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Table of Contents
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 24-27

Complete esthetic rehabilitation of young patient with gingival pigmentation

1 Prosthodontist, Department of Prosthodontics, Crown and Bridge and Implantology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India, Haryana
2 Reader, Department of Prosthodontics, Crown and Bridge and Implantology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
3 Professor and Head, Department of Prosthodontics, Crown and Bridge and Implantology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
4 Professor, Department of Prosthodontics, Crown and Bridge and Implantology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
5 Professor, Department of Prosthodontics, Crown and Bridge and Implantology, Madan Dental Care, New Delhi, India

Date of Web Publication26-Jul-2019

Correspondence Address:
Dr. Chetan Pathak
House No. 1697, Sector 16, Faridabad, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INPC.INPC_21_19

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Smile is an expression which can help people feel better. Smile can express a sense of affection, joy, happiness, kindness, and confidence. Dentistry is one such profession which deals with smile esthetics. Smile esthetics is a type of subjective evaluation. Few clinicians believe that smile harmony is determined by only the shape, position, and color of teeth. However, actually, gingival tissue also plays an important role in determining smile harmony. Visibility of periodontium depends on smile line which is the ratio between the upper lip and usually is convex in appearance. Excessive exposure of gums while smiling is referred to as gummy smile.

Keywords: All ceramic restoration, esthetics, gingival pigmentation, laser, platelet-rich fibrin

How to cite this article:
Sharma M, Pathak C, Pawah S, Gupta A, Madan B, Jain N. Complete esthetic rehabilitation of young patient with gingival pigmentation. Int J Prev Clin Dent Res 2019;6:24-7

How to cite this URL:
Sharma M, Pathak C, Pawah S, Gupta A, Madan B, Jain N. Complete esthetic rehabilitation of young patient with gingival pigmentation. Int J Prev Clin Dent Res [serial online] 2019 [cited 2020 Sep 18];6:24-7. Available from: http://www.ijpcdr.org/text.asp?2019/6/1/24/263457

  Introduction Top

Happiness is a state of mind. It is brought about by a feeling of well-being, security, and confidence in one's self. Reestablishment of proper esthetics and function in the anterior region is of utmost importance for the patient. Discolored, unsightly, malposed, malformed anterior teeth, and midline diastemas can make the individual psychologically depressed and socially less active. The relentless pace of innovation and development in restorative materials culminates in offering clinicians a whole plethora of esthetic materials with different techniques.

Dentistry has undergone a revolution in the past 30 years not only with regard to the introduction of new materials and techniques but also with regard to the scientific evidence supporting their clinical applications. As ceramic materials for dentistry evolve and as the patient's demand for esthetic restorations increases, practitioners must keep up with the science as well as the demand of the patients.[1]

The material which appears very much similar to the natural tooth is full ceramic restoration, as it is more translucent and life like when compared to the porcelain fused to metal (PFM) which has a more of the opaque core. For the anterior restoration in the esthetic zone, all ceramic system is best among all. The laboratory work is certainly more technique sensitive, however, the outcome is more esthetic. For a posterior area, one may consider PFM or all metal as forces of occlusion are far greater and esthetic requirements are minimum.[1]

The gingiva is considered as the most frequently pigmented soft tissue of the oral cavity. Brown or dark pigmentations and discolorations of the gingival tissues, whether physiological or pathological, can be caused by a variety of local and/or systemic factors.[2] There have been different techniques proposed in the literature for the treatment of gingival pigmentation including surgical removal and laser therapy. Laser depigmentation has become more preferable over surgical means as it includes less bleeding, reduced postoperational pain, and accelerated wound healing.[3] Gingival depigmentation is a periodontal plastic surgical procedure whereby the gingival hyperpigmentation is removed or reduced.[4] The first and foremost indication for depigmentation is patient demand for improved esthetics. The elimination of these melanotic areas can be done by scraping, free gingival autografting, cryosurgery, electrosurgery, and various types of lasers.[5] The selection of technique should be based on the clinical experience and individual preferences.[6]

  Case Report Top

A 24-year-old young female patient reported to the Department of Prosthodontics Crown and Bridge in Sudha Rustagi College of Dental Sciences and Research with a chief complaint of unesthestic smile and metal showing on labial aspect of the upper front tooth region and blackish discoloration of gums. On clinical examination, it was observed that the implant was malplaced high in the bone with bone dehiscence present with respect to labial aspect of the left lateral incisor through which metal was visible making the appearance very unesthetic as shown in [Figure 1] and [Figure 2]. There was poor gingival architecture in terms of scalloping and zenith. Furthermore, the patient presented with a high smile line with excessive gingival show and poorly fabricated PFM. Fixed partial denture with respect to left canine to right canine was already removed by some local dentist when the patient reported to the department.
Figure 1:Preoperative view

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Figure 2: Removal of abutment

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Treatment options

It was decided to primarily close the soft-tissue cleft to cover the exposed metal and followed by all-ceramic fixed partial denture restorations and gingival depigmentation with soft-tissue laser for complete esthetic rehabilitation of the patient.


A complete medical history and blood examination were carried out to rule out any systemic problems while performing this treatment protocol. The entire procedure was explained to the patient, and written consent was obtained. Routine oral hygiene procedures were carried out and oral hygiene instructions were given. Then, incision was given on the lateral margins of the cleft with no. 15 blade after administration of local anesthesia followed by primary closure to approximate margins to encourage healing. The periodontal pack was placed postoperatively for wound protection. After 1 week, no improvement was observed and metal was still visible through the cleft. Again margins of cleft were scored to induce fresh bleeding, and freshly prepared platelet-rich fibrin was placed over the soft-tissue cleft area and sutured to encourage soft-tissue healing as shown in [Figure 3]. After 1 week, satisfactory soft-tissue cover was achieved over the defect and also improved gingival architecture was observed. Modification in crown preparation was done to eliminate undercuts, and margins were finished to receive all-ceramic zirconia fixed partial denture. The final impression was then made using two-step putty reline technique with elastomeric impression material (addition silicon, Affinis, Coltene Whaledent, Spain), after the placement of gingival retraction cord (Ultradent, India) for the fabrication of fixed partial denture with respect to 11, 12, 13 and 21, 22, 23. Shade selection was done using Vita 3D-Master shade guide, and 6 units provisional FPD was fabricated using the indirect technique with polymethyl methacrylate, DPI, India, and cemented with temporary cement (RelyX, 3M ESPE). The crown with respect to implant was unacceptable esthetically; it was then decided to remove the implant abutment and sealing the implant with a cover screw to make it sleeping and was not used to support the prosthesis. Gingival depigmentation was performed using a diode laser. Sirona diode laser having a wavelength of 810–980 nm at 1.5–2 Watt power in a continuous wave mode with flexible fiberoptic quartz delivery system was used. After the selected power settings were entered, the laser was activated. The procedure was performed in contact mode under local anesthesia. The tip was held in light contact with the tissue and the procedure was performed with light sweeping brush strokes. High volume suction was used. The laser tip was directed to the target tissue until the blister formation occurred. Blistered gingiva was scraped off with wet, saline moistened gauze to remove the epithelium containing melanin pigmentation. No pain was experienced by the patient during the procedure. The patient was kept on analgesics for 5 days and was advised to use 0.12% chlorhexidine gluconate mouthwash for 2 weeks' postoperatively. During the postoperative period, the wound healing was uneventful without any discomfort. This final zirconia prosthesis was satisfactory in terms of shade and marginal adaptation, it was cemented with resin-modified glass ionomer cement (GC, Fuji, Japan) with respect to 13, 12, 11 and 21, 22, 23 as shown in [Figure 4], and postcementation instructions were given to the patient. The patient was recalled for checkup and was found to be satisfactory in terms of esthetics and function.
Figure 3: Suture placement with platelet-rich fibrin in socket

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Figure 4: Postoperative view after depigmentation and cementation

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  Discussion Top

The size, form, and appearance of the maxillary anterior teeth are important not only to dental esthetics but also to facial esthetics. The goal is to restore the maxillary anterior teeth in harmony with the adjacent tissues as well as the facial appearance.

According to the Young, “it is apparent that beauty, harmony, naturalness, and individuality are major qualities” of esthetics.[7] So far various materials have been used for the replacement of missing tooth in the anterior regions such as the full gold restorations, full ceramic crowns, PFM, leucite reinforced, alumina, zirconia, and others. In the present case, the difference can be make out between the PFM crowns and the full ceramic crowns in the anterior esthetic zone and what level of satisfaction according to the patient. PFM crowns can be color matched to the teeth and are the most common type of crowns used. These crowns are very strong, have a good appearance, and are very reasonably priced. However, in full natural light, the metal base can show through as a shadow in the tooth, especially for front teeth. Furthermore, over time, if the gums recede from the crown, the metal base can be seen as a dark line that will show where the crown meets the gingiva. On the other hand, full porcelain or full ceramic crowns provide the best natural appearance and are also an excellent choice for patients who have metal allergies. They are most commonly used for anterior teeth, as they have an excellent natural appearance. However, they are not as strong as PFM crowns, are more expensive, and can be prone to chipping or cracking.[8] In this present case, all-ceramic zirconia crowns were fabricated to achieve esthetic rehabilitation.

Pigmented gingival tissue many a times forces the patients to seek cosmetic treatment. Several treatment modalities have been suggested and presented in the literature, ranging from a simple scalpel method to sophisticated lasers.[9] According to (Cicek 2003),[6] melanin pigmentation is caused by melanin deposition by active melanocytes located in the basal layer of oral epithelium. In dark-skinned people, oral pigmentation is likely to increase, though there is no difference in the number of melanocytes between fair-skinned and dark-skinned individuals.[10] The degree of the pigmentation seems to be related to the differences in melanocyte activity. It is presented as a diffuse deep purplish discoloration or irregularly-shaped light brown, brown, or black patches, or strands resulting from melanin granules produced by melanocytes in the basal and suprabasal cell layers of the epithelium.[11]

Long-lived esthetics and biocompatibility are the promise of all-ceramic systems. They require resin cement for cementation, which enhances the strength of the crown through bonding. It is advisable to use light-cured resin luting agents, as they are more color stable compared to dual-cure resin cements, which may discolor due to the release of amines, over a period of time.[12] Full ceramic crowns with opaque cores are superior in strength, with good esthetics, and can be used for posterior teeth as well as for the anterior teeth with heavy discoloration.[13] Crowns with the zirconia core are recommended for fixed partial dentures. One can use resin or conventional luting agents for cementation as the color of the cement will not affect the shade of the crown. When restoring anterior teeth with these crowns, it is advisable to end the margin subgingivally, as there could be a mismatch in shade between the tooth margin and the restoration. The strength of these restorations is dependent on the ceramic material used, the core-veneer bond strength, the crown thickness, and the design of restoration.[14] However, metal-free restorations are not recommended in patients who have heavy bruxism. Proper guidance to the practitioner is required in selecting the appropriate system for crowns as well as the knowledge of the optical properties of available ceramic systems, which will enable the clinician to make appropriate choices when faced with the various esthetic challenges.

In this present case, complete esthetic rehabilitation was done in terms of all-ceramic fixed partial denture, gingival depigmentation, and decision was made to keep malpositioned implant sleeping in the esthetic zone for the esthetic outcome of the treatment.

  Conclusion Top

In today's era, there is a growing demand for esthetics. The maintenance of esthetics requires removal of excessively pigmented gingival areas, especially in people with high smile lines. This can be attained with the procedures described in this case report. The methods used here are easy to perform, and the results are satisfactory.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Spear F, Holloway J. Which all-ceramic system is optimal for anterior esthetics? J Am Dent Assoc 2008;139:19-24.  Back to cited text no. 1
Sreeja C, Ramakrishnan K, Vijayalakshmi D, Devi M, Aesha I, Vijayabanu B. Oral pigmentation: A review. J Pharm Bioallied Sci 2015;7:403-8.  Back to cited text no. 2
Abdel Moneim RA, El Deeb M, Rabea AA. Gingival pigmentation (cause, treatment and histological preview). Future Dent J 2017;3:1-7.  Back to cited text no. 3
Almas K, Sadig W. Surgical treatment of melanin-pigmented gingiva; an esthetic approach. Indian J Dent Res 2002;13:70-3.  Back to cited text no. 4
Deepak P, Sunil S, Mishra R, Sheshadri. Treatment of gingival pigmentation: A case series. Indian J Dent Res 2005;16:171-6.  Back to cited text no. 5
Ciçek Y, Ertaş U. The normal and pathological pigmentation of oral mucous membrane: A review. J Contemp Dent Pract 2003;4:76-86.  Back to cited text no. 6
Gomes VL, Gonçalves LC, do Prado CJ, Junior IL, de Lima Lucas B. Correlation between facial measurements and the mesiodistal width of the maxillary anterior teeth. J Esthet Restor Dent 2006;18:196-205.  Back to cited text no. 7
Holm C, Tidehag P, Tillberg A, Molin M. Longevity and quality of FPDs: A retrospective study of restorations 30, 20, and 10 years after insertion. Int J Prosthodont 2003;16:283-9.  Back to cited text no. 8
Fondriest J. Shade matching in restorative dentistry: The science and strategies. Int J Periodontics Restorative Dent 2003;23:467-79.  Back to cited text no. 9
Carranza AC, Saglie FR. Clinical features of gingivitis. In: Glickman I, Carranza FA, editors. Glickman's Clinical Periodontology. 7th ed.. Philadelphia: Saunders; 1990. p. 109-25.  Back to cited text no. 10
Rosa DS, Aranha AC, Eduardo Cde P, Aoki A. Esthetic treatment of gingival melanin hyperpigmentation with Er: YAG laser: Short-term clinical observations and patient follow-up. J Periodontol 2007;78:2018-25.  Back to cited text no. 11
Hassan Ahangari A, Torabi Ardakani K, Mahdavi F, Torabi Ardakani M. The effect of two shading techniques on value of zirconia-based crowns. J Dent (Shiraz) 2015;16:129-33.  Back to cited text no. 12
Kelly JR. Dental ceramics: What is this stuff anyway? J Am Dent Assoc 2008;139:4-7.  Back to cited text no. 13
Mizrahi B. The anterior all-ceramic crown: A rationale for the choice of ceramic and cement. Br Dent J 2008;205:251-5.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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