A 30-year-old male patient presented with gingival hyperpigmentation and intrinsic brown stains with pitting defects on all anteriors []. After taking proper history, it was diagnosed as Grade III fluorosis. Several treatment options were proposed such as microabrasion, macroabrasion, in-office bleaching, direct or indirect veneering, and crowns. Enamel microabrasion followed by template-assisted direct composite veneering was chosen for correcting stains and mottling of enamel.\nBefore treatment, the teeth were submitted to rubber cup prophylaxis with pumice/water slurry. The affected teeth were isolated with a rubber dam to avoid contact between the acidic material and other teeth as well as soft tissues of the oral cavity. Enamel macroabrasion of the affected enamel surfaces was performed, using a fine grit finishing bur []. The enamel microabrasive material (Opalustre, Ultradent Products Inc, Utah, USA) was applied with a rubber cup, mounted on a 10:1 gear reduction handpiece [Figure and ]. A small quantity of the product was applied firmly in each region affected by stains, 3 times for 1 min each; and periodic rinsing with water was done between each application. After the last application, the teeth were copiously rinsed and dried []. Next, a 2% neutral sodium fluoride gel was applied to the abraded dental enamel for 4 min in order to minimize postoperative sensitivity. Two clinical sessions of microabrasion were performed at the interval of 1 week [].\nAfter completion, a diagnostic impression was made with alginate which revealed labially placed left central incisor, incisal edge discrepancy between both central incisors and diastema between left lateral incisor and canine. With the help of this diagnostic cast, a resin replica mock-up was performed [] and a soft template was fabricated over it, which could help for the approximation of natural tooth contours. This template was sliced interproximally as evident by passing the Mylar strip intended to keep the bonded teeth from being splinted together. Furthermore, interdental vents were made by carving away the embrasure spaces, thus facilitating better gingival contouring of the composite. A small hole was punched on the labial aspect of the template adjacent to each tooth, matching the size of the tip of the compule for delivering composite [].\nConservative veneer preparation was carried out on the maxillary anterior six teeth with 0.3 mm reduction in the cervical region, 0.5 mm and 0.7 mm reduction in the middle and incisal region, respectively, whereas the incisal edge and the interproximal region were unaltered [Figure -]. After etching and bonding of the prepared tooth surfaces, template was adapted with Mylar strips being placed in the interproximal slits on either side of the tooth to be injected and the tip of the compule snugged into the receiving portal []. Composite (IPS Empress Direct, Ivoclar vivadent) was injected through the portal and allowed to flow within the template under significant seating pressure to carve away the excess material []. After the final carving and contouring of the restoration, composite was light cured. The final finishing and polishing of the restoration were carried out with the help of composite polishing kit (Shofu Inc., Japan) [].\nAfter 2 days, laser depigmentation procedure was performed with the help of diode laser at a wavelength of 810 nm []. No topical or local anesthesia was given to the patient. Melanin-pigmented gingiva was ablated by diode laser vaporization operated at 1.5 W irradiation power with a flexible, fiber optic handpiece in a contact mode and continuous wave motion along with water spray, under standard protective measures []. Remnants of the ablated tissue were removed using sterile gauze damped with saline. Analgesics and chlorhexidine 0.2% mouthwash were prescribed. The patient was instructed to avoid smoking and eating of hot and spicy foods for the first 24 h. The patient was recalled after 7 days for evaluation of any redness or discomfort, but no significant finding was observed [].
A 22-year-old nonsmoking patient of brown race was referred to the department of oral medicine and surgery at the University Dental Clinic of Monastir, with a chief complaint of a “dark-color upper gum.” He reported noticing darkening of the gums 10 years ago. The lesion was asymptomatic and has remained stable since then. He had no significant personal history and denied taking any medication or other substances that may have caused this pigmentation.\nIn clinical examination, periodontal tissues were healthy, but bilateral melanin pigmentation was present, associated with a fractured upper central incisor. A pigmentation index as mentioned by Kumar et al. [] was used to determine the level of pigmentation, and the score was diagnosed as “3” (diffuse brown to black pigmentation, marginal, and attached) ().\nAt first sight, the diagnoses evoked by this oral pigmentation of melanin were gingival pigmentation of exogenous origin (drugs, tobacco, metals,…), racial pigmentation, and Addison's disease. However, given the diffuse, bilateral appearance of these pigmentations which are not of recent appearance, the absence of smoking history or drug use, the patient's race, and the absence of systemic involvement, a final diagnosis of physiological gingival pigmentation (ethnic/racial) was established.\nFollowing the patient's request, a laser depigmentation procedure was planned after obtaining the patient's consent.\nA semiconductor diode surgical laser unit (Elexxion pico 808 nm diode laser, Elexxion AG, Singen, Germany) was used for the procedure; it is a digitally pulsed diode laser with a frequency of 20,000 Hz, a peak power of 5 W, and a pulse width of 26 microseconds. With this setting, the laser beam is “on” the tissue for only 26 microseconds which makes around one-third of the total cycle. The rest of the time is to allow the tissue to cool down. The semiconductor diode laser was operated in a contact method using a 400 nm flexible fiber optic handpiece.\nSpecial eyeglasses were worn by the patient and the staff to fulfill the Food and Drug Administration laser safety rules. After a local infiltration of anesthesia, the properly initiated tip of the diode laser was angled at an external bevel of 45 degrees. The melanin-pigmented gum was resected by circular movement of the fiber with a slight contact on the tissue, avoiding teeth structures.\nThis technique was performed on the entire pigmented anterosuperior attached gingiva for the deepithelialization procedure. Saline-soaked gauze was used to remove epithelial remnant. This procedure was repeated until the desired depth of tissue removal was reached, combined with a labial frenectomy (). The treatment time was two minutes compared to the ablative technique time up to 30 minutes in an area of first molar to first molar.\nAnalgesics and 0.2% chlorhexidine mouthwash were prescribed.\nThe patient did not report any postoperative pain, swelling, or other complications at the first and subsequent visits. It should be noted that a greyish-white fibrin layer completely covers the “laser wound” 6 hours after the operation (), which should not be misinterpreted as secondary infection. Four months later, the patient had no symptoms or signs of gingival melanin pigmentation ().