Laser Focused by Drs. Maia Berger and Sam Low

How to effectively use dental laser technology for gingiva depigmentation and gum bleaching

by Samuel B. Low, DDS, MS, MEd and Maia Berger, DDS, MS

This natural pigmentation, which does not pose any other issues other than aesthetics, is usually seen in the labial, anterior region of the maxillary and the mandibular arches. It’s more often seen in women and girls who have high smile lines (or “gummy smiles”) than in men or boys.

Several techniques can be used to de-epithelize the areas of pigmentation, including electrosurgery, cryotherapy, surgical scraping and bur/diamond abrasion. These procedures generally create a hemorrhagic wound surface with irregular contours, which results in melanin not completely being identified and removed, which can lead to minimal recurrence of pigmentation. There is also an increase in postoperative complications such as bleeding and discomfort.

A more effective method to reduce or remove melanin is the dental laser. Today’s lasers can ablate melanocytes, which will eliminate melanin production in the gingiva, resulting in a more uniform and lighter color of a pink gingiva (Fig. 1). Diode lasers utilize pigment as their chromophore (target), while erbium lasers such as the Er,Cr:YSGG have a wavelength that can be quickly absorbed in water to ablate and photoacoustically remove epithelium and the associated melanin.

Dental patients who present with high lip lines and gummy smiles are asking dental health professionals to remove the black spots to return pink gingiva. For some individuals, removal of the discoloration enhances confidence and self-esteem. They also desire a level of permanency. Because of safety and effectiveness, laser gingiva depigmentation is becoming the procedure of choice for dentists to change their patients’ gingival appearance.

Fig. 1: Before and after a typical case.

Fig. 2: Preoperative photo of case study patient

Fig. 3: Six months postoperative.

Case study

A 19-year-old patient from the West Indies presented with a chief concern of: “I don’t like it. Whenever I smile, the dark spots show, and it is just not attractive” (Fig. 2).

The considered treatment plan was the removal of melanin pigmentation in both the maxillary and mandibular anterior regions, while the maxilla was of most concern. An erbium laser (Er,Cr:YSGG) was to be used through de-epithelial ablation of gingival buccal epithelium.

A thorough medical and dental history was achieved and demonstrated noncontributory to the outlined procedures. The patient was not taking any prescribed medications. There was no demonstrated periodontal pathology by viewing radiographs and periodontal probing. Adequate attached gingivae was observed, with an adequate gingival biotype and thickness. An informed consent was acquired in which the risks, benefits and treatment options were explained in detail and documented. The patient underwent a thorough debridement and received oral hygiene instructions. She was adamant of her desire that the clinician remove or lighten the dark pigmentation on her gingiva.

Utilizing local anesthesia, an Er,Cr:YSGG all-tissue laser (Waterlase iPlus) was used to de-epithelize the outer surface of the gingivae and remove the pigmentation. The procedure, laser de-epithelialization, involved removal of the gingival epithelium along with a layer of the underlying connective tissue, where melanocytes are found. The wound healing would be via secondary intent.

The laser settings were 1.5 watts, 30Hz, 40% air and 50% water. An MZ6 9mm tip was used at a 45-degree angle to the gingival margin in a slow, overlapping vertical manner in a near-contact mode of 0.5mm. Care was taken to leave at least a 1–2mm margin at the coronal gingival margin to ensure no postoperative recession. A wet gauze was used to consistently wipe any hemorrhage or debris from the area so that the clinician could ensure that all of the melanin pigment was removed.

Postoperative instructions (utilize warm salt rinses and 400mg ibuprofen and 500mg acetaminophen as needed) were given verbally and written down for the patient. No chlorohexidine was prescribed, because the wound was of secondary intent and chlorohexidine is cytotoxic to fibroblasts. An anti-inflammatory gel was used by the patient to enhance wound healing. The procedures for both arches were completed in two separate visits.

The patient was seen seven days postoperatively with no discomfort or complications. She returned in three and six months with gingivae that was observed to be consistently pink with no pigmentation and a satisfactory smile (Fig. 3).

Clinical considerations

1. Ensure that there are no medical contraindications for coagulation, because no anticoagulant medications are prescribed.

2. Use appropriate laser settings to enhance postoperative wound healing.

3. Assess gingival biotype thickness before beginning the procedure. Where biotype is very thin, decrease power settings and use defocus mode so as to prevent osseous exposure and necrosis, because this is a secondary-intent wound.

4. Beware of possible tooth dehiscence or fenestration with this biotype, so as not to create adverse laser events with tooth structure.

5. Leave at least 2mm of coronal gingival margin to prevent gingival recession.

6. Never guarantee that the results will include no postoperative pigmentation, because recurrence and future touch-ups may be necessary.

Conclusion

Patients can present with a chief concern of pigmented gingiva, especially if they have high-lip line gummy smiles. Dental lasers with appropriate wavelengths can be used to remove melanin pigment with minimal trauma, excellent postoperative wound healing and significant patient satisfaction.