Promise To the Bride, Cosmedent, Inc., 2008.

Dr. Gerald Benjamin - The Bride

The Promise

On May 1, 2007 a 27 year old female presented to our office for a consultation for cosmetic dentistry. After being seated in the operatory to discuss what treatment she was interested in having, I introduced myself to the patient and asked her how I could help her. She told me that she was embarrassed by her teeth and smile and that she was getting married on July 7, 2007 and then she started to cry. I handed her a tissue and assured her that if she followed my suggestions, I promised her that I would make her a beautiful bride with a gorgeous smile. After examining her teeth, I wished that I had not made her a promise. Teeth # 5,6,7, 19 and 11 had advanced carious lesions with pulpal involvement. There were massive generalized deposits of supra and subgingival calculus indicating that the patient had failed to have professional dental hygiene care for many years. Lastly the patient’s central incisors were only 7 mm in length indicating that much of the enamel was below the level of the soft tissues.

I contacted my periodontist, Peter Collins of Troy, NY via email and attached the photos that I had taken and explained that I needed his immediate help in creating our beautiful bride. I next contacted my endodontist, Dr. Hilton Segal, also of Troy, NY and again asked for his help in salvaging as many of our patient’s anterior teeth with endodontic therapy as he could in an expedited manner. Dr. Collins performed debridement, deep scalings, intensive home care instructions and finally did full osseous surgery extending from #4 through 13. Tooth #5 was deemed hopeless and was extracted in conjunction with periodontal surgery. Dr. Segal performed root canals on teeth # 6,7,10 and 11 as well as #3 and 14.

Impressions were taken two weeks prior to the wedding date so that a waxup could be done and a PVS matrix impression using Splash (Discus Dental) could be fabricated from the wax up. The purpose of the waxup and matrix is to be able to quickly establish the correct width of each tooth and the exact incisal edge position without having to use trial and error methods.

A full day was set aside exactly 8 days prior to the wedding so that the patient could have as much healing time for her soft tissues as possible. It is virtually impossible to do esthetic bonding in situations where the soft tissue is inflamed and bleeding. The patient was called on several occasions during her healing from surgery to remind her how important her home care was to the success of the bonded restorations. A decision was made that restoring teeth # 4-13 would not meet our usual high level of meticulous attention to detail and the use of between 4 and 9 resin layers of Cosmedent Renamel as advocated by Newton Fahl. One Renamel Hybrid shade A1, one Renamel Opacquer shade A1-B1 and one Renamel Microfill Shade A1 would be used to complete the entire restoration. However, my esthetic sensibilities were offended by a monochromatic appearance to restoring a tooth and Renamel Microfill Incisal Light was added to the incisal 1/3 of each of the restored teeth in order to create realism.


Another decision was made that the reconstruction was not intended as the final restorations and that the restorations would only meet standards of excellence at 3 feet , the normal conversation distance, rather than meet the intense scrutiny of 1:1 close-up photography.

Unfortunately, as we began to isolate the area with rubber dam, we noted that the clinical crowns of teeth # 6, 10 and 11 were broken off 1 mm above the gingiva which necessitated the fabrication of direct bonded crowns. An indirect/direct fiber reinforced bonded bridge was planned to replace tooth # 5 which had been removed. Local anesthesia was administered on all teeth that did not have endodontics therapy and the labor intensive task of creating a beautiful smile began. All caries were removed and each tooth was treated with meticulous attention to bonding protocols while managing gingival seepage when it occurred. The palatal aspect of the Splash matrix was filled with Renamel Hybrid A1 , placed on the tooth and the resin cured 60 seconds. The Splash matrix was put aside for use on the next tooth. Renamel Opaquer A1-B1 then covered all of the Hybrid resin layer and any remaining natural tooth structure and cured for 60 seconds. The final contours of the restoration were completed with Renamel Microfill A1 with Incisal Light placed only in the incisal 1/3 of the finished restoration.

The direct/indirect bridge to replace tooth #5 was fabricated in the final hour of the 9.5 hour
appointment. A MO standard prep was placed on the occlusal surface of #4 and a post hole was fabricated to accommodate a medium fiber reinforced resin post for tooth #6. A standard crown and bridge Impragum impression was taken of the prep in tooth #4 and to pick up the post and its relationship to the remaining natural tooth structure of #6. The impression was removed from the mouth and immediately poured with Mach II (Parkell) die model material. The Mach II was removed from the Impragum impression after 6 minutes and an immediate model had been created to fabricate the bridge. A thin layer of a separating material was placed on the Mach II model to prevent the resin from adhering to the model. I went to my lab and fabricated a pontic using Renamel Hybrid A1 for 90% of the restoration with a labial layer of Renamel Microfill A1 for missing tooth #5 and placed it into the correct position on the Mach II die model. A trough was cut into the pontic to accommodate fiber reinforcement. A piece of Ribbond THM was cut to the appropriate size, covered with an unfilled resin and placed into the MO prep cut into tooth #4, through the trough cut into the pontic (which is correctly positioned in position #5) and around the fiber and resin post placed in the #6 post hole in the Mach II model . A sufficient amount of Renamel Hybrid A1 was placed around the Ribbond fiber and the fiber and resin were then cured for 60 seconds. The final contours of the labial surface of tooth #6 was added using Renamel Microfill A1 to the bridge framework that had been fabricated indirectly on the Mach II model. The Microfill was cured and the bridge was removed from the Mach II model and air abraded in preparation for bonding into the mouth. Teeth #4 and the root of #6 were etched with 37% phosphoric acid for 20 seconds and dried . A dual cured bonding agent was selected and placed into the mesial prep of tooth #4 and down the prepared post hole of tooth #6 without curing the bonding agent . Bonding agent was placed on the underside of the completed bridge and again not cured. Cosmedent Dual Cure Insure was used to bond the bridge to place. The completed bridge was equilibrated and the excess luting agent removed and polished.

After an intense 9.5 hour reconstruction, we had fulfilled our May 1 promise to give our
bride a fabulous smile. I have not included close up photos of the direct bonded resin restorations because the restorations were fabricated for the purpose of looking good at 3 feet.