Patient presented for emergency visit at Dr. Dorfman’s office with a broken filling on tooth #20.  Patient did not complain of any pain or swelling.  Tooth #20 was badly decayed and the only option other than extraction was to perform Root Canal Therapy, crown lengthening, gold post and core, and a porcelain crown. The patient decided to save his tooth and we began work immediately.

Root canal therapy was performed by the endodontist. Right after RCT the patient saw the periodontist for a crown lengthening procedure. After the procedure, healing dressing was placed and patient was scheduled for a recall. After 1 week the dressing was removed and I began preparing the tooth for a post and core. I took a final impression with Impergum in a triple-tray for fabrication of a gold post and core to fit the tooth.Three weeks after healing, and after making sure that the crown margins would not be exposed, preparation margins were defined for a porcelain-fused-metal (PFM) crown with a chamfer finish and the final impression for a crown was taken. Together, we chose a color shade and  I wrote a lab prescription.

In the final appointment the crown was cemented with the glass ionomer cement. The patient was extremely happy with the outcome of this treatment. The patient was also made aware of other dental needs and decided to take care of his other teeth to avoid emergency visits in the future.

P.B., New York University College of Dentistry

Today’s session proved to be quite educational. Dr. Dorfman met with a newly graduated endodontist seeking career guidance. Dr. Dorfman frequently meets with young dentists and specialists to help them prepare for the transition to private practice. The meeting consisted of the endodontist showing some pre-operative and post-operative radiographs of her work to show her competency. In addition, she answered some questions regarding endodontic and emergency care and afterwards took a tour of the the office. Being included in this meeting provided me two different viewpoints. While one view may be more applicable to my current position as a graduating student, hopefully the other view will be applicable in a few years as I begin to build my own comprehensive practice.

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

Today in the dental office there was a case that was very complex not only because of the dental work that was involved but because there was also issues of finance and patient management involved. The patients was chief financial officer of his company and had a lot of dental work that needed to be done. This patient was overweight as an adolescent and suffered from anorexia and bulimia. These two disorders ruined his upper teeth and neglect over many years worsened the situation. When he presented to the office the patient had almost no coronal tooth structure left on any of the maxillary teeth.

It was charted that 6-11 and 14 and 15 were restorable with guarded prognosis and any other root tips in the mouth were to be extracted. 6-11 and 14 and 15 were all to be treated with RCT in one visit and to be restored a few days later also in one visit with temporaries.

One of the main concerns with this patient was the loss of vertical dimension. After many years of going with the wrong vertical we were concerned that opening the bite again would cause stress to the TMJ. After endo and OS consults however it was deemed that restoration of the occlusion could be done immediately. It was also noted that this patient was very phobic and was pre-medicated prior to any treatment for the phobia.

The treatment time was about 4 hours in which 8 root canals, post space preparations, and impressions were done. The lab tech was on hand to observe the case so that he could process temps for the patient within 4 days when the post/cores are inserted. This is a case that would normally have taken months and a lot of patient visits but is going to be taken care of in a short span of time with specialist attention.

H.A., New York University College of Dentistry, Patient 10

Today at Dr. Dorfman’s office I got to see a new procedure. Yesterday a patient came to the office and had RCT done on tooth #8. This patient had visited the office previously with a chief complaint about tooth #8 which had changed color within the past 3 months and she wanted to whiten it. Even though external bleaching was performed on that tooth it had not changed the color, so the decision was made to do an internal bleaching. So after the RCT was completed the tooth was then filled with bleaching material and packed with Cavit. Overnight the patient achieved the desired result. However the tooth became one shade lighter and the patient felt as though the tooth was too light compared to the adjacent teeth.  

When she presented we were able to concur on the discrepancy in color. The patient however was happy with the result of the bleaching and felt that she wanted all her anterior teeth to be that shade.

We started the procedure by removing the cavit and rinsing out the bright red bleaching material. It was important to watch the buccal wall of the tooth and to watch how apically the tooth was being prepared in order to avoid ruining the endo fill. After all the material is rinsed out we see that the access has been preserved and it is ready to be filled with composite until it is deemed necessary to fill it. It is important again to create a barrier between the gutta percha and the composite fill with a layer of cavit. After the final fill and polish the patient made an appointment to have full arch, maxillary and mandibular bleaching.

Later in the day a patient of 15 years came in and needed a new crown on #2. It was interesting to see a different way that an existing PFM, which had decay on the distal margin, was removed in order to prep the tooth for a new crown.

H.A., New York University College of Dentistry, Patient 9

This turned out to be a great day for me because I learned many new things about endodontics and the different technologies that they have at their disposal.

The endodontist was telling me about D-MTA, which is a substance that contains tetracycline and a few other chemicals in it. It can clean the canal and kill the bacteria and works very quickly so you don’t need to pack the canal with CaOH and send the patient home to do the obturation a week later. With this product it is possible to clean and obturate all in the same visit. She also taught me about the different ways that gutta-percha can be melted and packed into the canal so it is easy to reach lateral and accessory canals and that reduces the incidents of retreats.

She taught me how products are compared and how different solvents and products are tested: The test involves packing the canal and checking for how much of a substance can pass through, thereby testing the seal. It was interesting to see how well she was able to laterally condense the gutta-percha without using too much cement. One of the roots had a bifurcation right near the apex and that had to be repacked and it was interesting to learn how that was done.

I also learned how the apex locator was used specially in conjunction with regular endo files as a self check. The patient had come from another country and was seeking full mouth reconstruction over the course of the next few years in multiple phases. This visit was focused on extractions and endo procedures in order to preserve teeth and allow for healing of extraction sites so that implants could be placed.

H.A., New York University College of Dentistry, Observation