SRM Journal of Research in Dental Sciences

CASE REPORT
Year
: 2013  |  Volume : 4  |  Issue : 3  |  Page : 125--128

Miracle of perio plastic surgery: Treatment for esthetic smile


Ruchi Srivastava1, Pushpendra Kumar Verma1, Thakur Prasad Chaturvedi1, Adit Srivastava1, Pramod Yadav2,  
1 Department of Dentistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Preventive and Community Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

Correspondence Address:
Pushpendra Kumar Verma
Faculty of Dental sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221 005, Uttar Pradesh
India

Abstract

A smile expresses a feeling of joy, affection, courtesy, self-confidence, and kindness. The harmony of a smile is determined mostly by the teeth, but also the gingiva plays an important role. The shape, size, and color of gums affect the smile and overall appearance of an individual. The appearance of unesthetic anterior teeth or gums may have a significant psychological and emotional impact on the patient. Gingival pigmentation occurs in all races of mankind. The clinical melanin pigmentation and excessive gingival display are of major esthetic concern for many people, especially when it is visible while smiling. Here is a case report describing a successful management of a 22-year-old female patient with gummy smile and dark unpleasant gingiva. This problem was resolved by simply removing the excess of gingival tissues with a crown lengthening procedure involving gingivectomy and the depigmentation of dark gums was done with scalpel surgery technique, simultaneously. Both these procedures ultimately produced a satisfactory esthetic result to the patient.



How to cite this article:
Srivastava R, Verma PK, Chaturvedi TP, Srivastava A, Yadav P. Miracle of perio plastic surgery: Treatment for esthetic smile.SRM J Res Dent Sci 2013;4:125-128


How to cite this URL:
Srivastava R, Verma PK, Chaturvedi TP, Srivastava A, Yadav P. Miracle of perio plastic surgery: Treatment for esthetic smile. SRM J Res Dent Sci [serial online] 2013 [cited 2022 Oct 3 ];4:125-128
Available from: https://www.srmjrds.in/text.asp?2013/4/3/125/121639


Full Text

 Introduction



The harmony of a smile is determined mostly by the teeth, but also the gingiva plays an important role in esthetics. The shape, size, and color of gums affect the smile and overall appearance of an individual. The patients with gummy smile combined with black/brown discoloration of gingival tissue often demand for cosmetic therapy. The excessive gingival display may be due to many etiologies which include extraoral etiology such as vertical maxillary excess, hyper mobile upper lip, or a short upper lip. In these patients, orthognathic surgery can be performed, but this requires hospitalization and entails significant discomfort. When it is due to intraoral reasons then this problem can be resolved by simply removing the gingiva, via precisely planned incisions which often produces satisfactory esthetic results. This exposure of clinical crown by gingival tissue excision is known as crown lengthening. In the presence of a good crown-to-root ratio, esthetic crown lengthening can provide an appropriate proportion of the anterior teeth. [1] Normally; the gingival margin is 1 mm coronal to the cement-enamel junction (CEJ). If it is greater, then the clinical crown is shorter than the anatomical crown and so, crown lengthening procedure is required. When a crown lengthening procedure is planned, the biological width needs to be considered and not encroached upon, as this may lead to periodontal breakdown. [2] The biological width is defined as the dimension of the soft tissue, which is attached to the portion of tooth coronal to the crest of alveolar bone. [3] Garguilo et al., [4] and Ingber et al., [5] established that the biologic width, calculated by addition of the linear measurement of the connective tissue and epithelial attachment, and quoted as 2.04 mm. The color of the gingiva is determined by several factors, namely number and size of the blood vessels, epithelial thickness, quantity of keratinization, and pigments within the gingival epithelium. [6] Melanin pigmentation is frequently caused by melanin deposition by active melanocytes located mainly in the basal layer of the oral epithelium. Brown or dark pigmentation or discoloration of the gingival tissue is however considered as multifaceted etiology, including genetic factors, [7] tobacco use, [8] systemic disorders, or a variety of local and systemic factors. Clinical melanin pigmentation is completely benign and does not present a medical problem, although this hyperpigmentation needs to be removed for esthetic reasons.

 Case Report



A 22-year-old female patient came to the Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, with the complaint of excessive gingival display and dark gums in maxillary anterior region while smiling [Figure 1]. Careful clinical and radiographic evaluations were performed prior to plan any treatment. Extraoral examination revealed no significant findings. Her smile line extended to first premolar and approximately 3 mm of excessive gingival tissue was observed on the maxillary anterior teeth on smiling. The treatment plan included esthetic crown lengthening by gingivectomy procedure and for depigmentation a scalpel technique was planned. Patient's medical history was reviewed to rule out any local or systemic diseases. The surgical technique was explained to the patient and informed consent was obtained. Preparation of the patient included scaling and root planing of the entire dentition and oral hygiene instructions.{Figure 1}

Surgical technique

First of all, the clinical crown length was measured with help of a UNC-15 probe from teeth 13-23 [Figure 1]. The gingival tissue was of thick biotype and had an adequate attached gingiva. After local anesthesia (2% lidocaine with 1:80,000 epinephrine), bleeding points were created from 13-23 with a pocket marker. The purpose of creating bleeding point is to outline the CEJ so that root surface will not be visible after surgery. Normally, the gingival margin is 1 mm coronal to the CEJ. If it is greater, then the clinical crown is shorter than the anatomical crown and a crown lengthening procedure is required. Therefore, we planned our surgical procedure by excising 2-3 mm of gingival tissue from the gingival margin in order to maintain sufficient esthetics in the anterior region and avoid the appearance of a long clinical crown postoperatively. The thick, fibrous gingival tissue was excised with a 15 no. blade, following a scalloped pattern around the gingival margin [Figure 2], [Figure 3], and [Figure 4]. This was followed by a second incision into the intracrevicular sulcus. Subsequently, the gingivectomy was completed and after this gingival epithelium or partial thickness flap was excised for depigmentation using scalpel technique [Figure 5]. Care was taken to remove all the remnants of melanin pigment as thoroughly as possible by scraping with scalpel blade. The marginal gingiva was also very thin and thus some remnants were left in order to prevent gingival recession. Finally a coe-pak was placed over the wound area and oral hygiene instructions were given. Postoperative analgesics and antibiotics were prescribed. After 10 days coe-pak was removed and there was no postoperative complication and healing was satisfactory. After 6 months a well-epithelialized gingiva appeared, which was pink and pleasant [Figure 6]. The patient was followed-up till 1 year with no evidence of repigmentation.{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Discussion



The primary goal of esthetic dental treatment is the restoration of natural, healthy, and esthetic appearance. An evaluation of clinical and anatomic crown lengths in patients with a high lip line is important because incomplete anatomical crown exposure may be the principle factor in the esthetics of a case. The appearance of healthy gingiva is an essential component of a pleasing smile. [9] Ideally the smile should expose minimal gingiva, the gingival contour should be symmetrical and in harmony with the upper lip. In order to maintain periodontal health, there should be 2-3 mm of attached gingiva. [10],[11] In our case, adequate attached gingiva was present and so gingival excision was considered as the treatment of choice. Periodontal crown lengthening is carried for various esthetics and restorative issues such as short teeth, excessive gingival display, uneven gingival contour, and to provide a 'ferrule' for post crown provision. [12] In order to avoid pathological changes, to predict treatment results more precisely, it is necessary to keep gingival biological width unaltered. Authors of wound healing investigations have reported that an average of 3 mm of supragingival soft tissue will rebound coronal to the alveolar crest and can take a minimum of 3 months to complete vertical growth. [13] So one must be aware that osseous resection could affect periodontal stability and may pose a contraindication to crown lengthening therapy. Our case also described a most popular technique, scalpel technique for depigmentation. The results obtained till 6 months posttreatment suggested excellent results. However, a long-term follow-up is required to study repigmentation patterns and durability. Above all as with any procedure, the patient needs to be informed of any potential complications such as possible poor esthetics due to 'black triangles', root hypersensitivity, root resorption, gingival recession, and damage to the periosteum and bone. The key to success is a three-dimensional analysis of the clinical objectives associated with the osseous component of the proposed crown lengthening surgery. The first dimension is the occluso-apical dimension, the second is the mesiodistal dimension, and the third is the buccolingual dimension. However, there was a dramatic improvement in the esthetics of the above mentioned case with concomitant lengthening of the teeth and reduction of the gingival pigmentation.

 Conclusion



Different treatment modalities have been employed by different clinicians to enhance esthetics. The treatment plan depends on a number of factors, including the level of alveolar bone crest, the height and thickness of attached gingiva and the patient's need for interdisciplinary treatment. In the above case patient's acceptance of the procedure was good and results were excellent as perceived by the patient.

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