Facial Esthetics Classification and Gingival Pigmentation Index of Treatment Needs

INTRODUCTION

The colour of gingiva, one of the factors that determine the intraoral ‘pink-white’ esthetics, is produced by the interplay between vascular supply of gingiva, the thickness and degree of keratinisation of the epithelium and the presence of pigment containing cells.¹ The pigmentation may also occur as a consequence of benign and malignant lesions, intentional tattooing, drugs, heavy metal ingestions, smoking, systemic diseases and conditions etc .

The amount, degree and pattern of pigmentation vary among populations and between individuals within the population. Melanin pigmentation in the oral cavity of darker skinned individuals has been found to be more than that found in light-skinned individuals.² The Indian population provides an extensive range of gingival pigmentation as the skin colour shade ranges show a gradation from fair to dark from the Northern regions to the Southern regions of India; although light-skinned individuals may be seen interspersed with darkskinned individuals in the South and vice-versa. South Indian Population, whose skin harbour more melanin tend to have more oral pigmentation than the North Indian population. The examination of the gingiva in a South Indian population has shown that the pigmentation was more in the attached gingiva and interdental papilla and was least in the marginal gingiva and interdental papilla together.³

A number of indices and classifications exist that describe the distribution of gingival pigmentation.^4,5,6 However, they do not provide a leeway to communicate the variation in pigmentation pattern within the gingiva of the same individual. A tooth and sextant wise description of the gingival pigmentation pattern would provide accurate data to facilitate the formulation of an efficient plan for depigmentation. A new classification system is being proposed in this article to categorise the facial esthetics and aid in the precise assessment of the pattern and distribution of gingival pigmentation. A treatment Index that includes the treatment modality for each category of facial esthetics is also given in this article.

Indices on gingival pigmentation

There are several indices that describe the distribution of gingival pigmentation. Some of them are given below:

1. Oral pigmentation index (DOPI):⁵

The Dummet Oral Pigmentation Index is simple and easy to use and hence, it is commonly used.

The scores are as follows:

Score 0: No clinical pigmentation (pink-coloured gingiva)

Score 1: Mild clinical pigmentation (mild light brown colour)

Score 2: Moderate clinical pigmentation (medium brown or mixed pink and brown colour)

Score 3: Heavy clinical pigmentation (deep brown or bluish black colour)

2. Recently Ponnaiyan et al³ have proposed a classification system for gingival pigmentation in a South Indian population. It is as follows:

Class I: Pigmentation in attached gingival

Class II: Pigmentation in the attached gingiva and interdental papilla

Class III: Diffuse pigmentation involving all parts of gingival

Class IV: Pigmentation in marginal gingiva only

Class V: Pigmentation in interdental papilla only

Class VI: Pigmentation in marginal gingiva and interdental papilla

Peeran et al have proposed another classification system that gives a detailed insight into the various etiologies of gingival pigmentation and they have proposed a scoring system based on the etiology and have also given the possible treatment plan taking into consideration the patient’s lip line.⁴

Proposed classification system

The proposed classification system has 5 components which would help in correlating the gingival pigmentation with facial complexion, lip colour and the lip line. This would further facilitate the development of a treatment plan tailored to fit the treatment needs of individual patients.

The components are the following:

1) The facial complexion: The Fitzpatrick scale, von Luschan scale and the scale of dermatological assessment of skin complexion in an Indian population as given by Hourblin, et al7 have been modified so as to satisfactorily categorise the Indian population (Figure 1).

Score FC1: Creamy white: von Luschan scale 1-2

Score FC2: Fair: von Luschan scale 7-8 Score

FC3: Wheatish: von Luschan scale 9-10

Score FC4: Mild brown: von Luschan scale 11-12 Score

FC5: Moderate brown: von Luschan scale 13- 16 Score

FC6: Dark brown: von Luschan scale 23-30 Score

FC7: Intense dark: von Luschan scale 31-36

2) The degree of pigmentation:

A modification of the Dummet oral pigmentation index has been used to categorise the degree of pigmentation. The modified index is given in Table 1.

3) Distribution of pigmentation

A categorisation of the distribution of pigmentation based on the sextant-wise location of pigmentation has been made.

X1: Pigmentation seen in Maxillary right posterior sextant

X2: Pigmentation seen in Maxillary anterior sextant

X3: Pigmentation seen in Maxillary left posterior sextant

N1: Pigmentation seen in Mandibular right posterior sextant

N2: Pigmentation seen in Mandibular anterior sextant

N3: Pigmentation seen in Mandibular left posterior sextant

4) The smile line

Liebart and Deruelle8 smile line classification has been used which is as follows:

Class 1(SL1): Very high smile line - more than 2 mm of the marginal gingiva visible

Class 2(SL2): High smile line - between 0 and 2 mm of the marginal gingiva visible

Class 3(SL3): Average smile line - only gingival embrasures visible

Class 4(SL4): Low smile line - gingival embrasures and cemento-enamel junction not visible.

5) Lip colour

The lip colour has been assigned based on the lip tone classification given by Iyer et al.9

LC1: Pink lips (No islands of melanocytes)

LC2: Light brown (Few light brown islands of melanocytes)

LC3: Brown (Mild dark hued islands of melanocytes)

LC4: Dark brown (Moderate dark hued islands of melanocytes)

LC5: Chocolate brown (Dark hued islands of melanocytes)

LC6: Blackish brown (Severe dark hued islands of melanocytes)

The Classification Based on the above mentioned five components a new classification system has been proposed in this article. The classification is:

i) Esthetic

ii) Unesthetic

Esthetics of a smile depends on Smile line, Facial complexion, Lip colour, Degree of gingival pigmentation and Location of gingival pigmentation.

Esthetic

A smile can be considered esthetic if the factors that determine the esthetics of a smile are combined in the following manner (Table 2):

Unesthetic

An unesthetic smile is the result of the disharmony among the various components that determine the facial esthetics. The Unesthetic-Mild and Unesthetic- Severe categories are given in Table 3 and Table 4 respectively.

The Index for Treatment Needs

Various treatment modalities have been suggested to enhance esthetics in patients with hyperpigmented gingiva. The techniques include; De-epithelization, Electrosurgery, Cryosurgery etc.¹⁰

Gingivectomy and Gingivectomy with free gingival autograft can be used to correct the excessive gingival display provided the procedure establishes an ideal gingival contour. Gingivectomy can be used in cases where the gingival display is due to the altered passive eruption.

A high smile line which produces an unaesthetic appearance may be corrected using the liprepositioning technique. It is especially useful in patients with hypermobile lips.¹¹

Lip hyperpigmentation mars the overall appearance of a person, if the skin complexion and the lip colour do not match. Lip depigmentation using LASERs can help in improving the overall facial esthetics.⁹

The newer classification system proposed in this article encompasses the different aspects of facial esthetics. Hence, the treatment plan for the mild and severe unaesthetic categories involves a combination of procedures to correct the individual unaesthetic component (Table5).

Content Validation

The proposed classification system was sent to three reviewers for content validation. There was a 100% agreement between all the judges for all the components of the classification system and Content Validity Index (CVI) was.¹

DISCUSSION

An artistic symphony of several components of the face creates perfection and beauty and, like any symphony, a single discordant element can create a cacophonous appearance. This article describes a classification that encompasses the various factors involved in facial aesthetics and an index of treatment modalities that can be adopted for the different scenarios.

The facial complexion, the lip colour, smile line and the degree and distribution of pigmentation, the factors considered paramount in determining the artistic excellence of the face and smile of a person, have been taken as the components of this classification in order to classify the facial esthetics into categories: esthetic, unaesthetic-mild, unaesthetic-severe.

It has been stated that in Caucasian, African, Asiatic and Indian populations, a definite correlation exits between the colour tone within the oral cavity and the external pigmentation of the individuals.¹² However, a study by Patel et al showed that there is no correlation between facial skin pigmentation type and amount and pattern of oral pigmentation.¹³

The treatment index being proposed in this article incorporates procedures that require careful patient selection and accurate treatment planning. Depigmentation techniques of lips and gingiva, lip repositioning and gingivectomy in patients with altered passive eruption when used in various combinations and permutations would render excellent esthetic results.

The techniques for depigmentation of gingiva can be classified into various categories (Table 6).

14 Scalpel surgical techniques involve the removal of the epithelium and the pigment containing tissues using scalpel.¹⁴

Cryosurgery is the direct application of liquid nitrogen with a cotton swab on the pigmented gingiva which causes the superficial layers of gingiva to slough off, thereby giving a pink, depigmented gingiva.¹⁴

Electrosurgery, on the other hand, uses electrical energy converted to heat energy to remove the pigmented tissues of the gingiva. Depigmentation using LASER is contemplated based on the concept that LASER is absorbed by the chromophores which, in-turn, aids in pigmented tissue ablation and the resultant depigmentation.⁹ Lip depigmentation can also be performed using LASERs and this has been shown to produce excellent results.⁹

Free gingival graft utilizes a palatal tissue graft to facilitate depimentation14 and acellular dermal matrix allograft utilizes the allograft, Alloderm, for depigmentation.

Lip repositioning, a technique that produces a remarkable esthetic outcome in a patient with a high smile line, can also mask the hyperpigmented areas. It is a very useful intra-oral plastic and esthetic surgical modality in patients with hypermobile lips.¹¹

The validity of any new tool discovered for assessment of scientific and biologic measures has to be determined. Lynn in 1986, had suggested that a minimum of three experts should evaluate a tool to assess its validity and the CVI should be 1 when the tool is being evaluated by Three to Five experts. Based on this, the proposed classification system was sent to three external validators and it was found to have the validity required.

CONCLUSION

‘Beauty lies in the eyes of the beholder’, but a little manoeuvring and management of facial esthetic components can create ‘a thing of beauty’ which will be ‘a joy forever’. Appropriate treatment planning and patient selection can produce a profound impact on facial esthetics. The classification proposed in this article attempts a comprehensive coverage of all combinations of facial esthetic components and the Treatment Index encompasses the treatment modalities for each combination. The reliability of the classification and the index has to be verified using clinical studies involving multiple investigators.