|Year : 2013 | Volume
| Issue : 1 | Page : 38-42
Comparative evaluation of ER:YAG and Nd:YAG Laser for gingival depigmentation
Dolly Motisingh Rathod, Sanjyot Mulay
Department of Conservative and Endodontics, Padmashree Dr. Dnyandeo Yashwantrao Patil Dental College, Pune, Pimpri, Maharashtra
|Date of Web Publication||19-Sep-2013|
Department of Conservative and Endodontics, Padmashree Dr. Dnyandeo Yashwantrao Patil Dental College, Pimpri - 411 018, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Melanin, carotene, and hemoglobin are the most common natural pigments contributing to the natural color of the gums. Although physiologic and ethnic melanin pigmentation is not a medical problem, complaints about "black gums" are common. Gingival depigmentation has been 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. Effective depigmentation of the gingiva requires removal of all or most of the melanocytes from the basal layer of gingival epithelium. In present case report the efficacy of gingival depigmentation using neodymium:yttrium-aluminium-garnet (Nd:YAG) and erbium:YAG (Er:YAG) lasers in same patient was evaluated.
Keywords: Er:YAG laser, gingival depigmentation, melanin, Nd:YAG laser
|How to cite this article:|
Rathod DM, Mulay S. Comparative evaluation of ER:YAG and Nd:YAG Laser for gingival depigmentation. J Dent Lasers 2013;7:38-42
| Introduction|| |
A smile expresses a feeling of joy, success, sensuality, affection, courtesy, and above all reveals self-confidence. The harmony of -"smile" is determined not only by the shape, position and color of the teeth, but also by the gingival tissues.  Gingival health and appearance are essential components of an attractive smile. "Pink zone" enhances the overall esthetics. The color of gingiva plays an important role in this aspect.
Melanin pigmentation is the result of melanin granules produced by melanoblasts intertwined between epithelial cells at the basal layer of gingival epithelium.  Although pigmentation may be observed in any location, gingiva is the most commonly affected site, followed by buccal mucosa, lips, palate, and tongue. ,,, The degree of pigmentation of mucosa varies from one individual to another which is mainly dictated by the melanoblastic activity.  Melanin pigmentation of gingiva is generally symmetric and it does not alter normal gingival architecture.  Literature documents use of lasers for treatment of hyperpigmented gingiva. 
The present case report evaluates and compares the efficacy of erbium:yttrium-aluminium-garnet (Er:YAG) and neodymium:YAG (Nd:YAG ) laser for gingival depigmentation.
| Case Report|| |
A 35 year old male patient reported to the Department of Conservative Dentistry and Endodontics, at Dr. D. Y. Patil Dental College and Hospital, with a chief complaint of "blackish gums" because of which he was reluctant to smile freely in social gatherings.
On intraoral examination, the patient had a very high smile line that revealed the deeply pigmented gingiva on the labial surface of both maxillary and mandibular arches. The color of gingiva was dark to black [Figure 1]. The laser depigmentation procedure was explained to the patient and written consent was obtained. His medical history was non contributory.
Gingival depigmentation was done by using two laser systems Er:YAG and Nd:YAG. Topical anesthetic spray (15% xylocaine) was applied on gingival mucosa for pain relief in right second premolar to left second premolar in maxillary and mandibular arches.
- Er:YAG laser was used in maxillary and mandibular right region (first and fourth quadrant)
- Nd:YAG laser was used in maxillary and mandibular left region (second and third quadrant).
Depigmentation procedure using Er:YAG laser
Treatment was carried out using Fotona Er:YAG laser using long pulse with setting parameters of 85 mJ, 1.25 W, 15 Hz for 4 s [Figure 2]. The beam was defocused to produce a 3 mm diameter circle, thus reducing the beam penetration to 2-4 micron/pulse while increasing the treated surface.  The laser beam was activated and used with "brush technique" as described by Tal et al., with continuous movement of the beam overlapping the laser spots by approximately 20-30% [Figure 3]. 
Depigmentation procedure using Nd:YAG laser
The Nd:YAG laser was set at 3 W, 30 mJ per pulse, and 6 s [Figure 4]. The procedures were performed with contact mode in all hyperpigmented areas by using a handpiece with a 300 micron diameter optic fiber [Figure 5].
The laser was cautiously used to avoid injury to the tooth surface or adjacent tissues during the ablation. In delicate areas such as the marginal gingiva, the Nd:YAG laser should be used with extra care. Ablation of the gingival hyperpigmented areas were accomplished without any bleeding complications or postoperative pain.
[Figure 6] shows immediate postoperative clinical comparison of Er:YAG laser (right quadrants) and Nd:YAG laser (left quadrants) in maxillary and mandibular arches.
After the procedure post-operative instructions were given:
- Normal oral hygiene procedures to be carried out
- Avoid spicy foods for a week
- Application of vitamin E gel on laser-treated mucosa for 1 week, two to three times a day.
Post-operative follow-up was done after 24 h. There was no discomfort, teeth sensitivity, pain or bleeding, or any other complications. The patient experienced no interruption in performing daily activities [Figure 7].
Patient was recalled after 1 week; healing was uneventful without any post-operative complications and required no supportive therapy. The gingiva appeared- pink, healthy and firm, giving a normal appearance. The results were very pleasing and the gingival appearance completely transformed [Figure 8].
Observations for Er:YAG and Nd:YAG lasers for treatment of gingival hyperpigmentation have been made and compared in [Table 1] and [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10].
| Discussion|| |
Esthetics has gained a lot of importance in today's dental practice. Clinicians are faced with cosmetic challenges as well as addressing biologic and functional problems. Complaints of dark color of the oral mucosa and gingival surface are occasionally encountered in dental practice. Hard and soft tissues of oral cavity contribute equally in having a "perfect smile".
Melanin pigmentation of the gingiva occurs in all races.  Melanin, a brown pigment, is the most common natural pigment contributing to endogenous pigmentation of gingiva and the gingiva is also the most predominant site of pigmentation on the mucosa.
Gingival pigmentation results from melanin granules, which are produced by melanoblasts. The degree of pigmentation depends on melanoblastic activity. Normal color of the oral mucosa is determined by many factors, the most important of which are the number and size of blood vessels, oxygenation of blood, epithelial thickness, degree of keratinization, and the amount of pigments in the tissue.  A few pigments, such as melanin, carotene, reduced hemoglobin, and oxyhemoglobin, contribute to its normal color, , with melanin pigmentation having the greatest significance. ,, Various methods of de-epithelialization of the pigmented areas of gingiva have been reported such as bur abrasion, surgical scraping, cryotherapy, electrosurgery, and laser therapy.
Lasers have been used in dentistry since the beginning of the 1980s.  Different lasers such as carbon dioxide (CO 2 ) laser, Nd:YAG laser, diode laser, argon laser, Er:YAG laser and Erbium, chromium:yttrium, scandium, gallium, garnet Er, Cr:YSGG laser have been reported.
Er:YAG laser has 2,940-nm wavelength with a fiber delivery system  and Nd:YAG laser has 1064 mm wavelength. 
Laser ablation for depigmentation has been recognized as an effective, pleasant, and reliable technique. It is preferred over other techniques by many clinicians. When laser energy interacts with biologic tissue, the effect is influenced by the emitted wavelength, laser energy, and time of exposure and rate of movement of the fiber tip across the target tissue. The absorption of laser energy in the tissue is the key element of laser-tissue interaction. Pain reduction, intra- and postoperatively, and rapid wound healing are important advantages of lasers.  Absence of pain may be due to sealing of ends of the sensory nerve. 
In this clinical case, the brush technique with a defocused beam was in accordance to the procedure carried out by Tal et al., 2003. 
The parameters or laser settings were made as per the manufacturers programs. Alterations may be needed depending upon the degree of keratinization of the gingiva.
In the present case report both Er:YAG and Nd:YAG laser showed similar post-operative results clinically. However, Nd:YAG laser presented no bleeding and no pain in contact mode, but took relatively longer for completion of procedure as compared to Er:YAG in non-contact mode.
| Conclusion|| |
The management of gingival melanin hyperpigmentation with Nd:YAG and Er:YAG laser is a safe, painless, and effective procedure providing excellent esthetic outcome. No considerable difference was noted between Nd:YAG and Er:YAG laser treatments clinically.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]