Today’s experiences encompassed the evaluation and editing of a complex treatment plan. The patient is a 57 year old female patient who is extremely phobic in the dental setting. Her past medical history includes smoking 1 pack per day, sinus problems, migraines, and dental phobia. Her chief complaint was that she wanted her top teeth fixed for her son’s wedding this upcoming summer.

The patient’s dental phobia is a major contributor in the execution of her dental care. Her dental phobia is so severe that she sent her husband to the first few visits to take care of the treatment planning instead of personally being there, and, due to past dental related trauma, when she is in the dental office she cries. She would like the treatment done all in one day and under IV sedation so that she can get it done as quickly and as painlessly as possible.

The patient would only like to focus on the upper arch at this time. She has #4-11, 13, and 14. She is missing #1-3, 12, 15, and 16. The patient has periodontal disease which could be classified as moderate to severe chronic generalized periodontitis, evidenced by photographs and radiographs. (Figure 1)

Figure 1. The moderate to severe chronic generalized periodontal disease is evident in this radiograph. Notice the low bone height on both the maxilla and the mandible.

Therefore, initial scaling and root planing of the upper arch is indicated. Although the patient also has the disease on the lower, the patient would only like to focus on the upper arch and the dentist would like to avoid any sensitivity on the lower arch. Because the patient is afraid of any possible pain from her dental work, endodontic therapy was suggested in all of the upper teeth to avoid the pain. On most of the teeth the endodontic therapy is not indicated for carious or disease related reasons, but primarily to avoid any post-operative pain.

After the periodontal and endodontic therapy is done, the planned restorations will be prepared and inserted. There will be crowns on #4, 5, 13, and 14 and there will be resin veneers on #6-11. The crowns will only be temporary since the patient would only like to come in for 1 visit. The temporaries will be placed under a condition that the patient will come back for final crown insertion within 6 months of this treatment. The veneers will be resin because the patient does not want to come back for another visit, which would be necessary if porcelain veneers were fabricated. The patient was informed that resin veneers are not as strong or long lasting as porcelain veneers.

In addition to the aesthetic work which will be done on the maxilla, there is also a concern of a red lesion on the hard palate. Since the patient smokes 1 pack per day, this puts her at a higher risk for oral cancer. The oral surgeon will examine and possibly biopsy the lesion during the visit. (Figure 2)

Figure 2.  The red lesion on the palate is of concern, especially since the patient is a smoker. An oral surgeon will examine and possibly biopsy the lesion.

All of this therapy will be done in one visit in order to comprehensively deal with the patient’s phobia of dentistry and pain. In addition, since the husband is the primary person involved in the treatment planning process, both the husband and the patient will sign the treatment plan, confirming that they both understand and agree to the treatment outlined.

Lateral, front, and occlusal views of the maxilla before treatment.

N.S., New York University College of Dentistry

Today I observed a cementation of a gold post and core of tooth #7, a shoulder preparation, fabrication of a temporary pre-fabricated crown, final impression technique of the prepped tooth, and then observed the temporary cementation of the #7 pre-fab crown.  

Patient presented with a past root canal treatment done on #7, but had recently fallen, hitting her front teeth, especially # 7 and #8.  She was seen by an Oral Surgeon to make sure that there was no bone or facial fracture and was given a splint to keep her anterior teeth intact. 

I learned that there are different treatment options for this patient.  She could have extracted #7 and placed an implant, or extracted #7 and make a 3 unit bridge from #6 to #8, or do ortho to recline #7 and then prep it to make a PFM crown or an all ceramic crown.  Since the patient fell and could have fractured her root or crown of #7, ortho tx to move tooth would cause more fractures, so the prognosis would be poor; therefore, ortho treatment before crown prep would not be a treatment option.  

The observation first began by opening up the access of #7 by removing the temp filling with a bur. Then the gold post and core of #7 was inserted. The post was refined with a bur, then it was checked with occlude spray to observe for pressure/tight areas. Once the post and core fit adequately, then it was permanently cemented which took 12 minutes to cement.  Then a shoulder prep was done with a bur, made the margins clear and checked to see if the prep was tapered and not labially reduced, in another words made the prep slightly more lingual on the facial side.  Then I observed the selection process of a pre-fab #7 crown.  Once the pre-fab crown was chosen, the margins were reduced to make it fit the prepped tooth.  A mixture of monomer and acrylic was made and poured into the pre-fab crown, and then the crown was placed into the prepared tooth to get the internal fit of the pre-fab crown.  Then, the excess was removed around the margins.   

After that, I observed the final impression of #7 prepped tooth.   Since the patient has existing porcelain veneers on her anterior teeth, it’s a good technique to put Vaseline on the veneers and to block out the embrasures with wax, so that when the impression is taken and then removed, there is no chance of her other porcelain veneers coming out.  I learned how to analyze an impression to see if the margins came out or not.  I observed the selection of the final shade of the porcelain crown which was B1. A Polaroid film was taken, so that the lab could match the correct shade. Then, the pre-fab temp crown was refined with a mixture of monomer and acrylic and the excess was removed with a bur.  Finally, once the fit was adequate, then the pre-fab temp crown was cemented with temporary cement.  I also observed the bite registration technique; the registration of the anterior incisors where taken so that the lab has the patient’s occlusion which helps with the fabrication of the porcelain crown.  Then the lower anterior incisal impression was taken with alginate, so that the lab could pour up a lower anterior cast as a guide to make the porcelain crown and check the occlusion. 

In conclusion, today’s observation was a great learning experience.  I learned that we should never put Vaseline on the prepped tooth to get the internal fit of the pre-fab crown because it could contaminate the cements.  Also, I learned that it’s more efficient to fabricate the temp crown before taking the final impression of the prepped tooth. 

G.Y., New York University College of Dentistry, Observation 1

Last Monday was a very educational and rewarding experience. I observed many procedures done by different specialists.

The first one that I participated in was Phase I Therapy of single implant placement on a middle-aged male patient. The surgery was done by an oral surgeon. He used an approach of first creating a flap to help visualize the path of implant insertion. I asked him afterwards whether there was a specific reason that he created a flap first instead of directly “drilling into bone”, and he said there wasn’t, except for the fact as I mentioned to enhance visibility (good reason for me if it means implant will be placed correctly). I was able to see on the x-ray the alignment of the placed implant, and according to my still limited knowledge, it was excellently positioned.

The treatment of the same patient was continued by the general dentist who cemented a temporary bridge in area where implant was placed.

In another treatment, the endodontist performed a root canal therapy on the mandibular molar of another patient. She demonstrated the lateral condensation technique when obturating all 3 canals. This time I saw her using an apex locator, a great device which as she explained showed her the apex both radiographically and clinically. She told me that it is the best to stay within 0.5 mm around the apex when placing master cone with the cement, because that will prevent excessive widening of the apex and perforation of the canal. Upon completion of the RCT I saw the final radiograph, which again showed a very successful end result.

After RCT, the patient was transferred to a different room, where the treatment continued with the core buildup and crown prep done by the general dentist. The patient did not need post and core placements because there was enough tooth structure to ensure longevity of the fixed restoration with the composite core. The finish line of the crown prep was a combination of shoulder with bevel and chamfer, done as such to avoid unnecessary compromise of the tooth structure. After the final impression and shade selection, a temporary crown (constructed at the chair-side via “block technique”) was cemented and patient was dismissed.

Throughout the entire time, what was most apparent in the office was the nature of the comprehensive and personalized treatment, excellent pain control and sensitivity to patient’s comfort. Interaction between Doctor and Patient was constant and conducted in comfortable yet respectful manner. The pain control was done not only during the procedure but also after the visit; because at the end of the treatment Dr Dorfman made sure the patient received post-op instructions and pain medication.

E.T., New York University College of Dentistry, Observation