My Crooked Smile

Craniofacial Habilitation
Updated March 24, 2020

Left lateral incisor replacement with a five-unit fixed bridge

• Long term outcome: Failure of the fixed bridge short of 20 year projected life
• Long term outcome: Facial asymmetry

Self-report by author:
Neil J. Gillespie
8092 SW 115th Loop
Ocala, Florida 34481
Tel. 352-854-7807
Email: [email protected]
 My Crooked Smile
Self-report by Neil J. Gillespie, author

Table of Contents

Author’s narrative, left lateral incisor replacement with a five-unit bridge; Long
term outcome: Failure of the fixed bridge short of 20 year projected life.

Diagram of the Tooth Numbering System, re 20 year projected life span.

Images of the five-unit bridge, after partial removal. (author’s images)

Long term outcome: Post-operative facial asymmetry. (author’s images)

Letter April 15, 1994 of J. Peter Hoguet, National Foundation for Facial
Reconstruction (NFFR); and page 88, proceedings of the National Foundation for
Facial Reconstruction's Conference, "SPECIAL FACES: Understanding Facial
Disfigurement”. Note: The NFFR is now called myFace, https://www.myface.org/

Assessment July 22, 1985 by Dr. Joseph Kusiak, M.D., Plastic & Reconstructive
Surgery, American Oncologic Hospital, progress report for Neil Gillespie

Author’s related medical records

Cleft Palate Foundation (CPF), Replacing a Missing Tooth, links 6/20/2016

http://www.cleftline.org/parents-individuals/publications/replacing-a-missing-tooth/
http://cleftline.org/docs/PDF_Factsheets/Missing_Tooth.pdf

Cleft Palate Foundation (CPF), Missing Tooth Fact Sheet, downloaded 8/5/2005
http://www.cleftline.org/publications/missingTooth.htm (obsolete link)

Waiver of confidentiality

In furtherance of craniofacial science, I hereby waive confidentiality under the Health

Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191.

http://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/
 Left lateral incisor replacement with a five-unit fixed bridge

• Five-unit fixed bridge expense $11,775, including partial removal 1

• In service 17 years, 6 months, 12 days (20-year projected life)

My left lateral incisor (tooth #10) was missing, along with the supporting bone and gingiva, due
to a cleft palate. This empty space remained until age 18, when I got a retainer with a prosthetic
left lateral incisor attached. The retainer was secured by a wire. Eating meals was difficult while
wearing this plastic retainer. Denture adhesive cream may have better secured the retainer, had I
been advised. By age 31 I wanted a better restoration for the missing left lateral incisor. (#10).

My craniofacial team in Philadelphia recommended a five-unit fixed bridge. I questioned

sacrificing four good teeth (#8 thru #12) in order to replace one missing tooth. An alveolar bone
graft filled the empty space at tooth #10. I asked about having a single dental implant instead.
The team prothodontist said an implant would cost more than a five-unit bridge. I explained cost
was not an issue; I was prosperous and owned a business. Earlier in my life, cost would have
been a consideration, but not in 1987. The issue was foreclosed without adequate discussion.

My records show the five-unit fixed bridge was completed August 17, 1987. The multi-visit
procedure included grinding down four good teeth, which I vividly remember because of the
intense pain I experienced. On April 4, 2002 tooth #12 had an apicoectomy under the bridge.
The five-unit fixed bridge failed February 17, 2005. A dentist removed a three tooth section
(#10-#11-#12) of the bridge while removing #11 and #12 that failed. A flipper with prosthetic
teeth for #10, #11 and #12 was provided. Tooth #9 failed June 1, 2006, and was removed with
another part of the bridge. A diagram follows this page. A consult May 30, 2006 suggested the
use of cadaver bone now instead of the alveolar bone graft procedure done in 1986.

Opinion: A quality metal partial, with a prosthetic left lateral incisor, with or without a speech
bulb, would be preferable to a five-unit fixed bridge. (in lieu of implants). My experience with
the five-unit fixed bridge shows it was not a good long-term decision. It failed after 17+ years. I
might have three more teeth today if I had done nothing. (teeth #9, #11 and #12 are gone; #8 is
loose). Restoration now is not likely due to unaffordable expenses, my lower tolerance of pain,
and the futility of these procedures now that I am age (62) and resolved to my mortality.

amount date provider

$3,800 March 10, 1986 Rosario F. Mayro, D.M.D., orthodontic services
$ 125 December 23, 1987 Rosario F. Mayro, D.M.D.
$3,765 For the year 1986 Mark B. Snyder, D.M.D., periodontal surgery
$2,858 August 5, 1987 Dennis Sanfacon, D.M.D., prosthodontist, five-unit bridge
$10,548
$ 135 April 4, 2002 David M Pedley, DMD, St. Pete, apicoectomy on #12
$ 570 February 17, 2005 Robert S. Pastorius D.D.S. St. Pete, extracted #11 and #12,
cut five-unit bridge, provided a flipper for #10-#11-#12
$ 75 May 30, 2006 Michael Gluhareff, DDS, Ocala, consultation
$ 447 June 1, 2006 Thomas Harter, D.M.D. Ocala, extracted #9, added
$11,775 prosthetic #9 to existing flipper.
1
Dental-related procedures only; alveolar bone graft and related surgeries are shown separately elsewhere.
Five-unit bridge: Prepared January 12, 2015
Installed August 5, 1987, #11 & #12 were extracted
Failed February 17, 2005. Diagram of the Tooth Numbering System February 17, 2005.
In service 17 years, (viewed as if looking into the mouth)
6 months, 12 days. only #8 remains #9 extracted June 1, 2006 Prosthetic #10 was removed
(20-year projected life) with the bridge section

Central Incisor
Lateral Incisor Single
Labial Surface Rooted
8 9 Cuspid
7 10
6 11 1st Bicuspid (Bi-Rooted)
5 E F
D G 12
C H 2nd Bicuspid (Single Rooted)
4
B I 13
Buccal (Facial) A J
Surface 3 Lingual 1st Molar
Surface
14

2 2nd Molar Tri-Rooted

15
Mesial

Primary
1 Surface
Maxillary Arch 16 3rd Molar
(Upper Jaw) Distal
Surface

Top Right (TR) Top Left (TL)

Quadrant I Quadrant II Permanent
Right Left
Bottom Right (BR) Bottom Left (BL)
Quadrant IV Quadrant III

Mandibular Arch
(Lower Jaw) 32 3rd Molar
17

31
18 2nd Molar Bi-Rooted

Occlusal 30 Lingual
Surface T Surface K 1st Molar
19
29 S L
M 20
R 2nd Bicuspid
28 Q P O N 21 Single
Rooted
27 22 1st Bicuspid
26 23
25 24
Cuspid
Single
Lateral Incisor
Rooted
Adult Dentition = Central Incisor
Permanent teeth 1-32 Incisal Surface

Child Dentition = Primary

teeth A-T Median Line

Wisdom Teeth = 1, 16, 17,

and 32
Images of the five-unit bridge, after partial removal
(#8 remains in place)

above - #12, #11, #10, #9

above - #12, #11, #10, #9

 Long term outcome: Facial asymmetry

One long-term outcome of cleft reconstructive surgery, inter alia, is the failure of underlying
structures over time. Compare/contrast the post-operative images from 1989 and 1992 with the
facial asymmetry shown in the 2013 image. The left side of my mouth/face is moving downward.
This is not the result of smoking, or facial paralysis. I am a lifetime nonsmoker.

Images below of Neil J. Gillespie

Graduation, Sunday May 21, 1989 Passport photo March 25, 1992 Passport photo 2013
After the Aug-1986 alveolar bone After the Dec-1990 cleft Mouth/face not symmetric; failure
graft, cleft lip repair, septoplasty. rhinoplasty with submucous of underlying structures, bone loss,
After the Dec-1986 reconstructive resection, pharyngeal flap, and tooth loss.
rhinoplasty, and cleft lip revision. cleft lip correction.

• Complete unilateral cleft lip (L), cleft palate

• Initial surgeries, 1956 and 1958 (Philadelphia, PA)
• Secondary surgeries, 1986 (Philadelphia, PA) and 1990 (Miami, FL)

August 12, 1986 alveolar bone graft, cleft lip repair, septoplasty.
December 15, 1986 reconstructive rhinoplasty, cleft lip revision.
December 14, 1990 cleft rhinoplasty with submucous resection, pharyngeal flap1, cleft lip correction.
Also as shown in this self-report: Orthodontics, endodontics, prothodontics, periodontics, and dentistry.

Conclusion: A high quality metal partial, with a prosthetic left lateral incisor, with or without a speech
bulb, would be preferable to a five-unit bridge, in my opinion, given my experience with the latter.

1
The flap was to correct velopharyngeal insufficiency (VIP), a speech disorder, but failed a month later.
Subsequently I got a speech bulb obturator to correct VPI; it worked for a number of years, but ultimately
failed, inter alia, due to lack of maintenance, and the unavailability of a specially trained prothodontist.
 National Foundation for 317 EAST 34TH STREET
NEW YORK, NY 10016

Facial Reconstruction 212-263-6656 1-800-422-FACE

FAX-212-263-7534

April 15, 1994

PRESIDENT
J. Peter Hoguet
VICE PRESIDENTS
Brownlee O. Currey, Jr
Frederick M. Friedman
John R. Gordon
Mr. ~eil J. Gillespie
Mrs. Demetrio Guerrini-Maraldi 266 7th Ave NE, Apt 5
Marguerite Prince Sykes, M.D. St. Petersburg, FL 33701
TREASURER
Daniel Rosenbloom Dear Mr. Gillespie,
SECRETARY
Eduardo Gaffron I am pleased to send you a copy of the proceedings of the National Foundation
EXECUTIVE DIRECTOR for Facial Reconstruction's Conference, "SPECIAL FACES: Understandin~;
Arlyn S. Gardner Facial Disfigurement" which you attended.
BOARD OF TRUSTEES
Robert E. Bochat Thanks to an outstanding panel of conference participants, this book will serve
Mrs. H. Lawrence Bogert
Phillip R. Casson, M.D.
as an invaluable aid to patients, families and professionals and help to further
Brownlee O. Currey, Jr the NFFR's goal to provide greater awareness and understanding about the
Robert F Dall problem of facial disfigurement.
Frederick M. Friedman

Tne confer~ilce b&<ik. wiii b~ di,.s·i.lib~icd to medica} m}fari~s, parent and patiem
Eduardo Gaffron
Mrs. Roswell L. Gilpatric
John R. Gordon support groups, plastic surgery units and rehabilitation -agencies thrQughout the
Mrs. Demetrio Guerrini-Maraldi country. It is our hope that the nearly 500,000 Americans who are disfigured
Anita Covington Heller
each year by congenital birth defects, fires, accidents and tumors will be the
Steven M. Heller
Ernest Heyn ultimate beneficiaries and will be given the opportunity they deserve to become
J. Peter Hoguet happy and productive individuals.
William E. Jackson
Richard B. Jennings
Joseph G. McCarthy, M.D.
Sincerely,

~NorruJ-
Bruce Morrow
Phebe Miller Olcay
Elizabeth D. Old
Thomas D. Rees, M.D.
Cliff Robertson
R. Bruce Robertson J. Peter Hoguet
Daniel Rosenbloom
Mrs. H. Virgil Sherrill
Marguerite Prince Sykes, M.D.
Mrs. Rawleigh Warner, Jr
Roger S. Weber JPHljg
John C. Wohlstetter
Enclosure
Barbara H. Zuckerberg
 MARGY MAROUTSIS: I work for the orthodontist at the Institute at NYU and my
question for Dr. Blumenfeld is why aren't pre-and post-surgical orthodontic proce­
dures covered when they are such an integral part of the facial reconstruction proce­
dure?

DR. BLUMENFELD: Any pre- or post-operative services requiring an orthodontist

are covered only when a rider to the policy so states. The fee for the surgery per­
formed by a plastic surgeon or an oral surgeon covers all of the procedures that are
necessary to properly perform the surgery. If the oral or plastic surgeon wants to
have an orthodontist involved in the care, that is their choice. However, if an ortho­
dontist is requested or required, the orthodontist's services may only be reimbursed if
there is a rider on the policy specifically for this type of care.

MS. MAROUTSIS: I'm not referring to the work done during the procedure; I'm
referring to the work done before and after this procedure, which is essential for the
successful outcome of this operation.

DR. BLUMENFELD: Again, reimbursement for the orthodontics, pre- or post-opera­

tively, is based on whether or not a patient's contract has a rider for this service.

NEIL GILLESPIE: My question is also to Dr. Blumenfeld. It touches on the previous

question. I was covered by Blue Cross/Blue Shield and they paid for a bone trans­
plant in 1986. However, I also required orthodontics, periodontics and prosthodon­
tics. None of that was paid by Blue Cross. These three procedures, which were over
$10,000 were absolutely part of the bone transplant. When I was an adolescent I had
separate orthodontics and that was something different. This is orthodontics specifi­
cally to arrange the upper jaw to accept the bone graft. Is that covered?

DR. BLUMENFELD: Your policy must be examined before your question can be
answered. I would be happy to speak to you afterwards about who can best answer it
for you.

88
 •
AMERICAN ONCOLOGIC HOSPITAL
• • • • 415-13
Rev. ]-8]

PROGRESS REPORT CHART COpy

Notll prairllss of caslI. complications. chanilll In dlaposls

condition on dlscharill. Instructions to patlllnt

GILLESPIE, Neil #74123

7/22/85

The patient is a 29 year old white male referred by Dr. Carver

who is status post left unilateral 'Class IV lip and palate repair
at approximately age two years old. He is unclear about the details
of the degree of his defects, the surgical procedures, who performed
this, or exactly where it was done. Apparently, after the initial
bout of surgeries to repair the lip and hard and soft palate, he had
no further surgical intervention. He had no ongoing follow-up for
this problem. At approximately age 13 to 14 years old, he underwent
orthodontic treatment at Temple University Hospital's Dental School
and this ultimately resulted in the placement of a retainer with a
prosthetic left lateral incisor. He has worn this since that time.
He notices drainage of food into the left nasal floor. His left and
·right nostrils are opened, although the left is somewhat stuffy and
occluded.

His main concerns upon presentation are related to the persistent

cleft in the left alveolus, the draining fistula, and the possibility
of foregoing the need fOD a prosthetic device. In addition, however,
it is obvious on confronting the patient that he has a moderate amount
of nasal deformity, flattening of the left side in the premaxillary
region, and lip distortion, particularly at the vermilion. In
addition, the patient has a significantly hypernasal speech pattern
with ~bvious velopharyngeal incompetence.

On physical examination beginning externally, the patient has

a slightly large nose with a small dorsal hump. The size of the nose
is slightly larger than proportional to his face, although not
exaggeratedly so. The right alar dome is full. The left alar
cartilage is posteriorly and laterally displaced and somewhat
hypoplastic compared to the left side. The left alar base is
also laterally displaced. The nostril sill is flattened, and there
is an obvious fistula between the distal nasal floor and the oral
cavity. The left columella, likewise, is somewhat hypoplastic and
twisted. The upper lip scar is well healed and appears to be a
LeMesurier or Tennison-Randall type repair. The upper lip tubercle
is preserved, but the vermilion border is somewhat irregular.
Length appears, however, to be satisfactory. There is a-lateral
orbicularis bulge of the left upper lip. Internally, there is a wide
cleft of the left alveolar ridge at the level of the lateral incisor
with a fistula into the nasal floor. This runs posteriorly and nearly
to the end of the secondary palate. The soft palate has a linear scar.
it is very short, and there is lateral movement but no central movement
of note.
continued ...•
GILLESPIE, Neil
Page Two .
7/22/85

My impression and recommendation to the patient generated

three specific areas of interest. One relates to the scar revision
of his upper nose and the relationships of his nasal tip, nose,
and secondary deformities in this area. The second area of interest
in importance is the alveolar cleft with the naso-oral fistula.
The third area is the palate with obvious velopharyngeal incompetence
and a foreshort and scarred palate.

My initial recommendations will be that the patient undergo

orthodontic evaluation. I will arrange for him to see Dr. Rosario
Mayro for evaluation as well as x-rays to assess his occlusal
relationships. It also should be noted that he, in general, had
a fairly satisfactory occlusal relationship.with some lateral collapse
and crossbite on the minor segment on the left and evaluate his
adequacy as a candidate for bone graftin~which I think he would
qualify. Subsequent to this, I will have him see Dr. Harvey Rosen
concerning the actual surgical procedure and also he will be seen by
Miss Marilyn Cohen, a speech pathologist with special interest in
patients having cleft lip and palate for an evaluation concerning
feasibility of posteropharyngeal flap in a patient of this age group.
Concerning the external revisions, this can be accomplished concerning
the upper lip, possibly at the same time as the fistula closure with
orlllcularis redirection, a revision of the nostril sill and the
lateral alar base, and also possibly tip rhinoplasty or this can
be accomplished at a later date with a formal rhinoplasty in concert
with other procedures. In addition, the vermilion border should be
repaired. This can be done by Z-plasty technique.

The patient, therefore, will be seen by the consultants and a

general plan with timing'for surgery, etc., will be made. We will
arrange to make these arrangements and follow-up with the patient.
No letter.

ep s1ak, M.D.
econstructive Surgery

JK:bsm
T--8/1/85
D--7/23/85

 ROSARIO FELIZARDO MAYRO, D.M.D.

1830 Rittenhouse Square

Philadelphia, Pennsylvania 19103

FEDERAL TRUTH-IN-LENDING DISCLOSURE STATEMENT

FOR PROFESSIONAL SERVICES TO BE RENDERED

We wish to confirm the verbal arrangements made with you for orthodontic treatment.

PATIENT:
Neil Gillespie
RESPONSIBLE PARTY: Sane

ESTIMATED TIME OF TREATMENT:

15-18 nos_
ESTIMATED TIME OF RETENTION: 'It> be detennined

The undersigned hereby agrees to the financial arrangements and office policies outlined in this memorandum.
TREATMENT FEE:
(Includes initial payment, regular payments $..;...3_8_0_0_-_0_0 _
INITIAL PA YMENT:
(Due on day of separation): $_8_0_0 0_0 _
BALANC~ to be
Payable in 15 equal8ayments of $ 200 - 00 and a retention payment of $ detennine 0laking the account paid in full. The
first payment is due 1 and a.II subsequent payments are due on the same day of each JTX)oth . The retention
payment and any past due payments are payable in full prior to appliance removal.
FINANCE CHARGE: None for accounts that are ma.intained on a current status: 18%

TIME ESTIMATE AND EXTENDED TREATMENT: annually for accounts that are delinquent by 30 days or nore_

Treatment time and retention time are estimates based on previous experience. We will do everything possible to alert you to poor progress
and reverse poor progress to keep treatment time within the estimate. When £ontinued poor cooperation and failed appointments prolong
treatment time beyond ] 5 ItD~ an additional treatment fee of $ ~OO - 00 per month will be continued until appliances are
removed. Once the remaining retention fee is paid, the account will be paid in full.
PAYMENT SCHEDULE:
The above payment schedule is arranged for your convenience in making payments and has no relation to the number of office visits per
month. In the event of vacations or ordinary illness of the patient, payments are not discontinued. Monthly payments begin 30 days following
appliance placement and quarterly payments begin 90 days following appliance placement.
PA YMENT BOOKLET:
Since our office does not send monthly sUilfments, the enclosed booklet is provided for your convenience in making and recording
payments. It has been noted that the 1 day of each month is best suited for making these payments. A booklet slip should
accompany each payment. To verify your payment records, a copy of your office ledger will be supplied at any time on request.
EXCLUSIONS:
Charges for dental services not routinely performed in our office such as filings, extractions, x-rays taken by your family dentist, etc., are not
included in this fee.
EXTRA CHARGES:
Treatment RedesIgn:
When orthodontic treatment is initially begun on a non-extraction basis, there can arise physiologic factors as well as cooperation factors
which do not permit adequate resolution of the orthodontic problem. Should extraction be required, the changes in appliance design and
treatment procedures will necessitate an additional charge of $ not for the ensuing extra care.
Broken or Lost Appliances: applicable
Normal wear and tear on appliances is expected. Unwarranted breakage or loss of appliances will require an additions.! charge. There is a
charge of $50 for replacement of a retainer, positioner, or lingual arch lost or damaged beyond repair.
MISSED APPOINTMENTS:
We realize that many problems may cause a missed appointment, but, with the exception of cases of extreme emergency, we ask that you call
the office 24 hours in advance to cancel routine appointments. Appointments such as banding and debandings are of great importance to
you and to others. If it becomes absolutely necessary to cancel such an appointment, call at least one week prior in order that we may
reschedule someone who may be anxiously waiting for care. Since the banding and debanding time is so valuable to our patients, a staffing
and administrative charge will be added to your account if your scheduled time cannot be reappointed because of inadequate notice.
PROGRESS REPORTS:
ApprOXimately every six months it is advisable to have a check-up with your family dentist. We will at that time tell you whether or not
treatment is on schedule. Should there be any treatment delays, we will tell you the reasons. A detailed monitoring of treatment progress is
done within one year of the start of care. When the monitoring findings show that the orthodontic treatment objectives are being met, we do
not schedule a progress consultation. Should you at any time, though, w~sh a treatment update from the doctors, do not hesitate to ask.
INSURANCE BENEFITS: ,
0 nce you have verified throug h the Confi rmation of EI ig ibi Iity Form that you are entitled to orthodontic benefits under you r health care plan,
our office will submit claim forms to your insurance carrier following appliance placement or following the consultation if no treatment is
currently needed. Since professional services are rendered to you and not to your insurance carrier, you are responsible for the above fee
arrangement and its payment schedule. Any benefits which you qualify for under your orthodontic health care plan must be paid directly to
you by your carrier. However, we·will help in any way we can to assure you that you receive the insurance benefits you are entitled to.

(over)
 FEDERAL TRUTH-IN-LENDING DISCLOSURE STATEMENT

FOR PROFESSIONAL SERVICES TO BE RENDERED

(Page 2)

TAX DEDUCTIONS:
All orthodontic fees paid within a calendar year can be combined with other medical dental expenses incurred within that year to be used as a
tax deductible medical expense. Depending on an individual's tax bracket, the savings in taxes can be substantial by paying the orthodontic
treatment fee balance within one year. Our bookkeeper will assist you in this matter should more information be needed.
CREDIT REFERENCES:
Accounts paid according to the above terms may feel free to use our office for future credit references.
TRANSFER OF TREATMENT:
In the event you must transfer your orthodontic treatment to another city, our office will find you a new orthodontist and will forward all
diagnostic records and instructions. An account balance for services not yet performed will be transferred. A refund will be arranged for any
overpayment. Records will not be transferred if an account is past due.
DISCONTINUE TREATMENT:
Treatment will be temporarily halted for patients whose accounts are 90 days or more past due. No additional charge will be made to the
account during this time. Treatment will resume when the past due balance has been paid in full. During this temporary halt in treatment,
periodic office visits will be requested to insure appliance stability.
In the event a patient wishes to permanently discontinue treatment, a "Waiver of Treatment" form must be signed. Once this form has been
signed and any current account balance has been paid in full, the appliances will be removed.
ACCOUNT COLLECTION:
If it becomes necessary to institute collection proceedings on this account, the undersigned agrees to pay all costs and expenses therefore,
including a reasonable attorney fee and all court costs incurred.

It is agreed that a signed copy of this statement and agreement will be returned before active treatment begins.

I/We hereby certify that I/We have read and received a copy of the foregoing Disclosure Statement and Memorandum Agreement

this Jtl
(
day of ~~ • 19 ~ .

Rosario Fellzardo Mayro, D.M.D.

ROSARIO FELIZARDO MAYRO, D.M.D.
PRACTICE LIMITED TO ORTHODONTICS
1830 RITTENHOUSE SQUARE, IA
..

THIS IS YOUR
RECEIPT FOR
THIS AMOUNT
•

STATEMENT
PLEASE PAY

THIS AMOUNT

PHILADELPHIA, PA. 19103

TELEPHONE (215) 735-5211

IV-Initial Visit
C-<:onsultation
SM-Study Models
TF-Total Fee
TO PI-Phase I Fee
PII-Phase I I Fee
Pili-Phase III Fee
AF-Appliance Fee
Mr. Neil Gillespie MC -MonthlY Charge
SP-Surgical Preparation
2020 Walnut Street Apt. 30-A RET-Retainer
POS- Positioner
RA-Replacement Appliance
Philadelphia, PA., 19103 NK-Unkept Appointment
ROA-Received on Account
PIF-Paid in FuJI

3895

1830 Rittenhouse Square, I-A

Philadelphia, Pennsy lvania 19103
(215) 735-5211

ROSARIO FELIZARDO MAYRO, D.M,D., D.D.S.

Practice Limited To Orthodontics

Children's Hospital of Philadelphia

34th and Civic Center Boulevard
Philadelphia, Pennsylvania 19104
(215) 596-9338
 STATEMENT

MARK B. SNYDER, D.M.D. , P.C.

220 SOUTH SIXTEENTH STREET, SUITE 900
PHILADELPHIA, PENNSYLVANIA 19102
(215)546-0729

CHARGES OR

PAYMENTS MADE

AFTER LAST DATE

SHOWN WILL APPEAR

ON YOUR NEXT

STATEMENT

•
fiR. ~II_ GII-'£SPIE
al20 WAt.NUT STREET ~T. IffJ A
PHII..AIE1.PHIA., PA 19103

AMOUNT

DETACH AND RETURN WITH YOUR REMITIANCE

ENCLOSED $ _
..
DATE DESCRIPTION TOTAL BALANCE FORWARD. BALANCE
FEE PAYMENTS ADJ. "­

4/7JJPfJ ((J\JSU_TATI~ 25 m 25 m -0­

S/8/PfJ SuR~RY (PERIa:x:mA'_) ml m ffi) m -{]­

8/4/8') r1t\INTENMCE (PREVENTIVE) f£) m f£) m -0­

9/'t3/PfJ MAINTENMK:E (PREVENTIVE) 60 m 50 [fJ -(]­
11/4/86 ~~INTENANCE (PREVENTIVE) ff) m f£) m -0­
12/12186 IVlJ\INTENANCE (PREVENTIVE) f£) m f£) m -o~

.. I

PLEASE PAY LAST AMOUNT IN BALANCE COLUMN ..

A-Allergy EX-Examination DB-Obstetrical ROA-Received on Account

BI·Biopsy HC-Hospltal Care OS-Office Surgery S-Surgery
C-Consultatlon HV-House Visit OV-Offtce Visit TR-Treatment
CPX-Complete Physical INJ-Injection PR·Proctoscopic UR-Urinalysis
OR-Dressings LAB-Laboratory PT -Physiotherapy X-X-Ray
EKG -Electrocardiogram NC-No Charge
 ()t:~ I ()~5/t:17

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.1' h fi~ C<':' :,.. '1 ·t, C) n I~l C) tJ S f:j

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Philadelphia, PA 19103

Nf.~ i'l (3 i ·1 '1 «~~; p i (::~

Apt, II ~?71<
2020 Walnut Street
Ph i °1 ~:\de'l ph i a PA 19:1.()3
ACCOUNT NO.. 2117

PATIEN°r DESC:RlpOfION CHARGES CREDITS BALANCE

0"710 L .':.~': . :.:., P"'ev i OtJS Ba 1 (OlnCf.~ () n 00

071:1. :' :.:.1 N(o~ i" PROSTH .. CONSULT 35 .. 00 3~5'00 n

()'7/ :1. : ,,:~: ',>' Nf:'~ °1 CROWN 550.00 5f.l5 00 It

07/:1. . " ".':'.:.:.1 N(~·~ °1 CROWN 550.00 j. :I.3~j .. 00

"··~1/:1. ..... ".>'

Z·.: '
N(~·~ 1 CROWN 550.00 :1. ~)t3~3 II 00
'·.:··I·:·: ·.··:;7 NE-:·~ ., ' CROWN 550 .. 00 2235.00
"'1" ..
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Dennis G. Sanfacon,D.M.D.
f?osthodontist
CROWN AND BRIDGE-RESTORATiVE-COSMETIC
REMOVABLE AND MAXILLOFACIAL DENTISTRY

THE CARLTON HOUSE, 1829 JOHN F. KENNEDY BOULEVARD

PHILADELPHIA, PENNSYLVANIA 19103
PHONE: 21515S1·D199

·A d.ental··lmplant is an·-artificial
device used to sup'por~ fixe.d'
prosthod·o.ntlc rep'lacem,ents for
those.. who suffer with retnov:abl~
d'entures ~Ioose or missi"ng teeth,
l

or loss Q·f: faci~1' tissue· support.

CALL FOR '{OUR EVALtJA7'ION APPOINTMENT TODAYI
IN CENTER CI TYCALL: INSOCIETYHILi-·CALL:
. 5E;i1·-05_..· .238"'9&77
THE CARLTON HOUSE':" 208 SOUTH 3ROSTREET
1829 J.FK BOULEVARD (opposite'SocietyH1U TQwers)
PHllAOELPH·IA. PA 191.03 .PHILADELPHIA, PA 19'"1-06
SPECIA/.JZIMlIN COSMETIC & IMPLANTOfNTISTRY
;'. AiJtJ1ImyW,BinaJdiD.M.D.
DIPLOMATE QF- THE AMERICAN BOARD OF PROSFHDOONnCS

';DellnisG.Sanfacon,QMQ
PROSTHOOONTI~& MAXILJJ1.FACIAL RECONSTRUCTIVE DENTISTRY
..leonardllln/qJw, D.o.$.
"-ClINICIAN, PIONEER" WBRtD ~HORITY AMJ INVENTOR OF THE'

.#LINKOW ENDOSSEt;JUS DEN~A~J¥P?A't.';. ~ ~

 STATEMENT DATE
Alex M. Gluhareff D.D.S., M.A.G.D, P.A.
3040 SW. 27th Ave. Suite 101 05-30-06
Ocala, FL 34474
DUE DATE ~ REMITTANCE
I

________-lI

Neil Gillespie MAKE CHECKS PAYABLE TO:

8092 SW 115th Loop Alex M. Gluhareff D.D.S., M.A.G.D, P.A.

Ocala, FL 34481 Phone Number: 352-237-7241

t~~G~~:~~. - !.o~~]~~-i~o ~J~-

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P~;:~; ~PREVIOUS BALA:~:~~IPTIO~ '----~ ~
I YOUR
DATE
CHARGES PAYMEN~LAN_C_E---++_P_O_RT_I_O_N '__ --j

05-30-06 i 0.00 0.00

05-30-06 Neil AMG** Periapical single, first (#9) 20.00 I 20.00 20.00
05-30-06 Neil AMG** Limited oral evaluation 55.00 I 75.00 75.00
05-30-06 Account FAC** VISA card payment 75.00 0.00 0.00

II
I

I
_ _ _- - - L ~ ____L. II
_____L_'___
. _J
_

i NOTES" PROVIDERS ** ==]

r AMG Michael Gluhareff I
We always welcome your referralsl
FAC DDS,PA Alex M Gluhareff
 DR. HARTER &
ASSOC
8602 SW. ST. RD. 200
SUITE P
OCALA, FL 34481
(352)873-1335

NEIL GILLESPIE

8092 SW 115TH LOOP

OCALA, FL 34481

NEIL Occlusal adjustment-limited 88.00

NEIL 9 D Unspecif restorative proced SIR 50.00
NEIL 9 Add tooth to exist part denture 139.00
NEIL 9 Extract,erupted thlexposed rt 170.00
NEIL VISA Card Payment -Thank You -447.00

EFFECTIVE APRIL 1, 2005 WE WILL NO LONGER OFFER THE 10% SENIOR DISCOUNT. SORRY FOR ANY INCONVENIENCE THIS
MAY CAUSE. THANK YOU FOR YOUR UNDERSTANDING.

©DENTRIX 1987-2003 DLWLK 1

 Replacing a Missing Tooth
Patients born with cleft lip and/or palate often During orthodontic treatment, an artificial tooth
find that they are missing one or more teeth, may be attached to the orthodontic wire as a
most often the lateral incisor (immediately next temporary replacement for the lateral incisor.
to the front central incisor). This tooth may be When the braces are take off, a removable
missing on one or both sides; in either case, retainer with an artificial tooth will serve to
special planning is needed to solve the maintain the space and improve speech and
functional and cosmetic problems the absence appearance until a definitive restoration is
creates. made.

Who will be involved in dealing with the Can the space of the missing tooth be filled
missing tooth? by another tooth?

Several types of dental specialists will be In many instances, the space for the lateral
important in planning treatment. Orthodontists incisor will be orthodontically and/or surgically
align improperly placed teeth, while closed by moving the canine tooth forward into
prosthodontists can replace missing teeth in a the space normally occupied by the lateral
variety of ways. Oral and maxillofacial incisor. The canine must then be modified to
surgeons perform surgery on the teeth, mouth, make it look like a lateral incisor, which is often
and surrounding areas of the head and face. accomplished by adding plastic or porcelain
Coordinated planning by all specialists filling material or a porcelain crown.
involved is necessary to select the best
method of treatment and achieving the best What options are available for permanent
result. replacement of the lateral incisor?

What role does the orthodontist play in Treatment options for the permanent
replacing a missing tooth? replacement of the lateral incisor depend upon
whether or not the cleft has been repaired with
The large majority of patients with clefts will a bone graft. (See below for information about
require full orthodontic treatment, especially if patients who have had bone grafts) In a non-
the cleft has passed through the tooth-bearing grafted dental arch, there are two options for
ridge. The goals of treatment will be to line up replacement.
the teeth in the arch of the upper jaw, create
an arch form that is harmonious with the lower In the first option, a removable partial denture
dental arch, and center the upper jaw over the may be used to replace the missing tooth.
lower jaw. When a tooth is missing, the other While this option may be made to look
teeth may be shifted off center, and their acceptable, it has several disadvantages. The
positioning must be corrected too. A space is removable prosthesis must cover most of the
often opened up and maintained for later palate for support, which may cause irritation
replacement of the missing lateral incisor. on the roof of the mouth or at the gumline
where it rests. Many patients also object to the
11/1997

Hope and Help are on the line.

information within 24 hours 800-24-CLEFT www.Cleftline.org
extra bulk and the removable nature of the requires less interference with other teeth, but
partial denture, reporting that it feels unnatural. still requires connecting teeth together.
This type of prosthesis is best used as a
temporary replacement. The most natural, lifelike restoration for a
patient with a bone graft is a single porcelain
The second option for a patient without a bone crown attached to an osseointegrated dental
graft is a fixed bridge. The missing tooth is implant. This method involves a surgical
replaced by an artificial one connected to procedure in which a titanium screw the size
crowns (caps) on the teeth on each side of the and shape of a tooth’s root is inserted into the
cleft. Because there is too little supporting bone at the site of the missing tooth. It is
bone beneath the teeth directly next to the covered by the gum for six months while the
cleft, two teeth on each side must usually be bone bonds to the implant surface. Then the
crowned to give adequate support to the implant is uncovered, and an artificial tooth
bridge. This type of prosthesis is not (crown) is attached. While this procedure does
removable. Its contours and appearance look require minor surgery, it does not require
and feel more natural than a removable partial cutting down or crowning any other teeth.
denture. However, it does require grinding Cleaning is also easier because the
down the support teeth in order to crown them replacement tooth is not connected to any
and connect them to the artificial tooth. other teeth. This restoration gives the most
Cleaning between the crowned teeth is also natural result, but does require that sufficient
more difficult since they are connected. bone is present in order to hold the screw.

At what age can a fixed bridge be made? For further information on cleft lip and
palate, or for a referral to a cleft
In a teenager or young adult, the nerves and palate/craniofacial team, please contact:
blood vessels in the tooth pulps are rather
large. Drilling these teeth down for crowns may Cleft Palate Foundation
expose the pulps and require root canal 1504 East Franklin Street, Suite 102
therapy. Therefore, this type of treatment must Chapel Hill, NC 27514
usually wait until middle adulthood when the
pulps are smaller. 800.24.CLEFT
919.933.9044
What options are available for a patient who 919.933.9604 fax
has had a bone graft? [email protected]
www.cleftline.org
Bone grafting the cleft site in the upper jaw
creates a more normal arch and may make
tooth restoration easier. (See CPF’s Factsheet
Bone Grafting the Cleft Maxilla for more
information on this procedure) A conventional
fixed bridge as described above may then be
used to replace the tooth. In many cases,
however, only one tooth on either side of the
cleft needs to be crowned, since the graft has
stabilized the arch and added bone. If the teeth
that hold the bridge are not otherwise in need
of restoration, a resin-bonded fixed bridge
requires much less tooth reduction of adjacent
teeth, and there is no danger of nerve
involvement. A porcelain replacement tooth is
held in place by metal extensions cemented to
the backs of the adjacent teeth. This process

11/1997


Cleft Palate Foundation Publications

Cleft Palate Foundation
CPF : Publications :Missing a Tooth

'Nelcorrle
Missing Tooth Fact Sheet
About CLP

Publications Patients with cleft lip or cleft lip and palate are often born with a missing tooth,

most often the lateral incisor (immediately next to the front central incisor).

Nev..-s This may occur unilaterally or bilaterally, but special planning is needed to

Team Care H
solve the functional and cosmetic problems the absence creates.

Who WeAre Who will be involved in dealing with the 11lissing tooth?

Support CPF ) Several dental specialists will be most important in planning treatment.

Orthodontists align improperly placed teeth, while prosthodontists can replace

:, links missing teeth in a variety of ways. Oral and maxillofacial surgeons perform

Research surgery to the teeth, mouth, and surrounding areas of the head and face.

Coordinated planning by all specialists involved is necessary for the best result.

Story of the Month

What role does the orthodontist play in replacing a missing tooth?

The large majority of patients with clefts will require full orthodontic
treatment, especially if the cleft has passed through the tooth-bearing ridge.
Goals of treatment will be to line up the teeth in the upper arch, create an arch
form that is harmonious with the lower dental arch, and line up the midline of
the upper arch with that of the lower arch. When a tooth is missing, the upper
midline is usually shifted, so this must be corrected. A space is often opened up
and maintained for later replacement of the missing lateral incisor.

During orthodontic treatment, an artificial tooth may be attached to the

orthodontic wire as a temporary replacement for the lateral incisor. When the
braces are removed, a removable retainer with an artificial tooth serves to
maintain the space and improve speech and appearance until a definitive
restoration is made.

Is the missing tooth always replaced?

In many instances, the space for the lateral incisor will be orthodontically
and/or surgically closed by moving the canine forward into the space normally
occupied by the lateral incisor. This will then require modification of the canine
to make it appear as a lateral incisor. This may be accomplished by adding
plastic or porcelain filling material or a porcelain crown to reshape its
appearance.

What options are availablefor permanent replacement ofthe

lateral incisor?
Treatment options for the permanent replacement of the lateral incisor depend
upon whether or not the cleft has been repaired with a bone graft. In a non­
grafted dental arch, there are two options for replacement:

http://www.cleftline.org/publications/missingTooth.htm 8/5/2005
 • First, a removable partial denture may be used to replace the missing
tooth. While this option may be made to look acceptable, it has several
disadvantages. The removable prosthesis must cover most of the palate
for support. This may cause irritation on the roof of the mouth or at the
gumline where it rests. Many patients also object to the extra bulk and
removable nature of the partial denture and report that it feels unnatural.
This type of prosthesis is best as a temporary replacement as described
above.

• The second option in a patient without a bone graft is a fixed bridge. The
missing tooth is restored with an artificial one connected to crowns (caps)
on teeth on each side of the cleft. Because there is loss of supporting bone
at each tooth on either side of the cleft, two teeth on each side must
usually be crowned to give adequate support to the bridge. This type of
prosthesis is not removable. Its contours and appearance look and feel
more natural than a removable partial denture. However, it does require
grinding down the support teeth in order to crown them and connect
them to the artificial tooth. Cleaning between the crowned teeth also
becomes more difficult since they are connected.

Can aped bridge be made iml1lediately after braces?

In a teenager or young adult, the nerves and blood vessels in the tooth pulps are
rather large. Drilling down these teeth for crowns may expose the pulps and
require root canal therapy. Therefore, this type of treatment must usually wait
until adulthood when the pulps are smaller.

What options are availablefor a patient who has had a bone graft?
Bone grafting the cleft site in the upper jaw creates a more normal arch and
eliminates special restorative considerations relative to the cleft. A conventional
fixed bridge as described above may be used. In many cases, only one tooth on
either side of the cleft needs to be crowned, since the graft has stabilized the
arch and added bone. If the teeth that hold the bridge are not otherwise in need
of restoration, a resin-bonded fixed bridge may be chosen. This type of bridge
requires much less tooth reduction of adjacent teeth, and there is no danger of
nerve involvement. A porcelain replacement tooth is held in place by metal
extensions cemented to the backs of the adjacent teeth. This is a more
conservative restoration with regards to tooth preparation but still requires
connecting teeth together.

The most natural, lifelike restoration for a patient with a bone graft is a single
porcelain crown attached to an osseointegrated dental implant. This involves a
surgical procedure where a titanium screw the size and shape of a tooth's root is
inserted into the bone at the site of the missing tooth. It is covered by the gum
for six months while the bone bonds to the implant surface. Then the implant is
uncovered and an artificial tooth (crown) is attached. While this procedure does
require minor surgery, it does not require cutting down or crowning any other
teeth. Cleaning is also easier because the replacement tooth is not connected to
any other teeth. This restoration does give the most natural result but does
require that sufficient bone is present in order to hold the screw.

http://www.cleftline.org/publications/missingTooth.htm 8/5/2005
 In summary:

• Finding the best treatment for a missing tooth requires cooperation and
planning among several specialists
• A variety of options for successful tooth replacement are available
• Patients with missing teeth and/or their parents should thoroughly
discuss treatment options with the multidisciplinary team before making
a decision.

top · available publications

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http://www.cleftline.org/publications/missingTooth.htm 8/5/2005