Today a 31 year old female presented for an external bleaching. The case was interesting in that a maxillary central incisor presented with much darker staining due to a previous root canal therapy treatment completed at a different office. The goal of the external bleaching performed today was to not only to lighten all of the teeth, but to attempt to gain a few shades of whitening for this darkened tooth in particular. The teeth were properly isolated with liquid dam material. At the beginning of each cycle of bleaching, the darker central incisor was bleached for 4 minutes. Then bleach was added to the remaining teeth and the teeth were bleached for 12 minutes. Two cycles were completed. Upon completion the central incisor had lightened several shades. The patient had little post-op sensitivity. She was happy with the esthetic results.

N.D., New York University College of Dentistry

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

My dentist is awesome! I’m a Broadway actor and my smile is my living. Dr. D bleached my teeth, then used “bonding material” to close several gaps and change the shape of my smile. Now I look like a Hollywood star. Thanks Dr. D!
-Anonymous

Porcelain Veneers in Cosmetic Dentistry are typically only about 1 millimeter thick (the thickness of several pieces of paper).  Therefore, minimal tooth structure is removed for their placement.  The results can be quite dramatic.

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

My next dental patient came in for an in-office tooth bleaching. She came in because she felt that her teeth were a bit too yellow and she wanted to have bleaching done. The in-office bleaching was done differently than dental school. The bleach we used in the office was much stronger due to a higher concentration and it didn’t involve mixing two different tubes. We did two applications for 12 minutes each and then the patient was given post-op instructions! She was happy with the result of the maxillary anteriors but wants the mandibular anteriors to be a little bit lighter. She will wait for 2-3 days and see if the color changes at all and if not satisfied with the final result she will come in again for a second bleaching visit.

H.A., New York University College of Dentistry, Patient 7

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

Female patient presents to the dental office for 3^rd tooth bleaching session and sculpting of upper and lower right anterior teeth. Patient was satisfied with previous bleaching sessions and reports no sensitivity. I performed a 3^rd bleaching treatment on the patient for two 12 minute sessions using Opalescence. The patient was very satisfied with the new tooth shade. Following this I performed sculpting on #6, 7, 26, and 27. Her crossbite was corrected and the patient was quite satisfied.

She brought in her lower RPD and we evaluated the fit and option of adding 2 new teeth on the lower right. RPD did not fit well and she had a lisp when she wore it. We decided we would look at it again at the next visit after we finish the bonding. We might try to reline the RPD and add new teeth in, or we might take an impression and make a new RPD.

For the next visit we are going to do bonding of #8, 9, 23, 24, and 25. Also, we are going to prep #21 and 23 for the Maryland bridge we are going to place there. We will be making preps that will be similar to RPD cingulum rests with slots.

N.S., New York University College of Dentistry, Patient 1 – part 4

Female patient presents today for her 2^nd bleaching session. Patient was very satisfied with the results of her first bleaching session which was completed yesterday. Patient states that she had no sensitivity from the bleaching thus far. We retracted the cheeks and lips, placed cotton rolls for isolation, and placed the liquid rubber dam. We did 2 sessions of Opalscence bleach each for 2 sessions. 2 post-bleaching pictures were taken and shown to the patient and she was quite happy.

We then took alginate impressions of the upper and lower arch. 2 models will be poured up—one of which will be a diagnostic cast and the other one I will use to practice the sculpting on prior to the sculpting appointment. A bite registration of the anterior teeth was taken with yellow PVS. There are minimal posterior teeth which was therefore why I took the registration of the anterior teeth.

The patient states she is now interested in fixing #28 and #29 for the wedding, and we will discuss this at the next visit when she brings in her RPD.

N.S., New York University College of Dentistry, Patient 1 – part 3