CASE REPORT

Successful Gingival Depigmentation With Laser-PatternedMicrocoagulation: A Case Report

Edward P. Allen,* Natalia D. Gladkova,† Yulia V. Fomina,† Maria M. Karabut,† Elena B. Kiseleva,†

Felix I. Feldchtein,‡ and Gregory B. Altshuler‡

Introduction:Currentmethods for gingival depigmentation, includingmechanical surgery, cryosurgery, laser treatments,and radiosurgery, create significant patient discomfort and risk of complications, thereby reducing attractiveness of the depig-mentation procedure for many patients. To our knowledge, this case report presents a first-time application of a new technol-ogy, laser-patterned microcoagulation (LPM) based on the concept of fractional laser photothermolysis that was successfullyapplied in dermatology and ophthalmology.

Case Presentation: One patient was treated for local hyperpigmentation of the labial attached gingiva in the maxillaryanterior area. A diode laser with wavelength 980 nm and power 20Wwas used to create microcoagulation columns with a 30%area filling factor. Two treatments were performed, 2 weeks apart, without anesthesia. The patient was followed for 5 months.The discomfort during the procedure was tolerable without anesthesia. Healing was uneventful and visually completed with sig-nificant reduction of pigmentation at 2 weeks after treatment. Complete visual depigmentation was observed at both 2 weeksand 2 months after the second treatment.

Conclusions: To our knowledge, this is the first clinical case of hyperpigmentation treatment using LPM, demonstratingfeasibility of a new, minimally invasive and effective method of localized gingival hyperpigmentation removal. The patient dis-comfort is significantly less than that reported for other methods for depigmentation. Clin Adv Periodontics 2011;1:210-214.

Key Words: Hyperpigmentation; laser therapy; lasers, semiconductor; surgical procedures, minimally invasive.

BackgroundBrown or dark gingival pigmentation often presents anesthetic problem because it may be apparent during smile

or speech. The most frequent reason of hyperpigmentationis melanin deposits mainly located in basal and parabasallayers of the epithelium.1 The traditional approach fortreatment of gingival hyperpigmentation is surgical andincludes mucoperiosteal flap, free gingival graft, or deep-ithelization as a less invasive approach. Still, all thesesurgical procedures are painful and expensive and have allthe typical risks associatedwith surgery, including infection,scarring, gingival recession, damage to underlying perios-teum and bone, and delayed wound healing.2 Multiple lessinvasive deepithelization alternatives have been explored,

* Center for Advanced Dental Education, Dallas, TX.

† Nizhny Novgorod Medical Academy, Nizhny Novgorod, Russia.

‡ Dental Photonics, Walpole, MA.

Submitted February 8, 2011; accepted for publication April 6, 2011

doi: 10.1902/cap.2011.110010

210 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011

including erbium lasers,3-5 CO2 lasers,6,7 cryogenic de-struction,8 near-infrared lasers1,9 and radiosurgery.10 How-ever, the majority of existing techniques are still associatedwith significant patient discomfort and protracted healingtime, making gingival depigmentation an unattractive pro-cedure for the majority of patients.

In the past several years, esthetic dermatologywas signif-icantly enhanced by a new technology known as fractionalphotothermolysis.11,12 It was successfully used with severalmillion patients for skin rejuvenation, wrinkle removal,scar conversion to normal tissue, and melasma treatment.The concept of fractional photothermolysis may be ex-plained as ‘‘Formation of isolated non-contiguous micro-thermal wounds creating necrotic zones surrounded byzones of viable tissue in a geometrical pattern that is notdependent on chromophore distribution.’’12 It was foundthat, if the size and concentration (area filling ratio) ofthemicroscopic wounds arewithin certain limits, the tissuecan regenerate without scarring and result in younger,healthier tissue after healing is complete. In addition to der-matology, the same concept was successfully applied inophthalmology,13 but it has not been applied for oral tissues.Because oral mucosa is known to have better regenerationproperties than skin, we hypothesized that fractional treat-ment of oral mucosa and gingiva will result in a similar orbetter response, facilitating regeneration and creating newtissue without scarring. Near-infrared radiation easily pen-etrates into soft tissues, because absorption in water and he-moglobin is not very significant, but strongly absorbedin melanin,14 providing natural selectivity in laser–tissue in-teraction. The tissue regeneration cannot restore melanindeposits concentrated in the basal layer and therefore thepigmentation should be eliminated, at least in the areasin which melanin was destroyed by direct laser radiation.Because the treatment procedure is substantially creatinga pattern of microcoagulated columns in the tissue, it maybe called laser-patterned microcoagulation (LPM).

Clinical PresentationA 36-year-old male was seen at a routine dental hygieneappointment. Several irregular brown pigmented spotswere noted on the attached gingiva labial to the maxillaryincisor teeth (Fig. 1). The pigmented regions were flat and

asymptomatic. The patient had considered them as an es-thetic problem, but had not sought treatment to remove thepigmentation. The pigmentationwas diffuse, bilateral, andexisted forz30 years; therefore, it was considered as phys-iologic pigmentation.15 The patient was offered the optionto treat the most pronounced spots with LPM, a new tech-nology similar to fractional photothermolysis widely usedfor skin rejuvenation and hyperpigmentation treatment.

Case ManagementThe case treatment was performed under the local ethicalcommittee permission (Protocol #1 of Nizhny NovgorodMedical AcademyClinical andAnimal Study Ethical Com-mittee, 2010), and the patient signed an informed consent.

The laser microcoagulation treatment is a quasi-periodicpattern of columns covering a pigmented spot, in whicheach column is created by application of a single laser pulsefrom a diode laser system. A diode laser operating at 980nm wavelength and generating up to 20 W of power wasused in this case. The delivery system had replaceable tipswith 0.6 mm diameter.

In this case, each column was created by an 80 ms pulse.No anesthesia was used. The gingival surface facial to theleft maxillary incisors was dried with compressed air andisolated by cotton rolls (special attention was paid to pre-vent cotton fibers from getting to the treatment field). The

FIGURE 1 Preoperative view of maxilla with pigmentation spots.

FIGURE 2a Immediate postoperative view of the same area after first LPMtreatment. 2b Healing 2 weeks after first treatment. Pigmentation is significantlyreduced.

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pigmented spot was covered with laser columns with a fill-ing ratio (coagulated area divided by total treatment area)of z30%. Digital photos (Figs. 1 through 5) were takenbefore the procedure, immediately after, and during eachfollow up visit. Red articulating paper and untreated pig-mented spots were used for brightness and color referencein the photos. A second treatment was performed 2 weeksafter the first treatment, also with a 30% filling ratio andwithout anesthesia (Fig. 3a).

Clinical OutcomesThe patient reported a tolerable slight burning sensationduring and immediately after the laser pulse and minor

tingling in the treated area at 1 day after treatment. Noother discomfort or side effects were observed. At 1 weekafter the first treatment, a noticeable bleaching of pigmen-tationwas noted compared to another area of hyperpigmen-tation near the right maxillary incisor teeth. The healingcolumns were noticeable on the surface as small indenta-tions. Complete visual healing after the first treatmentwas observed at 2weeks after treatment. The surface texturewas restored, and the pigmentation was inhomogeneous,more at the mesial part of the spot (Fig. 2b). At this time,a second treatment was performed (Fig. 3a).

Two weeks after the second treatment (Figs. 3b and 5c),the surface was smooth and shiny, the pigmentation was ab-sent, and therewerenovisible tracesof columns.Twomonthsafter the first treatment (Fig. 5d), the surfacewas smooth andshiny with no repigmentation, and the patient expresseda high level of satisfaction and willingness to treat remainingareas of hyperpigmentation. No repigmentation was ob-served at 5 months after the second treatment (Fig. 5e).

To our knowledge, this is the first clinical case of hy-perpigmentation treatment using LPM, demonstrating fea-sibility of a new, minimally invasive and effective methodfor localized gingival hyperpigmentation removal. The pa-tient discomfort was significantly less than that reportedfor other methods for hyperpigmentation treatment, in-cluding surgical (mechanical) techniques, erbium laser,CO2 lasers, cryogenic destruction, near-infrared lasers,or radiosurgery. n

FIGURE 3a Immediate postoperative view after second LPM treatment. 3bHealing 2 weeks after second treatment. Pigmentation is reduced to normallevel of surrounding tissue.

FIGURE 4 Two months after treatments.

FIGURE 5 Close-up view of the pigmented spot. 5a Preoperative view. 5b Two weeks after first treatment. 5c Two weeks after second treatment. 5dTwo months after first treatment. 5e Five months after second treatment.

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Summary

Why is this case new information? n To our knowledge, this is the first case report of the application of newtechnologydLPMdfor a successful removal of local gingivalpigmentation.

What are the keys to successfulmanagement of this case?

n Optimization of LPM parameters determined in previous in vitro andanimal experiments led to a minimally invasive yet efficacious methodwith less discomfort.

What are the primary limitations tosuccess in this case?

n Additional cases and longer postoperative evaluations are necessaryto determine the long-term benefit of this technique.

AcknowledgmentsThis case reportwas supported byRussian Federation StateContract 02.740.11.5149 and Grant 10-02-01175 of theRussian Foundation for Basic Research. Dr. Feldchtein isa co-inventor of a patent related to the LPM technologyand is an employee of Dental Photonics (Walpole, MA),a company commercializing LPM treatment. Dr. Altshuleris a shareholder and consultant for Dental Photonics andhas a patent application in LPM treatment. Drs. Gladkova,Fomina, Karabut, and Kiseleva have received financialsupport for research and consulting fees from DentalPhotonics. Dr. Allen reports no conflicts of interest relatedto this case report.

CORRESPONDENCE:Dr. Felix Feldchtein, Dental Photonics, 1600 Boston-Providence Highway,Walpole, MA 02081. E-mail: ffeldchtein@dentalphotonics.com.

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