Full mouth reconstruction, teeth braces and dental anxiety.

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

Categorised in: Dental Student Experiences

This post was written by Dr. Jeffrey Dorfman