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 32-year-old female who requested cosmetic therapy for "black gum" in the anterior part of the mandibular gingiva visited the Department of Periodontology, School of Dentistry, Kyung Hee University. There were no contributory medical problems. Melanin hyperpigmentation was found on the labial surface of the mandibular arches and maxillary lateral incisor. Compared with case 1, pigmentation showed more focal pigmented lesions ().\nThe same depigmentation techniques were applied: the Er:YAG laser on the right side and mechanical depigmentation of rotary round bur on the left side. Since the patient had focal pigmentation, depigmentation was conducted on both the maxilla and mandible area simultaneously. Due to the patient's thin gingival biotype and careless laser application, case 2 showed exposure of underlying bone around the incisal area on the right side of the mandible ().\nAt 1 week, the gingiva showed gradual epithelization, but was in an immature state. The laser surgery area showed redness and unfavorable healing with an appearance of necrosis. On the other hand, on the left side where the high speed rotary was applied, almost complete re-epithelization was observed (). After 2 weeks, epithelization was completed except in the right mandibular area (). A linear cleft was observed in the right mandibular area until 3 weeks. The wound healing was almost completed, but slight redness still remained at 4 weeks after surgery. However, the patient was satisfied with the significant improvement in color. Gingival recession and loss of papilla were not observed at 4 weeks after surgery ().