A 32 year old Caucasian male presented with the chief complaint, “I want to fix my smile.” The patient complained of hot and cold sensitivity as well as swollen, bleeding gums after brushing.

Past Medical History: The patient is not on any medication and has no known allergies to food or medications. The patient also denied using any illicit drugs.

This patient had very limited funds to have his mouth fully rehabilitated. However, several treatment options were discussed with the patient which include:

# Extraction of the non restorable teeth
# Root canal therapy, cast gold post and core with final crown restoration of restorable teeth
# Composite restorations
# Crowns and bridges

However, the patient could not afford the treatment options provided. Based on this, a maxillary round-house provisional restoration was agreed upon. This was treatment planned; however the poor prognosis of some teeth was largely noted. The patient was solely concerned about his esthetic look, hence requested that only the maxillary arch be treated. Appropriate consent forms and treatment plans were signed prior to any rendered treatment.

Treatment Procedure
A maxillary local infiltration with Carbocaine was performed. Extraction of teeth #s 2, 5, 12 and 15 was also performed and hemostasis was achieved through the placement of sutures.

Peripheral wax was adapted over the maxillary arch area where the patient had worn-out teeth. An upper alginate impression was taken to serve as a matrix for the provisional restorations. Gross crown preparation reductions were done on all existing maxillary teeth with the exception of tooth #4 and #13 which were used to achieve occlusal stops to maintain the patient’s vertical dimension of occlusion.

With the use of the previously taken alginate impression matrix, Luxatemp was used as the temporary restorative material. This was injected into the alginate matrix and then re-seated on top of the prepared teeth. The temporary round-house restoration was taken out of the patient’s mouth and was trimmed and recontoured to proper shapes and sizes. It was then tried-in and final adjustments were made for the margins and contour. The occlusion was checked and then cemented temporarily into patient’s mouth. The patient was pleased with the work completed. From start to finish, the entire treatment procedure took approximately two hours.

Although, this was not the most beneficiary dental procedure that could have been rendered, considering the patient’s limited finances and his desire to look esthetically presentable, this was the best treatment that could have been provided at that moment. The patient was well informed about possible sensitivity following this treatment as well poor long term prognosis of some existing teeth.

Another option for treatment could have been extraction of all maxillary teeth and subsequent fabrication of an upper maxillary complete denture. The denture could have been implant supported to enhance stability and function of the denture. But this would have cost much more money that the patient could not afford.

Apart from rendering quality care to patients like this, a thorough dental and social history should be elicited from patients so that the etiology or possible risk factors causing such rampant nature of the disease be identified and addressed. This constitutes part of the treatment options. If this is not addressed, no matter the treatment rendered, it will surely fail. Good oral hygiene instructions should be given and frequent recall appointments given to such patients.

O.O., New York University College of Dentistry

Before any dental treatment is commenced in this office, various treatment alternatives are presented to a patient with accompanying merits and demerits as well as long term prognosis of each of the treatment plans discussed. It is then left to the patient to decide which he or she prefers based on his or her financial state or medical/health related reasons. In some cases, the office may give a courtesy discount to the patient or render some of the treatments absolutely free especially if they are going to be treated by dental students under close supervision. If all is agreed upon, the patient is asked to sign the treatment plan as well as a consent form authorizing commencement of treatment.

A middle-age male patient presents to the practice with a fractured broken distobuccal cusp of tooth #18. The tooth has been previously restored with an occlusal amalgam dental filling many years ago. The patient complained of tooth pain sensitivity to cold drinks which was transient and disappeared on removal of the stimulus.

Past Medical History – Patient has a history of Asthma. An episode of Epilepsy occurred about 20 years ago.
Drug History –Ventolin, Advair and Theodur
Social History – Patient currently uses tobacco and is a social drinker - his head and neck were within normal limits during an oral cancer screening.

A periapical x-ray of tooth #18 revealed a slight radiolucency underneath the distal portion of the existing silver filling restoration. All other findings were within normal limits radiographically. Clinically, there was a distal marginal ridge and part of the distobuccal cusp fracture. Treatment options for this tooth included removing the old amalgam restoration, examining and re-evaluating it to see, if it could be re-restored with a filling. The patient was also informed that the tooth might need root canal therapy and final dental crown restoration. This was explained to the patient and all questions were entertained and answered by Dr. Dorfman. This constitutes part of the treatment plan and consent and was signed accordingly.

I was instructed by Dr. Dorfman to remove the amalgam filling, which I did. Following removal of the amalgam, it was confirmed that there wasn’t enough tooth structure left, the little left was unsupported. The patient agreed to placement of a dental crown as previously discussed. A little recurrent tooth decay was found clinically and this was removed. With these findings, the tooth wasn’t a good candidate for a regular restoration tooth bonding dental filling.

A supragingival circumferential shoulder preparation was performed as well as an adequate occlusal reduction. The purpose of the supragingival preparation was to enhance patient’s ability to keep the crown margins clean since this was a non esthetic zone. For aesthetic zones like the maxillary anterior teeth, an infragingival preparation would be ideal but bearing in mind not to violate the biological width. This can cause periodontal complications like gingival recession that would further make it non esthetic.

To also enhance retention on the preparation a small groove was created on the buccal aspect of the tooth. Final impressions included using impregum on a full arch tray, an alginate counter model impression of the maxillary arch, and a bite registration so an excellent occlusal contact can be achieved following the final fabrication of the crown by the dental laboratory. Another way to take a final impression is through the use of a triple tray but this was not used here since the prepared tooth was the most distal in the dental arch. Tooth shade selection was also performed.

A provisional tooth was created with an acrylic resin using the block technique. In doing this, acrylic resin is mixed until it reaches the dough stage. This is then adapted to the prepared tooth and the patient is asked to close on it in the centric occlusion. This is taken out and re-seated continuously so as to record the margins of the preparation. It is then trimmed into the shape of a tooth and possibly relined to get better marginal fit. Contacts and occlusion are also checked and finally cemented using temporary cement.

Two weeks later, a finished PFM dental crown was returned from the dental laboratory. This was shown to the patient before cementation. The temporary dental crown was removed using a crown remover and the temporary cement was cleaned out from the prepared tooth. The permanent crown had a Kaitlyn loop attached to the lingual metal collar onto which dental floss was attached to prevent possible aspiration during try-in. Crown try-in was done in the mouth. Contact was checked first followed by a check of the margins. A periapical X-ray was taken to see the interproximal margins and fit. The crown was removed and prepared tooth’s surface and was ready for permanent cementation. In this office, Rely-X cement is used. This comes as a powder and liquid which allows the doctor to create a preferred consistency. This is mixed on a mixing pad until the proper consistency is created. It is highly recommended that tooth is dried and isolated using cotton rolls and gauze. A small amount of Vaseline is applied to the outside of the crown to prevent the dental cement from adhering to the porcelain tooth crown.

The cement was applied to the internal surface of the crown and sat gently over the prepared tooth. The patient was then asked to bite on cotton roll placed on the occlusal surface of the crown to allow for adequate seating for about 10-12 minutes. All excess dental cement was removed from the margins. The occlusion was checked and the lingual floss holding loop was removed using a high speed with a diamond bur.

O.O, New York University College of Dentistry