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 21-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with the complaint of discoloration in upper front teeth []. History of the patient revealed the presence of yellowish brown and white patches on teeth since childhood. Clinical examination showed the presence of dark yellow patches in maxillary central incisors and white patches on the facial surface of all teeth. Careful exploration of teeth revealed intact and smooth enamel surfaces. Several treatment options suggested to the patient were microabrasion, microabrasion along with bleaching, and direct or indirect veneers. Patient declined any procedure that included preparation of her intact tooth surfaces. After discussion, it was agreed to use enamel microabrasion followed by bleaching to improve the appearance of her teeth. The maxillary canines and incisors to be treated were first cleaned with pumice and water slurry. Petroleum jelly was applied around the cervical portion of the teeth to prevent leakage of the hydrochloric acid or damage to the gingiva. The teeth were then isolated using rubber dam. Freshly prepared solution of 11% hydrochloric acid was applied using cotton pellet on the discolored area followed by application of coarse composite contouring discs (Super Snap, Shofu Inc., Japan) at low speed for 10 seconds per tooth []. Same procedure was repeated 3 times at the same visit, which resulted in lightening of the dark areas to a great extent []. White spots were still evident on the labial surfaces of teeth. Thereafter, the remaining acid was rinsed from the teeth by use of gentle air water pressure and a high-volume aspirator. All teeth were finished using fine and extra fine grit abrasive discs (Super Snap). After finishing, the bleaching agent (XX-White™, DENT’N Co., France) was applied over the labial surfaces of isolated teeth, followed by light activation using a bleaching light (Flexi Light whitening system, DENT’N Co., France) for 4 minutes []. Bleaching procedure was repeated one more time for 8 minutes. The bleaching agent was removed by means of moist cotton followed by rinsing with air water spray. Lightening of the teeth shade was noted and rubber dam was removed. All the treated teeth were polished using fine polisher (Compo Site, Shofu Inc, Japan) to obtain high luster. High gloss finish obtained after fine polishing, camouflaged white spots as well as remaining dark areas on the enamel surface []. The patient was informed regarding the likelihood of developing dentinal hypersensitivity, which would subside in a few days. The patient was prescribed the calcium sodium phosphosilicate-containing desensitizing tooth paste (Vantej™, Dr. Reddy's Laboratories Ltd., India) for 3 weeks and then discharged. At 1 month follow-up, the results were stable and the patient did not complain of any symptoms related to dentinal hypersensitivity [].