Dental Science 

- Case Report
Pink esthetics in periodontics – Gingival
depigmentation: A case series
Arthiie Thangavelu, Sugumari Elavarasu, Piranitha Jayapalan

Department of ABSTRACT
Periodontics, JKK
Smile expresses a feeling of joy, success, sensuality, affection, and courtesy, and reveals self-confidence and
Nattraja Dental College,
Komarapalayam,
kindness. The harmony of the smile is determined not only by the shape, the position, and the color of the teeth,
Tamil Nadu, India but also by the gingival tissues. Although melanin pigmentation of the gingiva is completely benign and does
not present a medical problem, complaints of “black gums” are common, particularly in patients having a very
Address for correspondence: high smile line. Thus, perio-esthetic treatment modalities strive to achieve a harmonious inter-relationship of
Dr. Arthiie Thangavelu, the pink with white, which is imperative of all treatment procedures. For depigmentation of gingival, different
E-mail: arthivarman@gmail.
treatment modalities have been reported, such as bur abrasion, scraping, partial thickness flap, cryotherapy,
com
electrosurgery, and laser. In the present case series, scraping, electrosurgery, and diode laser have been tried
for depigmentation, which are simple, effective, and yield good results, along with good patient satisfaction.
Received : 01-12-11
Review completed : 02-01-12
Accepted : 26-01-12 KEY WORDS: Depigmentation, electrocautery, laser, repigmentation, scraping

“E sthetics” is the science of beauty, which is the particular

detail of an animate or inanimate object that makes it
appealing to the eye. Esthetic or cosmetic dentistry strives to
Elimination of these melanotic areas can be done by scraping,
free gingival autografting, cryosurgery, electrosurgery, and
various types of lasers.[4] The selection of technique should be
merge function and beauty with the values and individual needs based on clinical experience and individual preferences.[2]
of every patient. These advances now allow the practitioner
to achieve a periodontal environment that complements and Selection Criteria
enhances the creation of optimal dental esthetics. Gingival
health and appearance are the essential components of an The cases were selected based on Dummett–Gupta Oral
attractive smile. Oral melanin pigmentation is considered to be Pigmentation Index (DOPI): (Dummett 1971)[5]
multifactorial, physiological/pathological.[1] Melanin, a brown 1. No clinical pigmentation (pink gingiva)
pigment, is the most common natural pigment contributing to 2. Mild clinical pigmentation (mild light brown color)
endogenous pigmentation of gingiva. It is a non–hemoglobin-
3. Moderate clinical pigmentation (medium brown or mixed
derived pigment formed by cells called melonocytes which
pink and brown)
are dentritic cells of neuroectodermal origin in the basal and
4. Heavy clinical pigmentation (deep brown or bluish black).
spinous layers.[2]
The smile line classification (Liebart and Deruelle 2004)[6]
Gingival depigmentation is a periodontal plastic surgical
Class 1: Very high smile line – more than 2 mm of the marginal
procedure whereby the gingival hyperpigmentation is
gingiva visible.
removed or reduced.[3] The first and foremost indication for
depigmentation is patient demand for improved esthetics. Class 2: High smile line – between 0 and 2 mm of the marginal
gingiva visible.
Access this article online Class 3: Average smile line – only gingival embrasures visible.
Quick Response Code: Class 4: Low smile line – gingival embrasures and cemento-
Website: enamel junction not visible.
www.jpbsonline.org

The present case series describes three simple and effective

DOI: surgical depigmentation techniques – scalpel, electrosurgery,
10.4103/0975-7406.100267 and diode lasers. All these techniques have produced good
results with patient satisfaction.

How to cite this article: Thangavelu A, Elavarasu S, Jayapalan P. Pink esthetics in periodontics - Gingival depigmentation: A case series.
J Pharm Bioall Sci 2012;4:186-90.

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 Arthiie and Elavarasu: Gingival depigmentation 

Case Reports patient had a very high smile line [Figure 7]. The patient and
the staffs were protected from laser by wearing manufacturer’s
Case 1 spectacles. After adequate anesthesia was given, diode laser
in contact mode was used. The ablation was operated using a
A 20-year-old female patient complaining of heavily pigmented hand piece with fiber optic filament, 320 µm in diameter set
gums visited Department of Periodontics, JKK Nattraja Dental at 0.8 W. The procedure was performed in a contact mode in
College and Hospital, Komarapalayam. On examination, DOPI cervico-apical direction on all pigmented areas [Figure 8]. No
score was 3 and the patient had a very high smile line that pain or bleeding complications were observed during and after
revealed the deeply pigmented gingiva from first premolar the procedure. One day postoperatively, it revealed no pain or
to first premolar and also had midline Diastema [Figure 1]. discomfort [Figure 9]. The ablated wound healed completely
Considering the patient’s concern, surgical depigmentation in 1 week. Three months after the ablation, the gingiva was
procedure was planned. The entire procedure was explained generalized pink in color and healthy in appearance [Figure 10].
to the patient and written consent was obtained. Routine
oral hygiene procedures were carried out and oral hygiene Discussion
instructions were given. Local anesthesia was infiltrated
in the maxillary anterior region from first premolar to first Pigmented gingival tissue many a times forces the patients to
premolar. Using a number 15 Bard Parker blade, scrapping of seek cosmetic treatment.[4] Several treatment modalities have
the pigmented epithelium up to the level of the mucogingival been suggested and presented in the literature, ranging from a
junction was carried out, leaving the connective tissue intact simple scalpel method to sophisticated lasers.[7] According to
[Figure 2]. After complete removal of the entire epithelium, Cicek (2003),[2] melanin pigmentation is caused by melanin
abrasion with diamond bur was done to get the physiological deposition by active melanocytes located in the basal layer of
contour of the gingiva. Bur was used with minimal pressure with oral epithelium.[8]
feather light brushing strokes. A frenectomy was performed
after the depigmentation was completed. A periodontal In the present case series, three techniques were selected for
dressing (Coe-Pak) was placed on the surgical wound area for depigmentation, which included scalpel, electrosurgery, and
patient comfort and to protect it for 1 week. The patient was laser. Following surgical procedure, patients were recalled at
kept on analgesics for a period of 5 days and was advised to 1 and 3 months to evaluate recurrence of pigments. All the
use 0.12% chlorhexidine gluconate mouthwash for 2 weeks techniques produced successful results with good patient
postoperatively. During postoperative period, the wound satisfaction.
healing was uneventful without any discomfort. Three months
postoperative examination showed well-epithelialized gingiva, The depigmentation procedure by scalpel technique is simple,
which was pink in color and pleasant, but with few sites showing easy to perform, noninvasive, and above all, cost effective.
remnants of pigmentation [Figure 3]. According to Almas and Sadiq (2002),[3] the scalpel wound
heals faster than that in other techniques. In our study also,
Case 2 the healing by scalpel was faster than that by cautery and laser.
But scalpel surgery causes unpleasant bleeding during and after
A young female patient aged 23 years visited the Department the operation. It is also necessary to cover the exposed lamina
of Periodontics, JKK Nattraja Dental College and Hospital propria with periodontal dressing for 7–10 days.[9]
with the chief complaint of blackish gums which esthetically
interfered with her smile. The DOPI score was 3 and revealed The superior efficiency of electrosurgery than scalpel seen
very high smile line [Figure 4]. Considering the patient’s in the present case series could be explained based on
concern, depigmentation procedure was planned using Oringer’s (1975) [10] “exploding cell theory.” According to
electrocautery. A loop electrode was used for depigmentation the theory, it is predicted that the electrical energy leads to
of gingiva[Figure 5]. It was used in a light brushing strokes molecular disintegration of melanin cells present in basal and
and the tip was kept in motion all the time to avoid excessive suprabasal cell layers of operated and surrounding sites. Thus,
heat buildup and destruction of the tissues. Finally, perio-pack electrosurgery has a strong influence in retarding migration of
was placed over the wound area and oral hygiene instructions melanin cells from the locally situated cells, which were detected
were given. The pack was removed after 1 week and the area clinically to be removed. Cicek (2003)[2] reported that there is
debrided. Pigmentation was absent in the newly formed no bleeding and there is minimal patient discomfort while using
epithelium, with the gingiva appearing pale pink in color after electrocautery. But electrosurgery also has its own limitations in
a period of 3 months [Figure 6]. that its repeated and prolonged use induces heat accumulation
and undesired tissue destruction.[10]
Case 3
Another effective treatment modality employed in the
A 25-year-old female patient complaining of heavily pigmented present case series is the depigmentation by diode laser. Here,
gums visited Department of Periodontics, JKK Nattraja Dental radiation energy is transformed into ablation energy, resulting
College and Hospital, with a request for esthetic treatment of in cellular rupture and vaporization with minimal heating of the
black gums. On examination, her DOPI score was 3 and the surrounding tissue.[11] According to Atsawasuwan and Greethong

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 Arthiie and Elavarasu: Gingival depigmentation

Figure 1: Preoperative view showing unsightly physiologic melanin Figure 2: View immediately after depigmentation, No. 15 blade being
pigmentation of upper labial gingiva used to remove the pigment layer and frenectomy done

Figure 3: 3 months postoperative view. Depigmented gingiva that is

Figure 4: Preoperative view showing highly pigmented upper labial
pink and healthy
gingival

Figure 6: 3 months postoperative view

Figure 5: Immediate postoperative view, using electrocautery
hemostasis, and decontamination and sterilization effects. But
(1999), laser beam produces bloodless field for surgery, causes
[12] this approach needs expensive and sophisticated equipment,
minimum damage to the periosteum and underlying bone, and which makes the treatment very expensive.[12] Laser beam even
the treated gingiva and mucosa do not need any dressing. This destroys the epithelial cells including those at the basal layer,
has the advantages of easy handling, short treatment time, and hence reduces repigmentation.[13] Thus, repigmentation was

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 Arthiie and Elavarasu: Gingival depigmentation 

Figure 7: Preoperative picture of 25-year-old female complaining of

black-colored gums Figure 8: Immediate postoperative picture, diode laser used

Figure 10: 3 months postoperative picture showing healthy gingiva

Figure 9: One day postoperative view with no increase in the extent of repigmented areas

minimal and patient compliance was much better in this case patients were satisfied with the outcome, which is the ultimate
series while using lasers with than other techniques. goal of any therapy that is carried out.

Pigment recurrence has been documented to occur following References

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