Case 4

“Is Beauty Really Skin Deep?”

By Neal Lehrman, DDS, MS

A healthy 29 year old female of Middle Eastern origin, presented for evaluation and treatment of her “dark gums”. Although an attractive person by any standards… she felt that the pigment in her gums was taking away from her smile. Her choice, her desire, and we then sat down to discuss her options.

Currently there are a few options for treatment of this condition. Namely, chemical peels which can be both costly and painful, mechanical abrasion of the surface epithelium, free gingival grafting which may or may not work over an extended period of time, and finally, ablation by laser, preferably one that picks up pigment but is transparent to non-colored connective tissue.

The source of the melanin is produced by specialized pigment producing cells called ‘Melanocytes’ situated in the epidermis and basal layer of the epithelium and which are developed from the neural crest cells. That does not mean, however that the tissue is pathological. Indeed, the overwhelming number of patients who present with pigmented gums are physiological in nature.  These cells reside in the basal layer of the epithelium and do not migrate over time. Therefore, a procedure which will only affect the surface layer of tissue is preferred.

The patient was anesthetized with local anesthetic in the maxillary and mandibular vestibules, bi-laterally. The Periolase was placed on an ablation setting and @4 w and 150 ms. 1100 J were used in both arches respectively. By placing the fiber almost touching the tissue, a reaction was created and the surface layer was peeled back exposing the underlying connective tissues. Copious irrigation was used to prevent overheating of the tissue and thereby preventing thermal damage. The patient had no need for post -op analgesics and indeed reported no pain, swelling or post-operative bleeding. No dietary restrictions were necessary.  The healing is uneventful and in some cases a follow up procedure to touch up areas may be indicated. As with all things Laser- better to under treat and then go back if necessary, as our first objective is “to do no harm. “ Despite the safety and predictability of these procedures, there is a learning curve and the best results come when time is taken to perform the surgery in a focused fashion.

The photos below tell the rest of the story…

fig 1. pre-op photo . labial view. n.b. generalized “melanin deposits
creating appearance of “dark gums”

fig 2.
Immediate post-ablation. No need for hemostasis. Note that the marginal tissue was left un-0changed. This is more important in cases where existing restorations are in place in the esthetic zone.

fig 3.
2 day post-operative visit. N.b deposition of fibrin where the pigment used to be. remaining tissues “pink”

fig 4.
3 month post-op. excellent healing slight residual pigment which can be removed at a later date if the patient desires.

fig 5.
A very Happy patient…..