Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

Think Pink by Dr. Ilies Tibaoui

View Comments (1) More by this author (1)
Categories: Orthodontics;
Think Pink 

An expanded view of excellence: The pink-tissue contribution

by Dr. Ilies Tibaoui

Many talented orthodontists do great jobs, use amazing mechanics, finish cases with a beautiful occlusion … and yet, looking at their finished cases, something’s missing. And usually, that missing factor is what would take the case from merely good to “Wow!”

Detailing each patient’s white- and pink-tissue microaesthetics is a sound strategy to ensure your cases really stand out (Fig. 1). My article in the September 2022 issue of Orthotown focused on the white-tissue aesthetics part of the story; in this one, we’ll look at the pink-tissue part—specifically, incorporating a soft-tissue diode laser as a routine element in finishing. These strategies have been refined with my friend and teaching partner, Dr. Wassim Bouzid, and incorporate ideas we’ve learned from colleagues around the world.
Think Pink
Fig. 1: In this patient, optimal tooth position and white-tissue aesthetics were complemented by optimizing pink-tissue contours with a soft-tissue laser.

The goals of this article are threefold:
  • To show how powerful pink-tissue aesthetics can be in the aesthetic smile.
  • To present a simple clinical strategy orthodontists can follow to effectively enhance pink-tissue presentation.
  • To create the recognition that pink-tissue procedures should not be limited to hypertrophic tissues and can be applied in almost every case

The pink-tissue factor
Understanding the importance of aesthetic gingival architecture is the first step, because it can have more impact on the beauty of the smile than the orthodontic treatment.

Assessing the pink-tissue aesthetic needs transcends the obvious soft-tissue concerns. In the same way that creating visual outcome objectives with a digital outcome simulator (DOS) has value, a tool for pink-tissue assessment is also needed—and some pioneering orthodontists have adapted the Pink Esthetic Score (PES) tool developed by our prosthodontic colleagues1 for use in orthodontics.2

We propose the PES should include an objective and subjective visual evaluation of gingival aesthetics in the upper and lower anterior region. This assessment should cover:
  • Mesial papilla.
  • Distal papilla.
  • Level of the soft-tissue margin.
  • Attached gingival contour, gingival zeniths and contours.
  • Alveolar process.
  • Gingival color.
  • Gingival texture.
For those unfamiliar with PES concepts, the use of a DOS similar to those used in the digital smile design process is helpful. Visually displaying the pink-tissue aesthetic target helps identify areas of concern, and indicates needed white-tissue refinements and the extent and nature of soft-tissue revision (Figs. 2a and 2b). This can be a wonderful onboarding tool to educate the patient.
Think Pink
Think Pink
     Figs. 2a and 2b: White- and pink-tissue aesthetic templates incorporating a Pink Esthetic Score (PES).


Factors above and below the CEJ
It is helpful conceptually to appreciate that pink-tissue contours may be affected by elements both above and below the cementoenamel junction (CEJ).

Tooth position and shape: Orthodontic tooth movement is known to influence gingival contour by affecting the proximity of the roots and the axial inclination of the teeth. Careful refinement of tooth shapes, considered tooth movement and attention to biological availability can optimize gingival contour before gingival-tissue revision (Figs. 3a and 3b).
Think Pink
Think Pink
     Figs. 3a and 3b: Samples of how relatively minor changes in white- and pink-tissue position can effect aesthetic presentation.


Below the CEJ: Consideration of the alveolar height, adherence to the “Rule of Five” in terms of connector length and respect of the natural biological width during revision are important factors both during treatment and when considering white-tissue revision after orthodontics.

Above the CEJ: Soft-tissue reduction and contouring pink tissue above the CEJ is where the soft-tissue laser is most appropriate. While many tools have been used, using a diode laser is a very well-tolerated and predictable technique.

Virtually every orthodontic patient can benefit from aesthetic gingival recontouring after treatment.

With an optimized image of gingival contour and an appreciation of the patient’s biological availability in mind, we are able to move forward in sequencing procedures.


Timing of pink-tissue revision
Before orthodontic treatment: As a follower of Tom Pitts’ approach to bonding that we call SAP bonding (short for “smile arc protection bonding”), we tend to bond the incisors more gingivally, which can lead to the need to use a soft-tissue laser before treatment starts when facing short clinical crowns or altered passive eruption patterns (Fig. 4).
Think Pink
Fig. 4: Gingival recontouring before bonding allowed optimal SAP bracket position for aesthetic improvement.


During treatment: A soft-tissue laser can be used during orthodontic treatment to address several situations, including impacted teeth; the need to rebond fixed appliances more gingivally to improve the smile arc; and if a patient’s soft-tissue response has been poor. In my experience, laser treatments performed during orthodontic treatment frequently benefit from refinement after fixed appliances have been removed.

After treatment: I suggest applying soft-tissue revision as a routine procedure in virtually every orthodontic case.


Technique strategies for soft-tissue laser refinements
After debonding the patient, we commonly wait four to six weeks to resolve any inflammation before recontouring. The patient is scheduled for a 15- to 30-minute appointment, depending on the extent of work, which includes pretreatment photography, measurement of sulcus depth and marking of the projected zenith points on the upper six anterior teeth, as well as the procedure itself and postprocedure photography.

If the need for laser is minimal, anesthesia is provided through a topical gel (20% lidocaine, 4% tetrocaine and 2% phenylephrindine) compounded by a local pharmacy. For more extensive recontouring, infiltration of short-acting local dental anesthesia is preferred.

Approaching the patient from the front, we optimize gingival contours starting with the upper central, then proceed distally to the second bicuspid or mesial of the first molar. The contralateral side is then matched. It’s important to view the patient either standing or sitting upright, so as to avoid creating iatrogenic gingival height or contour discrepancies during the procedure.

While the use of a high-quality laser at an appropriate setting minimizes charring and posttreatment discomfort, we’ve found that postoperative topical application of vitamin E oil two or three times a day for a week can improve healing. This is especially appropriate when resurfacing of the gingival tissue to improve gingival texture or color is a part of the recontouring.3

At the recall visit three or four weeks after the laser recontouring, final records are taken, including artistic photography to celebrate the patient’s final result.


Case study
The 15-year-old patient in Figs. 5a–d presented as a Class 2 with upper crowding and lower spaces. While the occlusal result at the end of orthodontic treatment (Fig. 6) is acceptable, the smile was far from ideal. Only after the application of soft-tissue laser and gingival recontouring could we fully appreciate the work done. Using the PES templates (Figs. 7a and 7b) to plan gingival recontouring application of a diode laser (Figs. 8a–8c) was a simple way to “go the extra mile.”
Think Pink
Fig. 5a
Think Pink
Fig. 5b
Think Pink
Fig. 5c
Think Pink
Fig. 5d

Think Pink
Fig. 6

Think Pink
Fig. 7a
Think Pink
Fig. 7b
Think Pink
Fig. 8a
Think Pink
Fig. 8b
Think Pink
Fig. 8c



In the final results (Figs. 9a–9e), we can clearly see how powerful and how much impact a very simple and fast procedure can have—on not only restoring the beauty of the teeth but also on the beauty of the smile and the whole face.  
Think Pink
Fig. 9a
Think Pink
Fig. 9b
Think Pink
Fig .9c
Think Pink
Fig. 9d
Think Pink
Fig. 9e

References
1. Furhauser R. “Evaluation of Soft Tissue Around Single-Tooth Implant Crowns: The Pink Esthetic Score,” Clinical Oral Implant Research, January 2006, pp. 639–644.
2. Su B. “IBOI White and Pink Esthetic Scores,” IJOI 28.
3. Ramesh A. “Healing Outcomes After Depigmentation With Scalpel and Diode Laser—A Split Mouth Study,” JSPIK, Vol. 12, Issue 3, December 2020, pp. 193–197.

Author Bio
Dr. Ilies Tibaoui Dr. Ilies Tibaoui is in private practice with his wife in Algiers, Algeria. He is also a member and instructor of the Pitts Master Program.

Because of the important roles management and communication play in orthodontics, Tibaoui is particularly interested in organizational and behavioral psychology.

He specializes in teaching aesthetics and beauty for orthodontists, the Pitts Protocol, blending extraradicular TADs with passive self-ligating brackets for complex cases, digital smile design, emotional dentistry and communication.

More In Orthodontics
An Ambitious Plan for Success
An Ambitious Plan for Success
by Dr. Jeremy Manuele
January/February 2023
Dental Pain Eraser
Dental Pain Eraser
October 2023
Permission To Intercept
Permission To Intercept
Dr. Michael K. DeLuke
CE Credits: 1.5
Understanding the Mechanics of the MDA Appliance
Understanding the Mechanics of the MDA Appliance
Kay Gerety
CE Credits: 1.5
Orthotown Magazine
September 2025
Orthotown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie® Poll
Do you have a dedicated insurance coordinator in your office?
  
Related Articles
A Career-Changing Conversation
A Career-Changing Conversation
by Dr. Christos Papadopoulos
July/August 2025
Board Profiles: 5 Questions With Dr. Glenn Krieger
Board Profiles: 5 Questions With Dr. Glenn Krieger
January/February 2023
Product Profile: OrthoFX
Product Profile: OrthoFX
October 2023
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Orthotown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450