Management of Gingival Overgrowth During Orthodontic Treatment Using a Blue Laser: A Case Report

ABSTRACT

Blue laser‐assisted management of gingival overgrowth demonstrated excellent healing with minimal postoperative scarring, along with reduced pain and bleeding, and a relatively shorter surgical time. Despite a partial relapse observed after 3 months, this incisional intervention facilitated the orthodontist's ability to achieve a more functional treatment outcome.

1. Introduction

Gingival overgrowth is an inflammatory condition caused by dental plaque accumulation, systemic disease, or the use of certain medications [1]. This condition is strongly associated with orthodontic treatment, especially during rapid space closure [2]. Although periodontal treatment, scaling, and oral hygiene instructions are primary approaches, they may be insufficient to completely resolve gingival overgrowth [3]. Consequently, treatment options range from scalpel surgery to chemosurgery, electrosurgery, and lasers. In this context, various laser devices have been used for this purpose, such as Nd:YAG, diode, CO2, and Er:YAG lasers [4]. Lasers offer numerous benefits, including a clinically significant reduction in postoperative complications and enhanced patient acceptance [5]. Several studies have demonstrated a favorable role of 808, 810, 940, and 980 nm diode lasers. Compared with the traditional surgical scalpel, diode lasers used in oral surgeries are associated with a reduced need for local anesthesia; this, in turn, reduces the need for painkillers. Moreover, bleeding and swelling are decreased, and neither sutures nor dressings are needed. In addition, wound healing is accelerated compared with conventional methods. Unlike the conventional methods [6, 7], bearing in mind that diode lasers have their pros and cons as alternative tools to the conventional scalpel, many points should be considered with caution, such as possible thermal effects, carbonization, or necrosis, which may result in poor tissue healing [8]. Recently, blue light‐emitting lasers have emerged in dentistry as a promising solution for oral applications compared with standard red laser systems. Their short wavelength allows for high absorption in the target tissue and low absorption in the surrounding tissue, resulting in shallower penetration, fewer thermal side effects, and enhanced wound healing. Owing to these absorption properties, this laser provides precise cutting with minimal bleeding and fewer side effects on adjacent tissues [9].

However, to the best of our knowledge, no prior clinical reports have evaluated the effectiveness of blue laser therapy in managing gingival overgrowth during orthodontic treatment. Thus, this paper presents the case of a 13‐year‐old female patient with gingival overgrowth during orthodontic treatment and describes its management using a blue laser.

2. Case History and Examination

A fit and well 13‐year‐old female patient was referred from the Department of Orthodontics, Faculty of Dentistry, Damascus University, to the Department of Oral Medicine. She presented with Grade 1 (according to the Angelopoulos and Goaz index) [10] gingival overgrowth associated with fixed orthodontic appliances (Figure 1). Her orthodontic diagnosis was Class 1 malocclusion with generalized spacing in both jaws and transposition of the lower right canine with the lateral incisor.

FIGURE 1.

Preoperative intraoral photograph demonstrating gingival overgrowth during orthodontic treatment.

3. Investigations and Treatment

This study was conducted at the Faculty of Dental Medicine, Damascus University, Syria.

Ethical approval for the study protocol was obtained from the Ethics Committee of Damascus University (Ref 3337).

Initially, scaling and polishing were performed, and a mouth rinse was prescribed for 1 week. Local infiltration anesthesia (2% lidocaine containing 1:100,000 epinephrine) was administered buccally for each tooth. Incision of the gingival overgrowth (Figure 2) was carried out using the Woodpecker Smart Laser Dental Diode Laser LX16 Plus, manufactured in the People's Republic of China by Guilin Woodpecker Medical Instrument Co Ltd. The device includes three wavelengths (450 nm blue, 650 nm red, and 976 nm infrared). A blue laser was set for this case with the settings listed in Table 1.

FIGURE 2.

Gingivectomy using blue laser demonstrating a well‐visualized surgical field with minimal bleeding due to laser‐induced hemostasis.

TABLE 1.

Blue laser settings parameters.

Wavelength	450 nm
Fiber tip	400 μm
Application	Contact
Emission mode	Pulsed
Pulse width	20 ms
Pulse interval	8 ms
Frequency	36 Hz
Duty cycle	71%
Average power	1.42 W
Peak power	2 W

The laser device was set up according to the manufacturer's instructions before starting the surgery. A standardized clinical protocol was followed, and the surgical procedure was performed by an experienced practitioner in laser‐assisted oral surgery to ensure a safe procedure and consistency. A dental polishing brush (FlexiBrush) mounted on a micromotor handpiece was then used to remove any remaining debris (Figure 3). A 0.12% chlorhexidine mouth rinse was prescribed for 1 week to prevent secondary infection. The patient was followed up at 1, 2 weeks, 1, 3, and 6 months to assess pain (using a visual analogue scale [VAS] scale), healing (using the Landry index), scarring (yes or no), and recurrence (yes or no). Additionally, bleeding during and after surgery (using the WHO index) and the total procedure time were recorded.

FIGURE 3.

Postoperative photograph showing clean gingival tissue after removing the remaining debris utilizing a FlexiBrush.

The patient used a 10‐cm VAS to assess pain level, with the scale extremes described using descriptors:

• Score 0–1 cm: no pain or distress.

• Score 2–3 cm: annoying.

• Score 4–5 cm: uncomfortable.

• Score 6–7 cm: dreadful.

• Score 8–9 cm: horrible.

• Score 10 cm: agonizing or unbearable distress.

WHO Bleeding Index:

• Grade 0: no bleeding.

• Grade 1: petechial bleeding.

• Grade 2: mild blood loss (clinically significant).

• Grade 3: moderate blood loss.

• Grade 4: debilitating blood loss, retinal or cerebral hemorrhage associated with fatality.

4. Outcome and Follow‐Up

On postoperative days 1 through 4, the patient reported VAS scores of 7, 4, 1, and 0, respectively. Analgesic medication (one 500‐mg tablet of acetaminophen (paracetamol)) was taken only during the first 3 days. There was no bleeding during or immediately after the laser surgical procedure (Grade 0); however, following the use of FlexiBrush, bleeding was recorded as Grade 1.

The laser procedure time was 8 min and 1.8 s for the upper jaw and 4 min and 25.96 s for the lower jaw.

No scarring was observed at 1, 3, and 6 months of follow‐up. Wound healing was rated as very good after 1 week and 2 weeks and excellent after 1 month.

No recurrence was detected at 1 month; however, partial recurrence was noted at 3 months, and the treatment was repeated using the same protocol. Positive outcomes were observed during the subsequent 6‐month follow‐up period (Figure 4).

FIGURE 4.

Six‐month follow‐up showing improved tissue healing and decreased gingival overgrowth.

5. Discussion

“Gingival overgrowth” is the more appropriate and widely accepted term to reflect the underlying pathological process in the gingiva, and it is defined as a localized or generalized enlargement of the gingival tissue, whereas gingival hyperplasia (referring to an increase in cell number) and gingival hypertrophy (referring to an increase in cell size) are histological terms [1].

Gingival overgrowth has many causes, including local factors such as abscess, epulis, tumors, and orthodontic‐induced gingival overgrowth, as well as systemic factors like leukemia, drugs, and hereditary gingival fibromatosis [11]. On the other hand, a study demonstrated that the thick phenotype showed enhanced connective tissue thickness accompanied by increased thickness of the gingiva [12]. Kloehn and Pfeifer discussed causative factors of gingival overgrowth associated with orthodontic treatment, including mechanical irritation from appliances, chemical irritation from cement accumulation of food debris, and inadequate oral hygiene [13].

Consequently, follow‐up sessions from the beginning of orthodontic treatment are essential to monitor gingival health and reinforce oral hygiene instructions [14].

Chesterman et al. described surgical management options, including laser surgery, electrosurgery, and scalpel gingivectomy. Lasers indicated for soft tissue surgery include diode, CO₂, and Nd:YAG lasers, each with different characteristics. Reported advantages of laser use include sterilization of the surgical site, reduced bleeding (improving visibility and precision), and the formation of a fibrin layer that may promote healing, often eliminating the need for periodontal dressings, minimizing postoperative pain, and enhancing patient acceptance. In contrast, laser treatment may reduce recurrence compared with scalpel surgery during the first 3 months post‐procedure; this is likely due to the laser's effect on decreasing collagen production in fibrotic connective tissue. Additionally, long‐term preventive and non‐surgical measures, along with initial follow‐ups every 3 months, can contribute to maintaining good oral hygiene and a healthy oral cavity free from calculus deposits [11].

Diode laser with its chromophores being melanin and hemoglobin potentially has an encouraging role in periodontal surgeries during orthodontic treatment [15].

Another study showed that the diode laser proved to be more efficient, with more satisfactory aesthetic outcomes than the CO₂ laser, better affordability, a smaller device, and a lighter weight compared with high‐energy lasers [16].

Blue lasers have recently been used in dentistry for various applications [17]. Their hemostatic effect may provide a clear field of vision, potentially reduce the need for sutures, and support favorable healing outcomes [18].

This laser system appeared to be reliable, user‐friendly, and associated with favorable wound healing and less postoperative pain [9].

It has also been reported to be effective in treating periodontitis, encouraging further evaluation for managing other gum diseases [19]. A study on drug‐induced gingival overgrowth suggested that blue laser therapy is minimally invasive, with greater patient comfort and a low relapse rate [20]. Compared with conventional infrared diode lasers, blue lasers have been reported to demonstrate shallower penetration and potentially reduced thermal side effects [21]. Our findings align with those of Sabouti et al., who compared 445 nm and 980 nm diode lasers and demonstrated that the 445 nm diode laser is superior in terms of a high level of hemostasis, reduced postoperative pain, better patient comfort, and also offering desirable tissue healing [22].

Laser use has been reported to be beneficial as an adjunct in orthodontic treatment [23], requiring close cooperation between orthodontists and periodontists [24].

Despite the evidence‐based advantages of dental lasers, there are some challenges associated with their use, for instance, the costly equipment, the need for a high level of training, and the cutting edges being less sharp than the conventional scalpel in some cases. Moreover, as neither sutures nor dressings are needed, patient adherence to postoperative instructions becomes more necessary. This is due to the type of healing by secondary intention [25].

Laser‐assisted gingivectomy is widely considered an effective alternative approach when non‐surgical periodontal treatment results in an unsatisfactory outcome; this alternative treatment procedure should be taken into account only after receiving adequate training on dental laser applications, safety instructions, and laser–tissue interactions. Furthermore, maintaining good oral hygiene and ensuring patient adherence to the given postoperative instructions play a significant role in achieving the desired outcome, particularly since healing occurs by secondary intention without suturing. Thus, patient inclusion criteria should be carefully selected. However, it may be less effective in patients with poor plaque control, uncontrolled systemic conditions, or limited adherence to instructions.

Although the clinical course observed in this present case aligns with these findings, especially in the high level of healing and hemostasis, findings provided by case reports remain at a low level of evidence compared with randomized controlled trials and systematic reviews; therefore, while the outcome of our report is clinically positive, it cannot represent definitive fractional preference.

6. Study Limitation

This report has several limitations.

The single‐patient design limits the generalizability of the findings, the absence of a comparator or control intervention (e.g., scalpel surgery, other lasers, or other wavelengths) precludes direct assessment of relative efficacy and safety, and the outcome measures were primarily subjective and not assessed in a blinded manner, which may introduce potential assessment bias. While the controlled academic environment ensured standardized procedures, real‐world variations in practitioner expertise, equipment availability, and patient factors could influence the findings, the follow‐up period was relatively short for evaluating recurrence in a potentially chronic condition.

Therefore, the results should be interpreted as preliminary and hypothesis‐generating. Future comparative controlled trials are warranted. The inclusion of blinded evaluator and objective parameters (such as standardized photographic analysis and validated gingival indices) is recommended in future studies. Furthermore, having a control group for non‐surgical treatment in prospective controlled studies can help differentiate between the independent effect of gingival incision and adjunctive preventive measures, and randomization and longer follow‐up periods may help clarify patterns of recurrence.

7. Conclusion

The blue laser may offer an effective modality for managing gingival conditions associated with fixed orthodontic appliances, promoting accelerated healing, minimal postoperative scarring, reduced pain and bleeding, and a relatively shorter operative time. However, the partial relapse observed after 3 months may be attributed to the continued presence of the orthodontic appliance and challenges in maintaining optimal oral hygiene. Although we obtained positive clinical results in this case report, since it is only one case, we must interpret the results with caution, as definitive conclusions regarding overall and generalizable efficacy cannot be drawn. Further controlled studies are needed to identify additional factors that may influence treatment outcomes.

Author Contributions

Rose Assaf: investigation, methodology. Omar Hamadah: methodology, project administration.

Funding

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient's parent for publication of this case report and accompanying images in accordance with the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

All data underlying the results are presented in this article No additional source data are required.