Case C
A 40 year old male patient presents with fractured incisal edges and anterior maxillary spacing. The patient is concerned about his appearance and hence presented to explore possible treatment options to address his chief complaint.

Past Medical History: None Contributory. The patient is not on any medication nor does he have any known drug allergies.  A radiograph was taken to evaluate periodontal health which was within normal limits.

Possible treatment options to address this issue include:

• • Veneers from Teeth # 7-10
  • Anterior ceramic crowns from teeth #7-10

It was agreed upon that veneers, rather than ceramic crowns, would be used to treat his condition. This is usually a more conservative option since very little tooth structure is actually removed.  Additionally, it is usually more aesthetically pleasing.

In the preparation, a 0.5 mm reduction is performed on the facial surface while a 1-1.5 mm reduction is performed on the incisal surface. The finishing margin is usually a 0.5 mm supragingival chamfer. The preparation is done under local anesthetic infiltration. It is recommended a matrix is fabricated prior to the preparation which will be used for making the temporary veneers.

Final impressions were taken using impregum and a counter model impression taken in alginate. This was sent to the laboratory for the veneer fabrication. The temporary veneers were made with Luxatemp using the impression matrix originally taken. Following their return from the dental lab, the veneers were ready to be cemented.

The temporary veneers were removed from the preparations and the teeth were polished using pumice without fluoride and rinsed with water. The veneers were tried-in to evaluate their fit. They were etched using hydrofluoric acid for about a minute and silane coupling agent painted on them and allowed to air dry. The prepared teeth were also etched using phosphoric acid for 15-20 seconds, rinsed with water and air dried. Bonding agent was applied to the etched surface and cured. The veneers were then cemented permanently and excess cement was removed from the margins and finished using finishing strips and finishing burs. The patient’s occlusion was checked and slight adjustments were made. Post-operative instructions were provided and the patient was delighted with the result.

Maintenance of good oral hygiene is of great value for any restoration.
This would involve frequent flossing and brushing using the correct technique.  The patient should therefore be aware of this in order to have a long lasting restoration.

Miscellaneous
One very challenging aspect of using composite restorative material in restoring class II lesions is establishing contact with this material. This elective program has helped me learn techniques to avoid this problem. This will be discussed as follows:

• • The preparation of a class II lesion is made
  • The matrix band is put in place and secured
  • The tooth is pre-wedged to cause slight separation between teeth
  • Cavity is etched with phosphoric acid, rinsed and dried
  • A bonding agent is applied to cavity walls and cured for 15 seconds
  • Matrix band is slightly loosened and burnished against the adjacent tooth.
  • Bisfil (an unfilled resin) is injected into the proximal box and left uncured
  • Composite beads (small round composites that have been pre-cured) are placed into the proximal box with the uncured bisfil
  • Using a plastic instrument, the composite bead is pushed into the proximal box and against the adjacent tooth.  This is then cured using the curing light.
  • Then, the remainder of the preparation is filled incrementally, curing after each increment. The final restoration is adjusted and polished

Such restorations restored in this manner usually have a very tight contact. This helps prevent food packing into the interproximal space that may give rise to recurrent decay.

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

I have many a times seen Dr. Dorfman patiently listen to the patient, while the patient is designing the shape of the porcelain crown for his anterior tooth on a piece of paper.

If a patient feels any pain during a procedure the treatment is stopped until all pain sensation is gone.  Patients will also be given control over the treatments they would like to get done during the visit. If a patient wants to have his teeth cleaned in two short appointments, he will be allowed to do so respectfully.

Dr. Dorfman suggests to wipe the area to be injected gently and apply the topical anesthetic on the dry tissue for 2 minutes.  If we need to work on the anterior tooth, he suggests to start injecting slightly posterior to the tooth, as the anterior area in the mouth is much more painful compared to the posterior area.  Carbocaine is used most of the times as its short acting.  Sometimes a combination of lidocaine and carbocaine is used to achieve effective anesthesia. After depositing the solution posterior to the tooth, slowly moving anteriorly through the deposited area, would tremendously help in achieving painless anesthesia for the anterior tooth.

The Gow-Gates block technique –

The Gow gates has many advantages over traditional Inferior Alveolar Nerve block. The path the needle traverses during a Gow Gates block technique contains much less muscle tissue than is traversed by the needle in a Inferior Alveolar  block, and thus there is little release of bradykinins which are the chemicals which cause the aching that patients feel when receiving a mandibular block.  Furthermore, the tissue through which the needle passes contains no nerve receptors, and thus there is little direct pain during the injection.  Patients usually remark that they felt no pain during the injection.

The area where the Gow-Gates is delivered is less vascularized than the area adjacent to the location of injection in a standard mandibular block.  Studies indicate that there is an 89-90% lower likelihood of giving an intra-vascular injection using this technique. In addition, because of the lower vascularization in the area, the anesthesia is less rapidly absorbed into adjacent blood vessels prolonging the presence of the anesthesia in the area, which means that mepivicaine without vasoconstrictor may be used to greater and longer lasting effect using the Gow-Gates.  Some users of this technique recommend that no vasoconstrictor be used at all.  The Gow-Gates technique anesthetizes the nerve trunk before it splits into its three main branches; the lingual branch, the buccal branch and the alveolar branch.  Thus a single shot does the work of three separate injections.

The success rate of the inferior alveolar nerve block is lower than for most other nerve blocks. Because of anatomical considerations in the mandible (primarily the density of bone), the administrator must accurately deposit local anesthetic solution to within 1 mm of the target nerve. The inferior alveolar nerve block has a significantly lower success rate because of two factors—(1) anatomical variation in the height of the mandibular foramen on the lingual side of the ramus and (2) the greater depth of soft-tissue penetration necessary—that consistently lead to greater inaccuracy. To achieve anesthesia of the mandibular molars, however, the inferior alveolar nerve must be anesthetized, and this frequently entails (with all its attendant disadvantages) a lower incidence of successful anesthesia. (Malamed, Stanley. Handbook of Local Anesthesia, 5th Edition. Mosby, 072004. 14).

The Gow-Gates mandibular nerve block is a true mandibular block injection because it provides regional anesthesia to virtually all the sensory branches of V3. In fact, the Gow-Gates may be thought of as a high inferior alveolar nerve block. When used, two beneficial effects are noted: (1) the problems associated with anatomical variations in the height of the mandibular foramen are obviated and (2) anesthesia of the other sensory branches of V3 (e.g., the lingual, buccal, and mylohyoid nerves) is usually obtained along with that of the inferior alveolar nerve. With proper adherence to protocol (and experience using this technique), a success rate in excess of 95% can be achieved. (Malamed, Stanley. Handbook of Local Anesthesia, 5th Edition. Mosby, 072004. 14).

S.S., NYU 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

Local Anesthesia and Nitrous dental sedation
Each operatory of the dental office is capable of supporting nitrous oxide (laughing gas) dental sedation.  There are many benefits and few risks of using nitrous oxide. The gas is administered through a comfortable mask placed over the nose, and the patient is instructed to inhale in through the nose and exhale through the mouth. As a precaution, patients should not eat anything for about two hours prior to use of the gas. The patient begins to feel a pleasant level of sedation anywhere from 30 seconds to three or four minutes after initial administration. After the gas has been adjusted to the appropriate dose and the patient is relaxed, the dentist can comfortably give the injection (if needed) to the patient, and then proceed with normal dental treatment. After the treatment is completed, the patient is given pure oxygen (100%) to breathe for about five minutes, and all the effects of sedation are usually reversed. Unlike IV sedation or general anesthesia, the patient can almost always leave the office by themselves, without an escort.

Nitrous oxide has few side effects. High doses can cause nausea in some patients. Patients that are claustrophobic or have blocked nasal passages cannot use nitrous oxide effectively. Nitrous oxide is one of the safest anesthetics available. Interestingly, it is also routinely used by anesthesiologists for general anesthesia in combination with other more potent gases.

Dentists find nitrous oxide especially useful for fearful patients as well as young children. The effect of nitrous oxide is often remarkable. A patient that was once anxious will become relaxed and calm. Since nitrous oxide is so effective, dentists rarely need to prescribe Valium for anxious patients before treatment. It works wonders!

Local Anesthetics/ Needles
The type of dental needle that is mainly used here is the “blue colored” needle which is a 30G needle and is relatively short in length. According to Dr. Dorfman, it causes less discomfort to the patient while delivering local anesthesia. However, before any needle injection to patient, a topical anesthetic gel is applied on the area to be injected. This helps to block the free nerve endings on the mucosa to be injected and patient feels little or no pain. It should also be emphasized at this point that the clinical skill of the practitioner in rendering a pain free dental procedure shouldn’t be undermined. I find Dr. Dorfman skilled at this as well.

Carbocaine, which contains no vasoconstrictors like epinephrine, is most often used at Dr. Dorfman’s practice. As such, the risks of medical emergencies are minimized to the barest minimum. Though rarely used. lidocaine may be supplemented at times.

Local infiltration
Most infiltrations are given in the maxillary quadrant. Sometimes, the mandibular quadrant can be used as an adjunct to a block.  If Dr. Dorfman is to perform a dental procedure on a maxillary anterior area of the mouth, he starts giving his injection from the premolar area at the mucobuccal fold and moves medially towards the midline while giving little time interval between injections. According to Dr. Dorfman, the area around the premolar is usually less of a discomfort to the patient during injection of local anesthetic. For the maxillary posterior, the anesthesia is given just towards the apex of the tooth in question in the mucobuccal fold area.
Mandibular Block
Dr. Dorfman prefers to use the “Gow-Gates Technique” for mandibular block injection.

Gow and Gates Technique
Fortunately, an Australian dentist named Dr. George A.E. Gow-Gates invented an alternative to the standard mandibular block in the mid 1970′s.  This block is appropriately named the Gow-Gates and is delivered towards the neck of the condyle just under the insertion of the lateral pterygoid muscle.  The Gow-Gates has a number of advantages over its more conventional alternative.

• Unlike the mandibular block, the path the needle traverses contains much less muscle tissue than is traversed by the needle in a conventional mandibular block. Thus there is little release of bradykinins, which are the chemicals which cause the aching that patients feel when receiving a mandibular block.  Furthermore, the tissue through which the needle passes contains no nerve receptors, and thus there is little direct pain during the injection.  It is not uncommon for patients to remark that they felt nothing during the injection.
• The area where the Gow-Gates is delivered is less vascularized than the area adjacent to the location of injection in a standard mandibular block.  Studies indicate that there is an 89-90% lower likelihood of giving an intra-vascular injection using this technique.  In addition, because of the lower vascularization in the area, the anesthesia is less rapidly absorbed into adjacent blood vessels prolonging the presence of the anesthesia in the area, which means that mepivicaine without vasoconstrictor (Carbocaine) may be used to greater and longer lasting effect using the Gow-Gates.
• Finally, the Gow-Gates anesthetizes the nerve trunk before it splits into its three main branches; the lingual branch, the buccal branch and the alveolar branch.  Hence the Gow Gates delivers three shots in one.  A single shot does the work of three separate injections.

Technique:
The tragus is a useful landmark since it lies just distal to the temporomandibular joint.  The little notch just below it is called the intertragal notch.  The intertragal notch is the landmark that is used as the “aiming point” of the needle when giving the Gow-Gates injection. The patient opens his/her mouth as wide as possible.

This technique is not possible if the patient is not able to open wide enough to allow the condyles to translate fully over the articular eminence. Place your thumb in the patient’s mouth retracting the cheek. Instructions to appropriately perform the technique are as follows:

1. Place the middle finger of the same hand over the intertragal notch. Allow the needle to enter the buccal mucosa just distal and apical to the tuberosity.
2. Now aim the tip of the needle toward the the intertragal notch. Keeping the middle finger in this position, and using it as the aiming point makes giving the Gow-Gates block easy and predictable.
3. Proceed until the needle hits bone.  The needle will enter about two-thirds to three-quarters of its length before hitting bone.  If the needle does not hit bone, then you have missed the target and should withdraw and try again, aiming slightly laterally, or medially.  Then deposit the anesthetic solution slowly.

My first encounter with The Center for Special Dentistry was in February of 2009 when I interviewed for this elective program. Something fascinating I first noticed was the cleanliness and general organization of Dr. Dorfman’s premium private practice. It has five dental operatories that are well equipped with state of the art equipment including two flat screen monitors and computers which support Dentrix software, intra-oral and extra-oral cameras, modern dental chairs, fiberoptic light illuminated hand-pieces to enhance vision in work-field areas, etc. The software allows dentists to effectively enter and store patients’ information including treatments discussed and provided, digital x-rays, photos, and clinical notes.  Also present are central dental laboratories where impressions are poured up and stored, a central sterilization unit that uses an autoclave machine and a pre-wash machine for used instruments, a dining area, and an audio vision recording system.

The office is also equipped with well trained staff members who work together as a team for the delivery of premium dental health care. Different dental specialists compromising of orthodontists, periodontists, oral surgeons, and endodontists practice here on certain days of the week.  Dr. Dorfman, the Director of the Center for Special Dentistry, mainly focuses on Cosmetic and Reconstructive Dentistry. This becomes necessary when there is need for a multidisciplinary approach in the rendering of health care services to patients who have such needs.

Patients
One interesting aspect I noticed about the practice is that a large portion of the patients have a phobia of dentistry. This may have been due to negative prior dental experiences or a pre-informed notion from individuals who have had poor experiences with their dental care in the past. It becomes necessary for the dental practitioner to accommodate all these challenges for the effective delivery of care.  I highly respect Dr. Dorfman for his flawless choice of words and his ability to condescend to varying personalities of the patients he sees on a daily basis. Simply put, I would refer to him as someone who gives excellent “Verbal Sedation.”

Furthermore, the manner in which new patients are welcomed warmly into the practice is another thing that amazes me. With the aid of a security camera, Dr. Dorfman is able to see every patient who enters the practice from his office. Regardless of what he was doing at the time, he stops his work and enters the waiting area to greet the patient in a friendly manner and may sometimes even make a good joke.  This is actually geared towards creating an enabling environment to receive premium dental care as well as calming the patients since most are phobic.

O.O., NYU College of Dentistry

This patient was a male in his mid-thirties with no significant medical history. Intra-oral and extra-oral exams were all within normal limits. When he presented into the office, his chief complaint was “My crown fell off.” Patient had PFM crown on #18 that was not retentive due to the lack of core tooth structure. He had this crown redone many times and the treatment would always fail since there was not enough physical tooth structure present. In addition, as observed in the photographs, the core build-up and prep was inadequate. The tooth was previously endodontically treated in another office.

As apparent in the periapical film of tooth #18, the RCT is satisfactory because the gutta percha filling material ends at the apex and there is no evidence of periapical pathology. In addition, there is sufficient amount of alveolar bone present to warrant restoration of the tooth. The patient agreed to the treatment plan of a gold cast post and core and a PFM crown. The purpose of the cast gold post and core is to retain the crown. Upon cautiously removing the old composite core, being careful not to pierce the pulp chamber, there were 4 canal orifices filled with gutta percha.

After the preparation for cast post and removal of gutta percha from distal buccal canal, a cast post impression was taken with impregum light and heavy body with the parapost system.  This allows for the hydrophilic impression material to flow into the canal while being stabilized by a plastic post to create an accurate pattern for the gold post. The canal was irrigated with sodium hypochlorite to reduce the likelihood of bacterial contamination and sealed with cotton and cavit until the next visit.

A 14 carat gold post with Kaitlyn loop (floss was threaded through during try-in to prevent swallowing or aspiration of the cast post) was created and ready for try-in and cementation. The post was cemented with powder and liquid Rely-X cement.

After post cementation, the final crown prep was refined with a chamfer margin design. Minor periodontal surgery was performed around the crown margin. In order to increase the retention of the new crown, a crown lengthening procedure was performed. An acrylic temporary was fabricated using the block technique. The temporary crown was cemented with Temp-Bond cement.

It was important to create a temporary that had a good anatomical contour and did not have any marginal deficiencies. Otherwise, the healing gingiva can grow over the margins, preventing proper seating of the final crown.The Final crown ready for cementation was created with a Kaitlyn loop attached to prevent aspiration or swallowing ligated with dental floss.

Crown try-in was followed up with a bitewing radiograph to confirm seating and marginal fit. There were no open margins in the radiograph and the crown was approved for final cementation. In addition, occlusion was also checked with articulating paper and adjusted prior and after final cementation.  Rely-X Cement was used for the final cementation of the PFM crown. The color and fit were confirmed with patient prior to cementation.

After cementation, the Kaitlyn loop was removed with a diamond bur.  Oral hygiene and proper home care instructions were reviewed with the patient. In completing this case, I learned about certain issues that a patient can present with when a fixed restoration fails. In this case, the tooth was able to be restored and the patient was confident that he would receive proper care at The Center For Special Dentistry, even though he had this particular crown replaced a number of times and they have all failed. The patient was told the reasons why this treatment was failing and the proper sequence of procedures that he would need to have in order to retain a new crown. Once he understood, he was more than happy to commit to the treatment plan.

L.R., New York University College of Dentistry

Patient Case:
A 38 year old female presents to The Center for Special Dentistry with CC:”I Need Consultations for multiple problems.” To the question of “How do you feel about your smile” patient responds: “Terrible”. Patient reports that her last dental visit was approximately one month ago and resulted in the extraction of one of the teeth on the lower right.

Relative dental history: Patient reports bleeding gums during flossing and brushing, sensitivity to hot, cold and sweet, food particles getting stuck between her teeth when she eats, occasional neck pains, popping, clicking sounds, and discomfort of the jaw. Patient lives in an area with fluoridated water supply but occasionally (weekly) uses bottled or filtered water. She denies any past periodontal or orthodontic treatments. Related Medical history: NSF

Social history: Smokes three cigarettes a day
Patient does not appear to be phobic but reports past negative experiences in the dental offices. Her long term dentist experience has involved repeated failures of dentistry and she is about to give up. At her previous dentist, patient was told she only had two cavities and no gum disease. As with most of the patients at The Center for Special Dentistry, this patient was evaluated by several specialists:

Oral Surgery Consult:
Evaluated Teeth #13,14. Tooth #13 has a root fracture and is non-restorable. Tooth #14 has buccal furcation and a possible fracture, therefore suggest extraction of tooth. Tooth #4 appears stable and no surgical treatment indicated at this time. Similarly, teeth # 20, 29 are stable and no oral surgery treatment indicated.

Endodontic consult:
Teeth #13 and #14 need extraction (as above). Tooth #4 will need RCT re-treatment at the appropriate time of treatment (it is asymptomatic for now, but patient understands if that changes it may need treatment sooner), #20 is vital and normal, #29 and #31 are vital and normal.

Orthodontic consult:
Treatment plan objective: correcting cross-bite with canines and alleviate anterior crowding. Level and align, and midline correction. Retention with removable retainer (Approximately 15 months). Limitations of treatment with posterior stops and anchorage (w/o implants).
My involvement with the patient consisted of restoring carious lesions in teeth # 10, 11, 21 and fabricating provisional restoration #5 to be attached to the orthodontic braces.
I met the patient and we discussed the treatment plan and my involvement with this treatment. Patient agreed to what we talked about and we scheduled the next appointment.

Second visit:
We started the session with reiteration of previous visit and I answered questions that the patient had regarding future treatment. Procedural phase of the visit started with administration of local anesthetic 2 carpules carbocaine MN block & 1/2 carpules of 2%lido w/ 1:100000 epi infiltration. I excavated # 10-DL and #11-DL. After excavation of carious lesions bonding agent and composite was placed. We used C2 shade to replace excavated dentine and C1 for the enamel. After placement composite was adjusted and polished. We managed to achieve very good color matching. After seeing the final result patient was very satisfied. We went over home care and patient was given oral hygiene instructions. Before the third visit I fabricated acrylic provisional to be attached to the orthodontic braces.

Third visit:
Reviewed past therapy, enquired if patient had any discomfort associated with previous treatment. Patient voiced her satisfaction with restorations and treatment in general and did not report any post operative discomfort.
Operative part of the treatment started with administration of local anesthetic. While the patient was getting anesthetized we tried in previously fabricated pontic. We did a minor occlusion adjustment, patient was very satisfied with the esthetics of the provisional. We excavated #29 DO and separate 29 O. Restored with C2 composite dentine shade, and C1 enamel shade. After adjusting and polishing composite, patient was shown the before and after images. As with the previous restorations we managed to get a very good shade matching so the restorations were indistinguishable from natural tooth structure. She was very satisfied with the final result. We went over the Oral Hygiene Instructions. At this point patient is ready for the orthodontic treatment.

Special points learned during treatment of this patient:
Management of a patient who was very dissatisfied with her previous treatment. Performing minimum invasive dentistry on severely misaligned teeth. Fabricating provisional to be attached to the orthodontic brackets and to do so using different shades to get excellent color matching.
–I.E., New York University College of Dentistry

I have learned a few techniques which help perform dentistry on fearful patients.

Dr. Dorfman taught us how important it is to get a good rapport with the patient, in reducing the anxiety of the patient. I have learned that when the patient trusts the dentist, he will be more relaxed and will be less fearful. The doctor starts the conversation after knowing their background and work place, and talks to them informally to ease them.  He becomes friends with the patient and gains their confidence before starting the dental treatment.

I have seen the doctor devote most of his time listening to concerns and exploring patient interests.  Discussing the patient’s concerns early on and demonstrating real interest in their life and how their situation might impact treatment, would dramatically affect the dentist-patient relationship.

Competent yet caring professional is best for the fearful patient. I have seen Dr. Dorfman communicate concern verbally and non-verbally.  I have seen him approach every patient in the center, getting treated with a hygienist or a specialist, to reassure about their comfort.  Expressing caring through humor can be useful in lifting patients’ spirits and providing distraction

Dr. Dorfman believes that the patient’s fear can be reduced by giving them control over the dental environment and by reducing or eliminating pain both during and after dental procedures.  He taught us that a physically strong athlete or successful executive might have become used to exerting a certain level of control over their environment.

These people have the most difficulty giving up control and therefore experience the most fear of dentistry.  At the Center for Special Dentistry, the doctor gives them control over what he does, when he does it, how he does it, what it will look like and how it will function.

S.S., New York University College of Dentistry

This week a patient presented that had 4 maxillary canines (instead of 2).
These 2 extra canines are supernumerary teeth (and are very rare). Also one
of her maxillary central incisors (tooth#9) what completely impacted. She
was also in a crossbite. The patient is concerned about her smile, and wants
an esthetic makeover. This is a multidisciplinary case which involved the
consultations of a periodontist (to make sure the gums are in good health
for dental work), an orthodontist (to advise which teeth to extract or keep,
or to extrude the impacted central incisor, and to move the teeth around for
proper alignment and occlusion, an oral surgeon (to safely and
atraumatically extract the impacted, and supernumerary teeth), and finally a
general dentist (to veneer or crown the anterior teeth to give the anterior
teeth the proper size, shapes, and proportions for an esthetic appearance.

There was another patient who presented with a painful feeling and that one
side of her mandible is heaver than the other. Upon taking a panoramic
radiograph had a radiolucency on her mandible. After a thorough clinical
examination by the oral surgeon, the patient was referred to get a CT-scan
for better images and borders to of the lesion. After looking at the CT-scan
the oral surgeon decided to biopsy the lesion. He opened a flap with 2
releasing incisions, to find that the buccal plate of the mandible had
resorbed, and the lesion extended interproximally between 2 of the teeth. An
excisional biopsy was taken and sent to a oral pathology lab for further
investigation. The patient was sutured and scheduled for follow-up.