]. For proper visibility, a no. 3 mastoid
suction cannula was used.
The area of interest was reexamined for the remaining
melanin pigmented patches. After thorough examination,
the area was wiped with saline-soaked gauze and
periodontal dressing (coe pack) was applied to cover the
surgical site. The patient was recalled after a week for pack
removal. The area was thoroughly irrigated with normal
saline mixed with povidone iodine (1:1) for removing
dental plaque and biofilm
[6,7]
beneath the periodontal
pack [Figures 4 and 5].
RESULTS
Fifty-seven depigmentation procedures were performed
in 48 patients, by surgical removal of the pigmented
epithelium through scalpel. This procedure was performed
either by slicing epithelium from underlying tissues
or by scraping (melanin pigmented) epithelium. No
complications with either the surgical procedure or
anesthesia or postoperative healing were encountered. No
recurrence till date with this technique has been reported.
None of the cases required a secondary intervention. In
all the cases, complete resolution of the chief complaint
and patient satisfaction was achieved.
DISCUSSION
Gingival pigmentation is discoloration of the gingiva due to
wide variety of lesions or conditions. The color of healthy
gingiva is variable, ranging from pale pink to deep bluish
purple hue.

Between these limits of normalcy are a large
number of pigmentation mosaics which depend primarily
upon the intensity of melanogenesis, depth of epithelial
cornification, and gingival vascularity.
The pigmented lesions
[8-10]
might be the following.
Developmental disorders (pigmented cellular nevus, labial
and oral melanotic macule, ForbesAlbright syndrome,
polyostotic fibrous dysplasia, neurofibromatosis, Peutz
Jeghers syndrome, racial pigmentation, chloasma),
functional/physiologic variants, specific agents (dental
amalgam, chewing/smoking of tobacco, betel nut chewing,
lead, silver), drugs (Busulfan, Chlorpromazine, Minocycline,
Quinacrine), deficiency disorders (Vitamin B12 deficiency),
endocrine disorders (Addisons disease, Cushings
syndrome, acromegaly), hyperthyroidism, and neoplastic
disorders (compound nevus, malignant melanoma).
[11-15]
Out of these varieties, melanin is the most common
of the endogenous pigments seen in the gingiva
of Indian population. It is the most common non
hemoglobin-derived brown physiologic (ethnic/racial)
pigment produced by melanocytes and present in the
basal layer of the epithelium.
[6]
Active melanocytes convert
tyrosine, through a series of intermediate stages mediated
by the enzyme tyrosinase, to melanoprotein (melanin).
[4]

The melanin (accumulated in the melanosome) is then
transferred outward to the basal and prickle cell layers.
Various stimuli can result in an increased production
of melanin at the level of mucosa, including trauma,
hormones, radiation, and medications.
[5]
A variety of treatment modalities have been employed for
esthetic correction of gingival pigmentation which can be
achieved either by removal of the pigmented layer or by
masking of the pigmented gingiva.
Removal of the pigmented layer has been tried in the form
of surgical treatment (scalpel surgical technique,
[16,17]
bur
abrasion, cryosurgery,
[18-21]
electrosurgery, lasers
[22-28]
) and
chemical treatment (90% phenol, 95% alcohol). Masking
of the pigmented gingiva can be achieved by free gingival
grafts (FGGs)
[29]
or acellular dermal matrix allografts.
[30]

But some of the treatment modalities have their own
limitations.
[21]
Lasers, electrosurgery, and cryosurgery are not cost
effective.
[21,31]
Depth of control is a limitation of chemical
cauterization and cryosurgery. Electrosurgery produces
latent heat, causing damage to the surrounding tissues.
Gingivectomy and bone denudation are invasive surgical
procedures causing patient discomfort and bone loss.
FGG is a surgical procedure that requires two surgical
sites (donor and recipient), has color-matching problems,
and causes delayed healing of recepient site.
Out of all the available treatment options, this case series
focuses on the use of scalpel surgical technique (scraping/
slicing) in gingival hyperpigmentation cases with
satisfactory results. This technique is simple and versatile
r equi ri ng mi ni mum ar mamentari um most easi l y
available in all dental clinics. Though the initial result
of the depigmentation surgery is highly encouraging,
repigmentation is a common problem.
Repi gmentati on after depi gmentati on has been
reported following the use of different techniques. The
mechanism of repigmentation is not understood, but
according to migration theory, active melanocytes
from adjacent pigmented tissues migrate to treated areas
causing repigmentation. Perlmutter and Tal described
repigmentation after 7-8 years. On the contrary, a study
by Oswaldo et al. in 1993 showed that gingival surgical
procedures performed solely for cosmetic reasons offer
no permanent results. But pigment recurrence has been
documented to occur, following the surgical procedure,
within 24 days to 8 years long period. This repigmentation
is attributed to the epidermal melanocyte unit also. The
epidermal melanin unit (EMU) denotes the symbiotic
relationship between a melanocyte and a pool of associated
keratinocytes. EMU, rather than the melanocyte alone,
serves as the focal point for melanin metabolism within
mammalian epidermis. The EMU is better labeled the
KLM unit (melanocytes, keratinocytes, and Langerhans
cells). There is little information on the behavior of
melanocytes after surgical injury. The timing of early signs
of repigmentation varies among studies and may be related
to the technique performed and patients race.
Further research is required on repigmentation to study
the factors affecting rate and length of time required for
recurrence of pigmentation. Research should also focus
on finding a solution for preventing the recurrence and,
till then, repeated depigmentation should be done to
eliminate the unsightly pigmented gingival.
In the present study, cases were followed for a period
of maximum 30 months and no r ecurr ence was
observed [Table 1]. However, the cases are being followed
up to study the factors af fecting the rate and length
of time required for repigmentation and to study the
repigmentation patterns.
Scalpel surgical technique is highly recommended in
consideration of the equipment constraints that may not
be frequently available in clinics (Almas and Sadiq, 2002).
It is known that the healing period for scalpel wounds is
faster than in other techniques. However, scalpel surgery
may cause unpleasant bleeding during and after the
operation, and it is necessary to cover the exposed lamina
propria with periodontal dressing for 7-10 days (Almas
and Sadiq, 2002).
Thus, gingival depigmentation procedure is performed
solely as a part of the periodontal plastic procedure for
cosmetic enhancement. This procedure will not be of
permanent value because pigmentation tends to return to
baseline values (Begamaschi O, 1993). The same surgical
technique can be repeated if signs of repigmentation
appear in the concerned area.
This case series describes a simple and ef fective
surgical procedure for the treatment of gingival melanin
hyperpigmentation, resulting in improved esthetics and
cosmetic appearance. This treatment procedure can be
performed as a normal chair-side procedure by all general
dentists for the cosmetic correction of hyperpigmented
gums.
CONCLUSION
Excessive gingival display and gingival hyperpigmentation
are the major concerns for a large number of patients
visiting the dentist. Esthetic periodontal plastic
surgery is a boon in patients having dark gums
and gummy smile. This case series of 48 patients
describes the depigmentation of the melanin pigmented
gums (not a medical problem) using surgical scalpel
technique (slicing/scraping). Scalpel technique is one
of the first and still popular techniques employed for
correction of gingival hyperpigmentation. The results
obtained in all the patients were minimum discomfort
and maximum patient satisfaction, with no signs of
recurrence after a 30-month follow-up period. The
cases are being tracked to notice signs of recurrence, as
repigmentation may occur post depigmentation; with
altered time durations as reported by multiple authors.
There is still paucity of literature regarding the control
on repigmentation followed by treatment of gingival
hyperpigmentation. Therefore, research should focus on
finding a solution for preventing recurrence and, till then,
repeated depigmentation should be done to eliminate
the unsightly pigmented gingiva.
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How to cite this article: Shah SS. Surgical esthetic correction for gingival
pigmentation: Case series. J Interdiscip Dentistry 2012;2:195-200.
Source of Support: Nil, Confict of Interest: None declared.
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