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Dental Tribune Middle East & Africa Edition | 5/2016 8 mCME Aesthetic laser therapy correction of physiological gingival hyperpigmentation mCMEarticlesinDentalTribunehavebeenapprovedby: HAADashavingeducationalcontentfor2CMECreditHours DHAawardedthisprogramfor2CPDCreditPoints CAPP designates this activity for 2 CE Credits By Howard Gluckman, Jonathan Du Toit,SouthAfrica A beautiful smile is dependent on many factors. One of those factors is thegingivalscaffold.Symmetry,pro- portion,aswellascolourandappear- ance of the gingiva are critical to an aesthetically pleasing smile. Physi- ologicalgingivalhyperpigmentation does not present as clinical pathol- ogyrequiringintervention,nonethe- less it may be of aesthetic concern to the patient. Minimally invasive intervention by means of cryosur- gery, electrosurgery, laser therapy or other may produce dramatic change in the appearance of the patient’s smile with a sustainable, long-term aestheticoutcome. Hereafter a case is presented dem- onstrating laser therapy removal of gingival hyperpigmentation with stable, pink gingival aesthetics at the 2-yearfollow-up. Casereport A 34-year-old female patient of In- dian descent presented by refer- ral to a specialist in periodontics and oral medicine at her request for “pink gums”. The patient was a non-smoker and the medical his- tory was non-contributory. Exami- nation of the face denoted multiple, poorly defined, hyperpigmented macules of the lips, mild in severity and greater in number on the lower lip. The patient’s high smile line was noted with excessive gingival dis- play, the entirety of which involved hyperpigmentation, blue-black/dark brown in colour (Fig. 1). Intraoral ex- aminationdenotedahealthy,largely restorative-free dentition, with ex- emplary oral hygiene maintenance. Hyperpigmentation was noted in- volving the attached gingiva of both the mandible and maxilla, with the latter greater in severity (Fig. 2). The patient scored 4 on the Dummet Oral Pigmentation Index in terms of pigmentation intensity (heavy clinical pigmentation), and scored 2 on the Takashi melanin pigmenta- tion index in terms of its extension (formation of continuous ribbon ex- tending from the neighbouring soli- tary units).4 In both the mandible and the maxilla the hyperpigmen- tation appeared mostly as singular, posteriorly extending macular le- sions with well demarcated borders limited coronal to the mucogingival junctions. A diagnosis of physiologi- cal gingival hyperpigmentation was made and intervention for aesthetic correction was indicated (the patient initially sought treatment of the maxilla only). Digital smile design (DSD) and smile analysis of the pa- tient indicated need for correction of the altered passive eruption. De- epithelializationoftheaffectedareas as well as crown lengthening by la- ser gingivoplasty was opted for. The working field was retracted and iso- lated (OptraGate, Ivoclar Vivadent), and local anaesthesia achieved by slow infiltration of a 4 % articaine withadrenaline(1:200,000)localan- aesthetic solution (Ubistesin™ forte, 3M ESPE). The area, mucosa and teeth surfaces, were cleaned with sterilegauzesoakedinchlorhexidine gluconate aqueous solution (never use an alcohol solution with medical lasers). An Er,Cr:YSSG laser (Water- laseiPlus2.0,Biolase)wasusedforall the periodontal soft tissue surgeries. The crown lengthening by gingivec- tomy was first carried out as per the DSD guide, with a fine tip (MGG6), applied more parallel to the tooth, with the unit's power settings at 3W 75Hz, with water and air settings 50 and 40 respectively. Thereafter, a broader, chisel tip (MC3) was inter- changed for the depigmentation/ gross de-epithelialization, with pow- er settings increased to 5W 25Hz. The tip size and power allowed for faster removal of tissue with water and air settingsonforcooling. Broad, gradual strokes de-epithelial- ized the pigmented areas up to 1 – 2 mm beyond the lesions’ borders. To conclude the procedure, the unit was set to "laser bandage" mode, withloweredpowersettingsat1-1.5W 75Hz,andwaterandairoffforhemo- stasis, leaving a layer of coagulum that would aid with the tissue heal- ing. After the entire affected area was de-epithelialized (Fig. 3) post- operative instructions were given (no tooth brushing near the treated area for 1 week, rinse with chlorhex- idine mouthwash BID 1 minute (Andolex C, iNova Pharmaceuticals), soft diet avoiding spicy/irritating foods). The patient was recalled at 10 days, reporting having had no pain or discomfort, and demonstrating near complete healing of the entire treated area (Fig. 4). There were no areas of hyperpigmentation noted (Fig. 5). The patient was rescored as zero for both pigmentation indices. Following dental bleaching the pa- tient presented at the 2-year recall with no notable signs of repigmen- tation. The patient remained a score of zero on both indices. The gingival contour and colour remained stable with aesthetic results pleasing to the patient(Fig.6). Discussion Pigmentation of the gingiva may pose an aesthetic concern to the pa- tient seeking cosmetic correction thereof. Laser depigmentation is an evidence-supported, beneficial treat- ment modality.1 “Laser” is an acro- nymforlightamplificationbystimu- lated emission of radiation.7 Possibly the first report of laser radiation on oral soft tissues was as early as 1965.8 The first commercial laser for use in dentistry, the dLase 300 Nd:YAG la- ser, was introduced in 1990.6 At pre- sent,arangeoflaserwavelengthsare usedindentistryforaplethoraofap- plications (Table 1). The fundamental modeofactionoflasersisthatwaves consisting of photons (basic unit of radiant energy, light) travel at the speed of light and these waves can be defined by their wavelength and amplitude.11 Amplitude is the verti- cal height of the wave, and in lasers this corresponds to “brightness”, its potential energy to do work. Wave- length is the distance between two corresponding points on the wave – the unit typically in laser dentistry is Figure1:Preoperativeviewof thepatient’ssmile Figure 3: Immediately postoperative, crown lengthening and deepithelializationofpigmented tissuecompleted Figure 5:The patient’s smile 10 days after the laser deepitheliali- zationandcrownlengthening Figure 6:Patient’s smile at the 2-year recall;dental bleaching, in- creased clinical crown size, coral-pink gingiva, all contribute to a healthy,aestheticsmile Figure 2: Retracted, preoperative, intraoral view demonstrating thedegreeofpigmentationandextensionof theaffectedareas Figure 4: 10-days postoperative, rapid healing with dramatic re- sultsingingivalcolour G L U C K M A N / D U T O I T since all the photons in the laser light are focused and “work together”.12 A laser consists of three structural components, namely the active medium, the pumping mechanism, and the optical resonator (Figs. 7a, b). In-depth electromagnetism physics may not be essential knowledge for the clinician, but it may be helpful to know that lasers derive their product 2780 nm, and at a frequency of 1 – 100 Hz. Hertz also states the number of laser pulses per second of emitted energy. To put these properties into perspective, light from a household bulb is white and diffuse, it is not focused. Laser light differs in that it is monochromic (a beam of single colour), and that its waves are coherent. This means they are Laser type Active medium Wavelength (nm) Treatments, applications Excimer lasers Argon fluoride (ArF) 488 Hard tissue ablation, phased out of dentistry. Medical use primarily Xenon-chloride (XeCl) 308 Dental caries and calculus detection Gas lasers Carbon dioxide (CO2) 9300;10,600 Sulcular debridement, peri-implantitis, soft tissue surgery Argon (Ar) 488 - 514 Phased out of dentistry. Medical use primarily. Helium-neon (HeNe) 630 Pulp vitality testing, therapeutic photobiomodulation Diode lasers Indium-gallium-arsenide- 800 – 1064 Dental caries and calculus detection phosphorus (InGaAsP) Galium-aluminum-arsenide Intraoral general and implant soft tissue surgery, (GaAlAs) sulcular debridement (subgingival curettage in Galium-arsenide (GaAs) periodontitis and periimplantitis), analgesia, treatment of dentin hypersensitivity, pulpotomy, root canal disinfection, aphthous ulcers, gingival depigmentation Potassium titanyl 532 Dental bleaching, medical applications phosphate (KTP) Solid-state lasers Neodymium:yttrium- 1064 Soft tissue surgery, sulcular debridement, analgesia, aluminum-garnet dentin hypersensitivity, pulpotomy, root canal (Nd:YAG) disinfection, enamel caries removal, aphthous ulcers, gingival depigmentation Erbium-doped yttrium 2940 Caries removal, cavity preparation, soft tissue Erbium group: aluminium garnet surgery, sulcular debridement (teeth and implants), (Er:YAG) scaling root surfaces, osseous surgery, Erbium: yttrium-scandium- 2790 dentin hypersensitivity, analgesia, pulpotomy, gallium garnet (Er:YSSG) root canal treatment & disinfection, aphthous ulcers, Erbium, chromium: 2780 gingival pigmentation yttrium-scandium-gallium garnet (Er,Cr:YSSG) Other Low level lasers 600 – 635 Non-surgical, photobiomodulation, caries detection Table 1: Lasers currently used in dentistry Table1:Laserscurrentlyusedindentistry ÿPage 9