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Case Report

Miracle of perio plastic surgery: Treatment

for esthetic smile

Ruchi Srivastava, Pushpendra Kumar Verma, Thakur Prasad Chaturvedi, Adit Srivastava, Pramod Yadav1
Department of Dentistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 1Department of Preventive and Community
Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

ABSTRACT
A smile expresses a feeling of joy, affection, courtesy, self-confidence, and kindness.
The harmony of a smile is determined mostly by the teeth, but also the gingiva plays an
important role. The shape, size, and color of gums affect the smile and overall appearance
of an individual. The appearance of unesthetic anterior teeth or gums may have a significant
psychological and emotional impact on the patient. Gingival pigmentation occurs in all races
of mankind. The clinical melanin pigmentation and excessive gingival display are of major
esthetic concern for many people, especially when it is visible while smiling. Here is a case
report describing a successful management of a 22-year-old female patient with gummy
smile and dark unpleasant gingiva. This problem was resolved by simply removing the
excess of gingival tissues with a crown lengthening procedure involving gingivectomy and
the depigmentation of dark gums was done with scalpel surgery technique, simultaneously.
Both these procedures ultimately produced a satisfactory esthetic result to the patient.

Key words: Crown lengthening procedure, depigmentation, gingivectomy, gummy smile,

scalpel technique.

INTRODUCTION mobile upper lip, or a short upper lip. In these patients,

The harmony of a smile is determined mostly by the teeth,
but also the gingiva plays an important role in esthetics. The
shape, size, and color of gums affect the smile and overall
appearance of an individual. The patients with gummy
smile combined with black/brown discoloration of gingival
tissue often demand for cosmetic therapy. The excessive
gingival display may be due to many etiologies which include
extraoral etiology such as vertical maxillary excess, hyper
Address for correspondence:
Dr. Pushpendra Kumar Verma, Faculty of Dental sciences, Institute
of Medical Sciences, Banaras Hindu University, Varanasi-221 005,
Uttar Pradesh, India.
E-mail: pushpendrakgmc@gmail.com
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DOI:
10.4103/0976-433X.121639
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 3 | July-September 2013
orthognathic surgery can be performed, but this requires
hospitalization and entails significant discomfort. When it
is due to intraoral reasons then this problem can be resolved
by simply removing the gingiva, via precisely planned
incisions which often produces satisfactory esthetic results.
This exposure of clinical crown by gingival tissue excision
is known as crown lengthening. In the presence of a good
crown-to-root ratio, esthetic crown lengthening can provide
an appropriate proportion of the anterior teeth.[1] Normally;
the gingival margin is 1 mm coronal to the cement-enamel
junction (CEJ). If it is greater, then the clinical crown is
shorter than the anatomical crown and so, crown lengthening
procedure is required. When a crown lengthening procedure
is planned, the biological width needs to be considered
and not encroached upon, as this may lead to periodontal
breakdown. [2] The biological width is defined as the
dimension of the soft tissue, which is attached to the portion
of tooth coronal to the crest of alveolar bone.[3] Garguilo
et al.,[4] and Ingber et al.,[5] established that the biologic
width, calculated by addition of the linear measurement
of the connective tissue and epithelial attachment, and
quoted as 2.04 mm. The color of the gingiva is determined
by several factors, namely number and size of the blood
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Srivastava, et al.: Treatment for esthetic smile
vessels, epithelial thickness, quantity of keratinization,
and pigments within the gingival epithelium.[6] Melanin
pigmentation is frequently caused by melanin deposition by
active melanocytes located mainly in the basal layer of the
oral epithelium. Brown or dark pigmentation or discoloration
of the gingival tissue is however considered as multifaceted
etiology, including genetic factors,[7] tobacco use,[8] systemic
disorders, or a variety of local and systemic factors. Clinical
melanin pigmentation is completely benign and does not
present a medical problem, although this hyperpigmentation
needs to be removed for esthetic reasons.
CASE REPORT
A 22-year-old female patient came to the Faculty of Dental
Sciences, Institute of Medical Sciences, Banaras Hindu
University, Varanasi, Uttar Pradesh, with the complaint
of excessive gingival display and dark gums in maxillary
anterior region while smiling [Figure 1]. Careful clinical and
radiographic evaluations were performed prior to plan any
treatment. Extraoral examination revealed no significant
findings. Her smile line extended to first premolar and
approximately 3 mm of excessive gingival tissue was observed
on the maxillary anterior teeth on smiling. The treatment
plan included esthetic crown lengthening by gingivectomy
procedure and for depigmentation a scalpel technique was
planned. Patient’s medical history was reviewed to rule out
any local or systemic diseases. The surgical technique was
explained to the patient and informed consent was obtained.
Preparation of the patient included scaling and root planing
of the entire dentition and oral hygiene instructions.
Surgical technique
First of all, the clinical crown length was measured with help
of a UNC-15 probe from teeth 13-23 [Figure 1]. The gingival
tissue was of thick biotype and had an adequate attached
gingiva. After local anesthesia (2% lidocaine with 1:80,000
epinephrine), bleeding points were created from 13-23 with
a pocket marker. The purpose of creating bleeding point is to
Figure 1: Preoperative gingival excess
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SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 3 | July-September 2013
outline the CEJ so that root surface will not be visible after
surgery. Normally, the gingival margin is 1 mm coronal to the
CEJ. If it is greater, then the clinical crown is shorter than
the anatomical crown and a crown lengthening procedure
is required. Therefore, we planned our surgical procedure by
excising 2-3 mm of gingival tissue from the gingival margin in
order to maintain sufficient esthetics in the anterior region and
avoid the appearance of a long clinical crown postoperatively.
The thick, fibrous gingival tissue was excised with a 15 no.
blade, following a scalloped pattern around the gingival
margin [Figures 2, 3, and 4]. This was followed by a second
incision into the intracrevicular sulcus. Subsequently, the
gingivectomy was completed and after this gingival epithelium
or partial thickness flap was excised for depigmentation using
scalpel technique [Figure 5]. Care was taken to remove all
the remnants of melanin pigment as thoroughly as possible
by scraping with scalpel blade. The marginal gingiva was
also very thin and thus some remnants were left in order to
prevent gingival recession. Finally a coe-pak was placed over
the wound area and oral hygiene instructions were given.
Postoperative analgesics and antibiotics were prescribed. After
10 days coe-pak was removed and there was no postoperative
complication and healing was satisfactory. After 6 months
a well-epithelialized gingiva appeared, which was pink and
pleasant [Figure 6]. The patient was followed-up till 1 year
with no evidence of repigmentation.
DISCUSSION
The primary goal of esthetic dental treatment is the
restoration of natural, healthy, and esthetic appearance.
An evaluation of clinical and anatomic crown lengths in
patients with a high lip line is important because incomplete
anatomical crown exposure may be the principle factor in the
esthetics of a case. The appearance of healthy gingiva is an
essential component of a pleasing smile.[9] Ideally the smile
should expose minimal gingiva, the gingival contour should
be symmetrical and in harmony with the upper lip. In order
to maintain periodontal health, there should be 2-3 mm of
Figure 2: Incision
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Srivastava, et al.: Treatment for esthetic smile
Figure 3: After gingivectomy
Figure 5: After depigmentation
attached gingiva.[10,11] In our case, adequate attached gingiva
was present and so gingival excision was considered as the
treatment of choice. Periodontal crown lengthening is carried
for various esthetics and restorative issues such as short teeth,
excessive gingival display, uneven gingival contour, and to
provide a ‘ferrule’ for post crown provision.[12] In order to
avoid pathological changes, to predict treatment results
more precisely, it is necessary to keep gingival biological
width unaltered. Authors of wound healing investigations
have reported that an average of 3 mm of supragingival soft
tissue will rebound coronal to the alveolar crest and can take
a minimum of 3 months to complete vertical growth.­[13]
So one must be aware that osseous resection could affect
periodontal stability and may pose a contraindication to
crown lengthening therapy. Our case also described a most
popular technique, scalpel technique for depigmentation.
The results obtained till 6 months posttreatment suggested
excellent results. However, a long-term follow-up is required
to study repigmentation patterns and durability. Above all
as with any procedure, the patient needs to be informed of
any potential complications such as possible poor esthetics
due to ‘black triangles’, root hypersensitivity, root resorption,
gingival recession, and damage to the periosteum and bone.
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 3 | July-September 2013
Figure 4: Excised tissue
Figure 6: Postoperative after 6 months
The key to success is a three-dimensional analysis of the
clinical objectives associated with the osseous component of
the proposed crown lengthening surgery. The first dimension
is the occluso-apical dimension, the second is the mesiodistal
dimension, and the third is the buccolingual dimension.
However, there was a dramatic improvement in the esthetics
of the above mentioned case with concomitant lengthening
of the teeth and reduction of the gingival pigmentation.
CONCLUSION
Different treatment modalities have been employed by
different clinicians to enhance esthetics. The treatment
plan depends on a number of factors, including the
level of alveolar bone crest, the height and thickness of
attached gingiva and the patient’s need for interdisciplinary
treatment. In the above case patient’s acceptance of the
procedure was good and results were excellent as perceived
by the patient.
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Srivastava, et al.: Treatment for esthetic smile

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How to cite this article: Srivastava R, Verma PK, Chaturvedi TP,
Srivastava A, Yadav P. Miracle of perio plastic surgery: Treatment for
esthetic smile. SRM J Res Dent Sci 2013;4:125-8.
Source of Support: Nil, Conflict of Interest: None declared

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