الفهرس 
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Abstract
Physiological gingival hyperpigmentation is regarded as a problem of an esthetic concern among many individuals. It occurs due to increased melanocytic activity rather than increased number. Many treatment options are available for gingival depigmentation either surgical interventions or non-surgical ones. Surgical procedures aim for removing or peeling of gingival epithelium to reduce the number of melanocytes, while non -surgical procedures aims for suppressing the process of melanin synthesis itself. One of the non-surgical interventions that demonstrated its tremendous effect in the last decade as a safe minimally invasive procedure for gingival depigmentation is using vitamin C. Several case reports, randomized clinical trials and systemic reviews illustrated its capability to inhibit melanin synthesis either when it’s topically applied or injected intramucosal.
Despite the variable available treatment modalities, one of the main drawbacks after depigmentation is recurrence of the pigment. It showed to occur after most of the depigmentation procedures. Variable factors affect this process including the used treatment modality for depigmentation; follow up period for detection of the recurrence, methods used in detection and other patient factors.
According to the researcher knowledge there was only one case report that investigated the adjunctive role of using topical vitamin C after surgical depigmentation to delay the recurrence. This case report demonstrated satisfactory esthetic results and revealed no pigmentation was detected after 9 months. This study was conducted to compare the efficacy of vitamin C either injected or topically applied after surgical depigmentation in achieving long term gingival color stability.
Twenty-four patients seeking treatment for physiological gingival hyperpigmentation were included in this study. Patients were recruited from the outpatient clinic in the Faculty of Dentistry Ain Shams University. Patients were then included in the study following the predetermined inclusion and exclusion criteria. Patients should be medically free patients; classified as type I individuals according to ASA classification (American Society of Anesthesiology), consequently pregnant, lactating females and smokers were excluded. Patients who reported any allergic reaction to ascorbic acid or those diagnosed to have periodontitis were excluded as well. Then patients were randomly allocated to receive one of these treatments:
group I (Vit.C.In): Included 8 patients that were treated with surgical depigmentation after then they received intramucosal vitamin C injection on weekly intervals for one month then monthly intervals for additional 5 months.
group II (Vit.C.T): Included 8 patients that were treated with surgical gingival depigmentation, then vitamin C was topically applied at home twice weekly for 6 months.
group III (Control): Included 8 patients that were treated with surgical gingival depigmentation only.
The clinical outcomes were assessed at baseline (preoperative), then 5 times (postoperative) as follow: at 1 month, 3months, 6 months, and 9 months and finally after a year.
Clinical assessment was done by measuring the pigment surface area SA and the intensity of recurred pigment using DOPI and MDV. Subjective assessment of the results was done through using patient satisfaction questionnaire.
Tissue biopsies were taken at baseline, 6 months and at 12 months. Histopathological assessment was carried out to detect the melanin synthesis on the tissue level. The slides were stained with Fontana Masson stain and digital images were captured using a digital camera mounted on a light microscope, then images were transferred to the computer to calculate MAF using image J, 1.41a, software.
Regarding pigment intensity assessment using DOPI, mean DOPI in group I was less than that in group II along the follow up visits without a statistically significant difference between them. However, group I showed a statistically significant difference between mean DOPI at one month and 9&12 months. group II showed that mean DOPI at one month was statistically significant with that recorded at 12 months only.
Comparing the intensity of recurred pigment between group I &II using MDV, it showed that mean MDV was higher in group I than that of group II along the follow up visits, with a significant difference between group I & group II at 3 & 6 months of the treatment phase. The follow up period at 9 &12 months showed that mean MDV decreased in both groups decreased by time without a significance difference between them, yet mean MDV value was higher in group I than that recorded in group II. In addition to that group II showed a significant difference in mean MDV between 1 &9 months which was not detected using DOPI.
The surface area of recurred pigment in both groups showed a gradual increase by time, meanwhile SA in group I was less than that in group II without a significant difference between them except at 3 & 12 months. Both groups showed that at 12 months the mean SA was significantly different from that recorded at baseline, being lesser at 12 months.
Histopathological assessment showed that both treatment modalities revealed a significant decrease in MAF at 6 & 12 months from baseline without a significant difference between them. On the other hand, after a year, calculated MAF in group I & II were significantly less than that of Control group.
After a year, comparing the recurred pigment intensity and surface area of group I&II patients to control group, it revealed that vitamin C either injectable or topically applied was effective in decreasing the intensity and area of recurred pigment in comparison to the control group. group I patients revealed that all clinical and histological assessed parameters were significantly less than that of the Control group. These observations highlighted the role of vitamin C in delaying the recurrence of gingival pigment, favoring injectable to the topically applied vitamin C.
Patients in both groups noticed marked cosmetic change at 6 months without a significant difference between them. On the other hand, there was a significant difference between both groups in number of patients who were ready to repeat the treatment if necessary. More patients in group II expressed their readiness to repeat the treatment if necessary than in group I.
The clinical assessment of recurred pigment showed that there was a gradual increase in pigment SA and intensity by time reflecting that recurrence is an inevitable process but it may be interfered with the adjunctive use of vitamin C either topically or injectable reflecting its pivotal role in inhibiting melanogenesis