SURGICAL TREATMENT OF MELANIN- PIGMENTED GINGIVA; AN
ESTHETIC APPROACH.
Khalid Almas, MSc, FRACDS, FDSRCS(Ed-), MSc, DDPH1 Walid Sadig, BDS.MS2
Div. Periodontics, Dept. Preventive Dental Sciences, Dept. Prosthetic
Dental Sciences, College of Dentistry, Riyadh, Saudi Arabia
ABSTRACT : The aim of this clinical article is to review the methods of depigmentation of melanin
pigmentation of gingiva and explain scalpel surgical technique for depigmentation of gingiva.
INTRODUCTION
Oral melanin pigmentation is well
documented in the literature and is considered to
have multifaceted etiologies including genetic
factors1'2, tobacco use3'5, systemic disorders6 and
prolonged administration of certain drugs
especially antimalarial agents 7'8 and tricyclic
antidepressant.
Melanin pigmentation often occurs in the
gingiva as a result of an abnormal deposition of
melanin. This type of pigmentation is symmetric
and persistent and it does not alter normal
architecture. This pigmentation may be seen
across all races10 and at any age9 and it is without
gender predilection.11 Melanosis of the 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
(neurofibromatosis).12-13
In dark skinned and black individuals
increased melanin production in the skin and oral
mucosa has long been known to be result
1- Asst. Professor (Dept. PDS)
2- Asst. professor (Dept. Prosthetic D.S.)
Address for Communications
Dr. Khalid Almas
Asst. Professor/Consultant
Div. periodontics
Department of Preventive Dental Sciences
College of Dentistry
King Saud University,
Riyadh 11545, P.O.Box. 60169
Kingdom of Saudi Arab!
E.mail: khalid almas ©yahoo, com
IJDR, VOL13,
of genetically determined hyperactivity of their
skin and mucosal 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, whereas melanocytes of
dark skinned and black individual's are uniformly
highly reactive, and in light skinned individuals,
melanocytes are highly variable in reactivity. 14-16
Although melanin pigmentation of the
gingiva is completely benign and does not
present a medical problem, complaints of 'black
gums' are common. Demand for treatment is
usually made for esthetic reasons; however,
there is not much information in the literature
about the depigmentation of gingival.17 Except
elimination of these melanotic areas through
surgery 18'19 and laser surgery 11 as well as
cryosurgical depigmentation through use of a
gas expansion system a has been reported.
These treatment modalities, however, are not
widely accepted or popularly used. The present
case report introduces a simple and effective
surgical depigmentation technique that does not
require sophisticated instruments or apparatus
yet yeilds esthetically acceptable results.
MATERIAL AND METHODS
A twenty-eight years old male,
Caucasian, dark skinned Arab with generalized
maxillary and mandibular gingival melanin
pigmentation was treated with simple surgical
procedure. The patient had acceptable oral
hygiene level with good plaque control. Topical
anesthesia with 4% lidocaine gel minimized
discomfort before treatment. Then infiltration of
local anesthesia was administered in
premaxillary and anterior mandibular areas
No.2 April-June 2002
70
Blade no. 15 with Bard Parker handle was used to
scrap the epithelium with underlying
pigmented layer carefully. The raw surface was
irrigated with saline solution. The surface was
cleaned and bleeding stopped. The exposed
depigmented surface was cover with Coe-pak
periodontal dressing for one week. The patient
was
prescribed
chlorhexidine
0.12%
mouthwash for two weeks.
bleeding during and after the operation, and it is
necessary to cover the lamina propria with
periodontal packs for 7 to 10 days. Electro
surgery requires more expertise than scalpel
surgery. Prolonged or repeated application of
current to tissue induces heat accumulation and
undesired tissue destruction. Contact with
periosteum or alveolar bone and vital teeth
should be avoided.22
RESULT
Cryosurgery is followed by considerable
swelling and it is also accompanied by
increased soft tissue destruction. Ishida and
Silva23 and Gage & Baust 21reported that in
cryosurgery, all the parts of the freeze-thaw cycle
can cause tissue injury and healing is eventful.
Depth control is difficult and optimal duration of
freezing is not known, but prolonged freezing
increases tissue destruction.'
No post-operative pain, hemorrhage,
infection or scarring occured in any of the sites on
first and subsequent visits. Healing was
uneventful. Patients acceptance of the procedure
was good and results were excellent as
perceived by the patient. The follow up period
spanned 6 months. There was no
repigmentation. The patient is being monitored for
longitudinal period for any repigmentation. See
the step by step (figs. 1 to 5.)
DISCUSSION
Melanin pigmentation is the result of
melanin granules produced by melanoblasts
interwined between epithelial cells at the basal
layer of the epithelium.21
Previous clinical and experimental
reports describe the different depigmentation
methods. It is known that the healing period for
scalpel wounds is faster than other techniques;
however, scalpel surgery causes unpleasent
Fig.1 28 years old patient with melanin gingival
pigmentation in pre-maxillary area.
71
The CO2 laser causes minimal damage to
the periosteum and bone under the gingiva being
treated and it has the unique characteristic of
being able to remove a thin layer of epithelium
cleanly. Although healing of laser wounds is
slower than healing of scalped wounds, laser
wound is a sterile inflammatory reaction. (24>
Patients frequently report greater postoperative
pain after electro surgery than after laser surgery.
However, unlike an electrosurgical wound, a
laser wound is not a burn; 10.6 um photons are
experimentally absorbed as a function of amount
of water, not as a result of resistance or
conduction, and CO 2 laser's air cooling function
Fig.2 Pre-surgical appearance of gingival
pigmentation in mandibular anterior area.
IJDR, VOL. 13, No.2 April-June 2002
Fig.3 Coe-pak periodontal dressing in upper
anterior teeth.
Fig.4 Coe-pak periodontal dressing in lower
anterior teeth.
therapy modalities achieved satisfactory results,
but they required sophisticated equipment that is
not commonly available in hospitals and clinics
in developing countries. Therefore, scalpel
surgical technique is highly recommended in
consideration of the equipment constrains in
developing countries. It is Simple, easy to perform,
cost effective and above all with minimum
discomfort and eshetically acceptable to patient.
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Fig.5 Post operative appearance after 4
weeks.
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