Esthetic Management of a Patient with Severely Fluorosed Enamel and Pigmented Gingiva: A Conservative Approach.

Isolated brown or white defects of less than few tenths of millimeter depth can be successfully treated with microabrasion. However, for deeper enamel defects, a combination of various techniques such as microabrasion/macroabrasion along with bleaching or full or partial veneering are available. Template-assisted direct veneering technique helps for better separation and contouring of individual tooth through which composite resin can be applied directly to tooth structure and artistically sculpted. Frequently, the gingival hyperpigmentation is caused by excessive melanin deposits mainly located in the basal and suprabasal cell layers of the epithelium. Recently, laser ablation has been recognized as one of the most effective, pleasant, and reliable techniques. This article describes a conservative approach for a complete smile makeover of a patient with severe fluorosis and pigmented gingiva with the help of enamel microabrasion and template-assisted direct composite veneering followed by laser depigmentation of gingiva.

Introduction

Cosmetic dentistry aims to correct the smile esthetics of the patient which may be occasionally compromised due to some discoloration or stain either on an individual tooth or on all teeth or due to the gingival hyperpigmentation. Melanin, carotene, and hemoglobin are the most common natural pigments contributing to the normal color of the gums, but excessive melanin deposition in the basal and suprabasal cell layers of the epithelium may cause hyperpigmentation. Whereas, one of the most common reasons for tooth discoloration is dental fluorosis occurring among people residing in areas with high fluoride content in drinking water. Various noninvasive or minimally invasive methods have been suggested to remove or mask tooth discoloration such as vital or nonvital bleaching, microabrasion, macroabrasion, and direct or indirect veneering procedure. Gingival depigmentation has been traditionally carried out using surgical, chemical, electrosurgical, and cryosurgical procedures. Recently, laser ablation has been recognized as one of the most effective, pleasant, and reliable techniques.[12]

This article presents a conservative approach for correcting smile esthetics with the help of enamel microabrasion followed by template-assisted direct composite veneering done to mask discoloration and mottling caused by fluorosis, as well as use of diode laser for gingival depigmentation.

Case Report

A 30-year-old male patient presented with gingival hyperpigmentation and intrinsic brown stains with pitting defects on all anteriors [Figure 1a]. 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.

Figure 1

(a) Preoperative view of maxillary incisors and canines showing mottled enamel surface. (b) Macroabrasion with a fine grit finishing bur. (c) Microabrasive paste application. (d) Mechanical rubbing of abrasive using a rubber cup. (e) Rinsing of the abrasive paste with water. (f) Immediate postoperative view after microabrasion. (g) Resin mock-up. (h) Template with injection portals and interproximal slits. (i-l) Conservative reduction for veneer

Before 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 [Figure 1b]. 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 1c and d]. 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 [Figure 1e]. 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 [Figure 1f].

After 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 [Figure 1g] 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 [Figure 1h].

Conservative 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 1i-1l]. 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 [Figure 2a]. 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 [Figure 2b]. 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) [Figure 2c].

Figure 2

(a) Mylar strip application through interproximal slits in template. (b) Composite placement through injection portals in template. (c) Postoperative view after direct composite veneering of maxillary anteriors. (d) Diode laser equipment. (e) Laser depigmentation procedure with diode laser for maxillary arch. (f) Seven-day postoperative view after depigmentation of maxillary arch

After 2 days, laser depigmentation procedure was performed with the help of diode laser at a wavelength of 810 nm [Figure 2d]. 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 [Figure 2e]. 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 [Figure 2f].

Discussion

Conservative treatment options such as microabrasion can produce dramatic improvements in brown and yellow discoloration, providing a satisfactory interim result before more invasive procedures such as veneers or crowns are considered, if necessary. Enamel microabrasion corrects surface enamel hypomineralization and discoloration defects by removing superficial enamel. This may be achieved by the use of up to 18% hydrochloric acid and pumice slurry and removes approximately 100 μm of enamel.[3] The Opalustre™ microabrasive slurry used in this case contains a lower concentration of hydrochloric acid (6.6%) and silicon carbide microparticles. Enamel microabrasion using acidic/abrasive products is a noninvasive, conservative, and a time-saving approach which gives immediate and permanent esthetic results, with insignificant and unrecognizable loss of enamel and thus causes minimal patient discomfort.[4]

The indications for a no-preparation or minimally invasive veneer preparation include teeth that have displeasing shapes or contours and/or lack of size and/or volume, requiring morphologic modifications; diastema closure; minor tooth alignment, restoring localized enamel malformations; fluorosis with enamel mottling; and teeth with minor chipping or fractures.[5] Minimal veneer preparation (0.3 mm cervical third, 0.5 mm middle third, 0.7 mm incisal third, no incisal and no interproximal reduction) was done that allows to conserve tooth structure, use supragingival margins, and bond exclusively to enamel, although such preparations are also associated with some challenges including limited ability to change tooth color and risk of bulky labial contour.

Bis-acryl mock-up of the proposed tooth position was done over the diagnostic cast and used as a guide during preparation which facilitated accurate and conservative reduction, thus preserving tooth structure. A soft template was fabricated over the resin mock-up, serving as a matrix for delivering composite which helped for avoiding bulkier restorations. Template adaptation was a less technique-sensitive method and also saved time for cutting off the extra unwanted resin material, and at the same time, physiologic embrasure spaces were maintained. Furthermore, it was easy to remove the template from the cured resin composite without disturbing the restoration.[6]

Constant advancement of resin technology and advent of newer materials have resulted in reduced shrinkage, improved color stability, wear resistance, and biocompatibility. IPS Empress Direct is a universal nanohybrid filling material for direct esthetic restorative procedures that is claimed by the manufacturers to combine the esthetic qualities of ceramics as well as convenient handling characteristics of composites providing high polishability and life-like fluorescence to the restoration. Thus, it may be considered as an interesting alternative to ceramics, minimizing invasiveness, chair time, and costs for patients.

The 810-nm diode laser has energy and wavelength characteristics that specially target the soft tissues. Since it has an affinity for hemoglobin and melanin and does not interact with dental hard tissues, the laser is an excellent soft-tissue surgical laser, indicated for cutting and coagulating gingiva and oral mucosa and for soft-tissue curettage or sulcular debridement. The primary advantage of using laser for depigmentation of gingiva is hemostasis, relatively dry operating field, and minimal patient discomfort.[7]

Conclusion

Correct application of the microabrasion technique, complemented with template-assisted direct composite veneering, allowed for significant improvement in the appearance and color uniformity of the teeth. Furthermore, the use of a diode laser for gingival depigmentation was shown to be a safe and effective treatment modality to provide overall facial esthetics to the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.