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 9-year-old boy was referred to the Department of Pediatric Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran. The patient needed comprehensive dental treatment due to amelogenesis imperfecta. At the same time his parents requested to treat his gingival pigmentation. His oral examination revealed that his gingiva is deeply pigmented from the right second primary molar to the left second primary molar (). He had been checked by a physician previously and there were no pathologic disorders (e.g. Albright syndrome, trauma, hemachromatosis and racial pigmentation) in this case. Therefore, we started depigmentation therapy by cryosurgery technique.\nLiquid nitrogen was provided in the morning of treatment day by a consumer gas factory and was transferred to the dental facility. In order to transfer the liquid nitrogen, it had been saved in a two-layer flask (metallic inner layer and glassy outer layer).\nIn the first step isolation was instated by suction and cotton rolls; then hyperpigmentation areas were dried byair spray and 10% topical lidocaine gel was used to achieve anesthesia. During treatment, liquid nitrogen was poured into the glass mug and was rolled on the pigmentation area by cotton swabs (). After the gingiva blanched, the operation was started in another area; after 20 seconds this process was repeated. It is possible repeat this process three or four times for each area. The total time needed for this operation was 30 minutes. In order to record and analyze the results, five standard photos were taken in different positions. Standard high-quality images were taken at baseline and after one, three, six and twelve months (). All the photos were taken by a Canon digital camera (Ixus 800IS, Japan) in the same position, while the patient was sitting upright, and the distance between patient and camera was fixed to about 30 centimeters.\nMinimal reddish erythema was observed after cryosurgery. After one month the gingival color was ideal. No complications were observed during the follow-up. No recurrent lesions were observed in 12-month follow-up ().