Today is an exciting and rewarding time to practice dentistry. Unlike ever before, patient demands for aesthetic treatments have been met with great consistency, due in large part to material and technique advancements made in the last decade through the collaborative efforts of dental professionals, laboratories, and material manufacturers. As a result, the dental experience is now more fulfilling for everyone involved.
This is especially true when developing a treatment plan for a “charity case.” By coming together as a team, clinicians, specialists, and laboratory technicians can achieve far superior results that can dramatically and positively transform a patient’s life. The following case history chronicles the commitment to collaboratively provide pro bono treatment to a young woman and the evolution of her smile—and her life.
MEET THE PATIENT
Orthodontist Scott Meier met the 21-year-old female patient at a Denny’s restaurant; she was his waitress. The tongue ring she wore seemed to contradict her sweet disposition. More unfortunate, however, was that she demonstrated low self-esteem. She was very nice, and it was obvious to her customer that she could use some help. Dr. Meier left his card for her and asked her to call his office.
She did—the next day—and an appointment was made for her to visit the dental office for a preliminary examination. During that appointment, radiographs, study models, etc, were taken, and the patient was told that she would be contacted within a week or so. It was at that time that restorative dentist Dr. Christopher Ramsey was contacted about providing some pro bono dental treatments.
MAKING THE DEAL
From the onset, the biggest consideration was ensuring that the young patient fully understood the level of restorative work that would be completed for her. During the first inclusive meeting with the dentist and orthodontist, the patient was given strict ground rules that could not, under any circumstances, be broken. These included the following: removal of the tongue ring; never missing an appointment; no recreational drug use; and recognizing the value of the time and work that would be required for her treatment.
WHERE TO BEGIN
When faced with the challenge of not just restoring—but rather, reconstructing—a patient’s smile, simply figuring out where to begin the process can be the most daunting task. If you ask 10 dentists for their opinions of where to begin, you’ll likely receive 10 different answers.
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| Figure 1. Full-face preoperative view of the patient. | Figure 2. Close-up preoperative view demonstrating extensive decay. |
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| Figure 3. Right lateral preoperative view of patient’s decayed dentition. | Figure 4. Left lateral preoperative view of patient’s decayed dentition. |
In this case, the patient presented with an oral environment that was an absolute “train wreck” (Figures 1 through 4), so anything accomplished for her would be a step in the right direction. Fortunately, there were no monetary or time constraints to limit treatment; the orthodontist and restorative clinician could proceed in as ideal a manner as possible.
Anterior tooth pain was an obvious concern, and the majority of her problems existed in her maxillary arch. She exhibited rampant caries from neglect, some nonrestorable teeth, and isolated periodontal pocketing.
Treatment began in the anterior maxillary arch with root canal therapy to relieve the pain that the patient lived with on a daily basis. Further, it was determined that once caries was eliminated and periodontal health stabilized, the team could move forward with orthodontics to help set the stage for success when placing the final restorations.
Ultimately, the restorative dentist planned to provide the patient with restorations that would match her mandibular natural dentition. Because all-ceramic was the material of choice, IPS Eris restorations (Ivoclar Vivadent) were selected. Pressed ceramics, which are pressed from one ingot and cut back and layered by the ceramist, could have also been selected. However, the ability to conventionally cement the final restorations was ideal in this case, so IPS Eris restorations—which are fabricated from pressed cores with all existing characteristics built up and layered over the core—were planned.
TREATMENT AGENDA
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| Figure 5. Facial view of the patient; stick bite registration. | Figure 6. Face-bow transfer records were obtained. |
During the first working appointment together, complete records were obtained. These included conventional and panoramic radiographs, models mounted in centric relation, stick bite registrations (Figure 5), and face bow transfers (Figure 6). Additionally, a complete oral examination was performed.
Root canals were performed on teeth Nos. 7 through 10 at the following appointment, and 4 individual polycarbonate crowns were placed. When the patient left this appointment, she was able to smile for the first time in years.
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| Figure 7. Shade A2 of TetricCeram matched the patient’s teeth perfectly. |
The next 4 appointments—each of which lasted between 3 to 4 hours—were dedicated to a quadrant-by-quadrant “cleanup,” during which anything necessary to restore the patient’s dentition was performed, starting in the maxillary right quadrant. Where necessary, her teeth were built up using a shade A2 direct composite (Tetric Ceram, Ivoclar Vivadent), which matched her teeth perfectly (Figure 7). Each quadrant exhibited at least one tooth that required root canal therapy. Once all caries and other issues were treated in that specific quadrant, the clinicians took advantage of the patient being anesthetized to thoroughly clean the quadrant and address periodontal concerns. Additionally, any necessary tooth extractions were performed during that specific quadrant appointment.
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| Figure 8. Orthodontic treatment was performed to create a ferrel effect. |
Once the patient’s periodontal health was resolved, all caries was removed and those teeth filled. Then, all nonrestorable teeth were extracted, and the patient was referred back to the orthodontist for treatment. The main goal of the orthodontic treatment was to extrude teeth Nos. 7 through 10 to create a ferrel effect (Figure 8).
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| Figure 9. Idealized temporary restorations. |
Following orthodontic treatment, the patient’s maxillary 12 teeth Nos. 3 through 14 were prepared for IPS Eris crowns. The certified dental technician waxed the case to ideal, enabling the team to idealize the patient’s occlusion and anterior guidance. An A-1 shade of a provisional material (LuxaTemp, Zenith/DMG) was used to fabricate the new, idealized temporaries (Figure 9).
The final restorations were inserted 3 weeks later. The units were conventionally cemented using a Type-I glass ionomer cement (Vivaglass, Ivoclar Vivadent).
CONCLUSION
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| Figure 10. Postoperative close-up of the patient in natural smile. | Figure 11. Full-facial view of the patient postoperatively. |
What is most significant about this case is that it was truly life-changing. The patient had no other chance of achieving a healthy mouth. Although she received between $25,000 to $30,000 worth of dentistry for free, the case cost the dentists nothing but time. Today, she radiates beauty (Figures 10 and 11) and exudes a previously nonexistent self-confidence whenever she enters the dental office for a follow-up visit. Now engaged, she is a satisfying example of how giving back a smile can positively impact a person’s future. With successful independent practices and fulfilling careers, providing a pro bono case once a year has proven to be very rewarding for each professional involved.
Acknowledgement
The restorations the patient received were fabricated and provided by Lee Culp, CDT, the Institute of Oral Art and Design, Sarasota, Fla.
Dr. Ramsey is a graduate of Temple University School of Dentistry in Philadelphia, Pa. Dr. Ramsey lectures nationally on aesthetic dentistry and customer service in the dental office. He is currently a clinical instuctor for the Institute for Oral art and Design in Sarasota, Fla, and an alumni of the Pankey Institute in Key Biscayne, Fla. Dr. Ramsey practices comprehensive aesthetic dentistry in Palm Beach Gardens, Fla. He can be reached at (561) 626-6667.
