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 23-year-old male patient complaining of heavily pigmented gums [] visited department of Periodontics, Institute of Dental Studies and Technologies, Modinagar. On examination, the patient was otherwise healthy but had a deeply pigmented gingiva. Pigmentation was unsightly and hence laser depigmentation procedures were planned. The procedure was explained verbally to the patient and the consent was obtained.\nPatient and operating staff wore special diode-laser protective eye glasses. Highly reflective instruments or instruments with mirrored surfaces were avoided as there could be reflection of the laser beam. A semiconductor diode surgical laser unit (Sunny Gold; Mikro Scientific Instrument Pvt Ltd., India, wavelength 980 nm, power 2-4 W) was used for depigmentation of the maxillary and mandibular anterior gingiva up to the second premolar on both right and left sides. The semiconductor diode laser was emitted in gated-pulsed mode, and was operated in a contact method using a flexible fiber optic handpiece. The Laser settings used were: fluence between 5 and 15 J/cm2, pulse length between 20 and 50 ms, spot diameter of 2 mm and thermal relaxation times of 0.15 to 0.20 milliseconds. No topical or local anesthesia was given to patients. Laser ablation started from the mucogingival junction toward the free gingival margin, including papillae. The motion of ablation was circular with overlapping circles. High attention was taken to avoid passing the laser beam on teeth structures and over mucosa. During the procedure, laser ablated the gingival epithelial surface little by little to reach the pigments without causing any bleeding which was beneficial for clear visualization. [] To enhance visualization, normal saline-soaked cotton or gauze was used to remove epithelial remnant.\nThe ablation of the gingiva was completed within 20-25 minutes on the maxilla and mandible. Laser ablation of pigmented epithelium immediately produced a melanin pigment-free surface without any carbonization. The wound looked fresh with no bleeding []. There was no need to apply a periodontal dressing. Patient was instructed to avoid smoking and eating of hot and spicy foods for the first 24 hours and was discharged from dental office to perform normal daily activity. Healing was good at 1 month with pink color comparable to nearby non-treated area, resulting in a significant improvement in aesthetic appearance []. No infection or significant postoperative complications such as pain or bleeding were encountered. Fifteen months follow-up showed no signs of recurrence of pigmentaion.