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Gingival depigmentation: comparison of two techniques.

introduction

Esthetics has become an important aspect of dentistry and clinician has to face the challenge of achieving acceptable gingival esthetics, along with addressing the biological and functional problems. Pigmentation is a discolouration of the oral mucosa due to a wide variety of lesions and conditions. Oral pigmentation has been associated with a variety of exogenous and endogenous etiologic factors. (1)

Most pigmentation is caused by five primary pigments. These include: Melanin, Melanoid, Oxyhemoglobin, Reduced haemoglobin, and carotene. (2) Physiological pigmentation of the oral mucosa is clinically manifested as multifocal or diffuse melanin pigmentation with variable amounts in different ethnic groups worldwide and it occurs in all reces. (3) Brown or dark pigmentation or discoloration of the gingival tissue is however considered as multifactorial, including genetic factors, tobacco use, systemic disorders (endocrine disturbance, Albright's syndrome, malignant melanoma, Peutz-jeghers syndrome, hemochromatosis, Addison's syndrome and von Recklinghausen's disease), antimalarial drugs, heavy metals (silver, bismuth, mercury, lead), zidovudine, amalgam tattoo, nevus, melanoacanthoma, kaposis sarcoma. (4)

Melanin is the most common non haemoglobin derived endogenous pigment produced by meanocytes present in the basal layer of the epithelium. (5) Melanocytes have a round nucleus with a double nucleus membrane and clear cytoplasm lacking desmosomes and attachment plates. (6) The number of meanocytes in the mucosa corresponds numerically to that of skin, however in the mucosa their activity is reduced. Various stimuli can increase the production of melanin including trauma, radiation, and medications. (7) Clinical melanin pigmentation does not present as a medical problem, even though the complaint of dark gums may present an esthetic concern for the individuals. (8)

Case presentations

Two patients with a chief complaint of dark pigmented gums since childhood and consented for esthetic cosmetic therapy to enhance their smile were selected. On examination they were periodontally as well as systemically healthy. Considering the patient's concern surgical deepithelization with scalpel, blade and diode laser was performed and compared.

Case report 1.

A 27 year male patient who reported to the department of periodontolgy, kamineni institute of dental sciences with a chief complaint of dark appeared gums while smiling. On examination the patient had diffuse melanin pigmentation (Hedin score 2) and with good oral hygiene. And The treatment modality chosen for this particular case was conventional scalpel method of depigmentation-(slicing technique) .

[FIGURE 1a OMITTED]

Procedure: After anesthetizing the area, a horizontal incision was given to demark attached gingival from the oral mucosa at the mucogingival junction and a split thickness flap was raised and excised, maintaining the normal architecture of the gingiva (fig 1b). The exposed depigmented surface was covered with barricaid-pack periodontal dressing for 1 week (fig 1c) and prescribed aceclofenac-parecetamol combination BID for 3 days and post operative instruction were given.

[FIGURE 1b OMITTED]

[FIGURE 1c OMITTED]

Case report 2

A 29 years male patient who reported to the department of periodontolgy, kamineni institute of dental sciences with a chief complaints of dark appearance of gums (fig 2a) while smiling. On examination the patient had diffuse melanin pigmentation(Hedin score 2) and with good oral hygiene. And the treatment modality chosen for this particular case was deepithelization using diode laser at 810nm wavelength and 4.0 wt power in continuous mode.

[FIGURE 2a OMITTED]

[FIGURE 2b OMITTED]

Procedure: After anesthetizing the area (for the patient comfort) deepithelization was done using with Denlase diode laser (fig 2b) and was aceclofenac -parecetamol combination SOS and post operative instructions were given.

Results:

Scalpel technique

No postoperative haemorrhage, infection or scarring was observed and healing was uneventful with good patient's satisfaction for the outcome. However though milder, repigmentation was noticed at the marginal gingival after 6 month follow up.(fig 1d)

[FIGURE 1d OMITTED]

Laser technique

The discomfort during and after the procedure was minimal and healing was uneventful. The results were similar compared to scalpel technique except that there was minimal or no repigmentation noticed even after 6 months

[FIGURE 2c OMITTED]

Discussion:

Depigmentation is treated by using numerous techniques like deepithelization with scalpel, laser, gingival abrasion with diamond bur, Gingivectomy, Gingivectomy with free gingival graft, Electrosurgey, Cryosurgery, and with Chemical agents. (9) The depigmentation procedure involves scalpel and blade surgical technique to remove or peel off the gingival epithelium layer and new epithelium layer is allowed to form by secondary healing which was devoid of pigmentation (10) Scalpel deepithelization is simple and inexpensive and does not require any sophisticated armamenerium and is easy to perform. However it might result in unpleasant haemorrhage and discomfort during or after surgery, and necessiates use of periodontal dressing for 1 week post operatively. (11)

While using with laser surgery bleeding is minimized and surgical duration is shortened. Laser technique has additional advantages viz. sterilization effects and excellent coagulation. Incidence of repigmentation was minimal as compared to scalpel technique but epithelial regeneration is delayed (lack of wound contraction) and need a expensive armamenerium. (12)

Conclusion

Gingival melanin pigmentation occurs as consequence of local, systemic, environmental or genetic factors. Growing cosmetic demand necessitates removal of gingival pigmentation for sthetic purposes. This can be easily achieved by deepithelization of pigmented areas by using scalpel, blade and diode lasers.

References:

(1.) Meyerson MA, Cohen PR, Hymes SR. Lingual hyperpigmentation associated with minocycline therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:180-184.

(2.) Steigmann S. Treatment of melanin-pigmented gingiva and oral mucosa by CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90: 14-15.

(3.) Dummet CO. Oral pigementation: first symptoms of oral pigmentation. J Periodontol 1960;31 :356.

(4.) Hedin CA, Larsson A. The ultrastructre of the gingival epithelium in smokers melanosis. J Periodont Res 1984;19:177-181.

(5.) Carranza CA, Saglie FR. Clinical features of gingivitis in; Carranza FA .Glickman Clinical Periodontology, Philedelphia: WB Saunders 1990;109-125.

(6.) Dummet CO, Barens G. Oromucosal pigmentation; an updated literary review. J Periodontol 1971;42(11);726-736

(7.) Amir E, Gorsky M, Buchner A et al. Physiologiac pigmentation of the oral mucosa in israel children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1991;71 :396 398.

(8.) Dummet CO, Sakumara JS, Barnes G. The relationship of facial skin complexion to oral mucosa pigmentation and tooth color. J Prosthet dent 1980;43:392-396.

(9.) Rahul karthikey, Pradeep AR. Split mouth de-epitheliaztion techniques for gingival depigmentation: a case series and review of literature. J Ind Soc Periodontol 2011;15:161-168.

(10.) Roshna T, Nadakumar K. Anterior esthetic gingival depigmentation and crown lengtheninig .J Contem dent Pract 2005;6:139-147.

(11.) Almas k, Sadig W. Surgical treatment of melanin pigmented gingival. Indian J Dent Res 2002, 13:70-73.

(12.) 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.

Department of Periodontics & Implantology Kamineni Institute of Dental Sciences Narketpally, Nalgonda Dist., AP.

Sunil Kumar P [1], Satyanarayana D [2], Vikram Reddy G [3], Ramprasad B [4]

Senior Lecturer 1&3

Professor [2]

Post Graduate Student [3]

Article Info

Received: January 13, 2012

Review Completed: February, 12, 2012

Accepted: march 13, 2012

Available Online: April, 2012

[C] NAD, 2012 - All rights reserved

Email for correspondence:

drpsunilkumar@gmail.com
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Article Details
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Title Annotation:Case Report
Author:Sunil Kumar, P.; Satyanarayana, D.; Vikram Reddy, G.; Ramprasad, B.
Publication:Indian Journal of Dental Advancements
Article Type:Report
Geographic Code:9INDI
Date:Jan 1, 2012
Words:1187
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