A 21 year old female presented as a first time patient to the dental office. Her chief complaint was she was unhappy with smile, specifically the position of teeth #6, 10 and 27. Both upper and lower arches were severely crowded. Another dentist had suggested braces as the only treatment but the patient absolutely refused it as a treatment option. It was explained that orthodontics was the best treatment option, but not the only one.

For teeth #6 and 10, alternative treatment options to address the patient’s chief complaint were crowns, veneers or cosmetic bondings. All benefits and risks were explained. The patient’s finances limited her options to cosmetic bonding. Due to the labial flare of #6 and 10, sculpting (reshaping) the teeth would require removal of a significant amount of tooth structure. This would lead to nerve exposure so root canal therapy was strongly planned.

On the lower arch tooth #27 was completely lingually displaced from the arch. There was no room for this tooth in the arch, so the only reasonable non-orthodontic treatment option was extraction of #27. On the day of the extraction the patient was anesthetized with 3.6cc of lidocaine, and the extraction was completed by an Oral Surgeon without complication. A simple chromic suture was placed to allow soft tissue approximation and healing by primary intention. The 1 week re-evaluation showed the area of #27 had epithelialized over the wound and healed properly. Treatment of the remaining minor crowding in the mandibular arch was not desired by the patient.

At the next visit, prophylactic root canal therapy on # 6 and 10 was completed by the endodontist. Tooth #6 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 25mm, obturated with gutta percha and cement, and temporized. Tooth #10 was anesthetized with 1.7 cc Septocaine and isolated with rubber damn. Access was obtained, and the single canal found was instrumented to 22mm, obturated with gutta percha and cement, and temporized.

During the following visit, bonding and sculpting of #6 and 10 began. Tooth #6 was completed by an NYU senior dental student, and tooth #10 was completed by a Columbia University senior dental student. No anesthesia was necessary, as the teeth were root canal treated. The temporary fillings on the lingual of #6 and 10 from endodontic access was removed and replaced with a permanent composite filling. The lingual surfaces were roughened with a bur to allow for better retention. Next, the labial surface of the teeth were etched, bonded and MIDLF surfaces were built incrementally with Herculite bonding shade A1. The facial surfaces of the teeth were sculpted, bringing the teeth back into the arch. The occlusion was adjusted as needed. The patient was satisfied with the cosmetic results.

During a followup visit the patient requested a few cosmetic adjustments. The facial surface of #10 was etched, bonded and built up with Herculite bonding shade A4 followed by a external layer of XL2 bonding cover shade. The final contours were sculpted and the occlusion was adjusted. The patient was satisfied with cosmetic results.

After acclimating to the cosmetic bonding on #10, the patient scheduled another visit for cosmetic bleaching of the surrounding teeth. The teeth were isolated with a liquid dam to protect the gingival tissue. Two rounds of bleaching at 10 minute intervals on both upper and lower arches were completed. Patient informed that some white spots are normal and will resolve with time as the color of the teeth settles. Patient was satisfied with the color. Tooth #6 facial composite bonding was adjusted to improve color and give uniformity to the facial surface. Tooth #6 was reduced 1mm facially, etched, bonded and 1mm increments of XL2 composite were added on the facial; Bonding was sculpted and the occlusion adjusted. Patient was satisfied with cosmetic result.

The patient was encouraged to return for any other dental work needed, regarding the cosmetic bonding done, or any future treatment. She was advised to avoid hard foods on teeth #6 and #10. In the future if financially possible, she was encouraged to have porcelain crowns placed on #6 and #10. She was very happy with the final outcome and less timid about smiling and showing off her new teeth. Overall the treatment was delivered in a satisfactory and timely manner.

N.D., New York University College of Dentistry

Patient presented with multiple caries and restorations that needed treatment. When I arrived at the clinic, the dentist was just beginning to restore the patient’s heavily worn incisal/mesial edge of #9. His tooth was restored with a simple composite placed after etching (placing an etching gel for approximately 30 seconds, washing, and lightly air drying), priming, and bonding (priming and bonding with achieved with a single solution that was cured for about 20-30 seconds after placement). Composite chosen to match the patient’s tooth shade was A4.

After the composite restoration, the dentist proceeded to complete the TPS, evaluating each tooth and restoration for caries and defective restoration. Multiple defects were found in the patient’s dentition, but the patient decided to restore only the four of the defective restorations at this time. Furthermore, the patient was recommended to receive a bite guard in order to prevent supra-eruption (which Dr. Dorfman explained to the patient).

To address the proliferation of decay present throughout the patient’s dentition, the dentist discussed the effects of high sugar levels on the enamel, and the precautions that the patient could take in order to reduce detrimental effects of sugar on the teeth (ie. avoiding sugar, rinsing the mouth with water immediately after heavy sugar consumption). Next Visit: Patient has agreed to receive bonding treatment on the four teeth shown above as well as a bite guard.

H.C., Columbia University School of Dental Medicine

Patient presented with a chief complaint of severe pain on the upper right. There was a root canal and crown done on #2 in the past, so before examination it was thought that perhaps this tooth would be the culprit. However, the patient was quite specific in pointing out that the pain was coming from the cervical region of #3. A periapical radiograph was taken and it showed that there was neither pathology nor caries.

It was determined that the pain was probably due to abrasion from abrasive tooth brushing habits. The area was slightly abraded with a high speed, acid etched, bonded, and composite was placed.

The patient was told that initially there may be more sensitivity but that in a few days the pain should go away. Should the pain not go away it may warrant further exploration and possibly necessitate endodontic therapy.

N.S., New York University College of Dentistry

A 48 year old male patient presented for restoration of tooth #29 DO with composite. Patient had an amalgam filling in the tooth and according to a PA, there was a recurrent decay present around and on the gingival floor under the temporary filling.

I went in with a 1556 bur and removed the amalgam filling to assess the amount of decay present under it. I also removed the temporary filling to assess the remaining amount of decay. Under the amalgam there were a few spots where decay process had begun. Also, on the distal wall, there was extensive decay. After having reevaluated the PA that we had available for #29 to see the depth of the distal axial wall decay, we also became suspicious of the mesial side of #29 where we saw a radiolucency that could have been potential decay. In order not to come back to #29 later in the treatment process, we decided to take another bitewing centered on the mesial of #29.

R.F., New York University College of Dentistry, Patient 2

Today I was able to observe a tooth bonding procedure and do an in-office teeth bleaching. The first patient was a former model and she was quite fun to work with! She came in because she didn’t particularly like the appearance of her maxillary and mandibular anteriors and she also had a number of amalgam fillings with recurrent decay! When she smiled you could instantly notice the asymmetry in her smile was coming from her maxillary anteriors. The mandibular anteriors also were all inclined towards the mesial causing crowding. In the office, Dr.Dorfman did bondings on #10 and #4 because the patient noticed that she had some yellow staining on those teeth. Tooth number 10 had a bevel placed on it so that the B1 composite shade wouldn’t contrast with the actual shade of her teeth. The same shade was used on #4 and the patient was happy with the result of both bondings. The patient also had a number of class 3 restorations as well as a number of other concerns which will be addressed in her next visits. She also had enameloplasty performed on #8 and #11 because #8 was causing trauma to her lips every time she smiled and #11 was out of the occlusal plane and looked like a fang.

The patient has the option of getting invisalign to straighten out her mandibular anteriors and then having a retainer put in to maintain the shape. Even though she has the option of leaving her teeth as they are, most likely she will be paying a lot more attention to them since she noticed that many people who live around her, on Park Avenue, have so much money and don’t fix their teeth and she doesn’t understand why!

H.A., New York University College of Dentistry, Patient 6

My first patient today needed a bonding on tooth #2.

The patient presented with an occlusal sealant underlied by black staining and caries. The patient was anesthetized with carbocaine and the procedure was started. The cavity was excavated; and as I proceeded the cavity got deeper and deeper. The patient was informed that the decay is extensive and that there are also cavities on other teeth in the mouth as was seen in the x-ray. The patient however decided to wait for her insurance before she started her other restorations. 

The decay was excavated the bonding was completed. The bonding was redone due to a void on the distal of the restoration. Once the restoration was completed occlusion was checked and adjusted.

I have learned many things. There were a number of unexpected challenges; working in an unfamiliar operatory was a challenge for me despite having been on the clinic floor for over a year. Light curing, taking pictures, chair positioning, patient communication and hand pieces were all new to me and made the procedure much more challenging. I am used to finishing a bonding procedure in about 45 minutes, but it took me about 2.5 hours today and that was quite surprising. The tooth I was working on was the second molar and visibility, moisture control and drilling all became even harder and increased the amount of time it took me to complete the procedure.

H.A., New York University College of Dentistry, Patient 3