2013

Preclinical Exam

Fixed Pros
Qsn 1:
60 yr old male presented with Max 2nd premolar 25 which was recently
extracted due to caries. The patient is hoping for a fixed solution to replace
the missing tooth 25. There is insufficient mesio-distal space available for
this placement of a dental implant. Tooth 24 is unrestored and tooth 26 is
restored with small mesio-occlusal and disto-occlusal amalgam
restorations. The patient has bilateral canine guidance during lateral
excursive movements.

a) Outline in detail the dental exam and any special tests you would
perform for this pt (20 min)

Dental exam for this patient would include regular dental charting to assess the
patient’s caries risk and if any other treatments are required for the care for his
overall dental health.
- Comprehensive intraoral and extraoral examination
o Smile line, tooth display, etc.
o TMJ
o Occlusion – static and dynamic, overjet, overbite
o Parafunction (*contraindication for RBB)
- Healing of extracted site (25) – find out when the tooth was extracted,
complications
- any other fixed/removable prostheses present (patient acceptance)
- condition of other prostheses (patient oral hygiene and prognosis for new
prostheses)
- any other missing teeth in upper arch – determine if denture would be
more suitable
- Examine 24 and 26 – any caries, restorations satisfactory
Periodontal probing should be carried out to assess the presence and severity of
any present or previous periodontal disease.

Special investigations
• If there is no current OPG (within 2 years), obtain an OPG and examine for
any pathology/apical radiolucency/caries/bone loss. Examine the root
length and conditions of 24 and 26. Monitor healing of extracted site of
25.
o Alternative – PA for 25 (try to get 24 and 26 in)
o BW’s may be useful for interproximal caries (ALARA)
• Diet assessment à caries and erosion risk
• Saliva test
• Plaque index
• Vitality tests, TTP tests for potential abutment teeth – if indicated from
radiographs
• Study casts
• Shade match


b) Outline the available tx options in descending order of preference
together with the advantages and disadvantages of each option (20
min)

1. Resin-bonded bridge
• Advantages: - Reduced chair time and cost - Rebonding possible - supragingival prep
o Minimally invasive (potentially reversible)
o Cost effective
o Long-lasting (if good case selection, prep dsign, lab techniques, and
clinical techniques)
o no compromise to abutment teeth - less potential for pulp trauma of abutment tooth
o shorter tx time Supraginbgival margins
• Disadvantages:
o long-term prognosis as definitive restoration unknown
o may be less retentive than conventional bridge
o technical variability between practitioners (different designs)
o Requires excellent oral hygiene from patient
o Enamel modification is required
o Good alignment of abutment teeth required

2. Conventional bridge
• Advantages:
o Potentially more retentive than RBB
• Disadvantages:
o Destructive to tooth structure (especially for sound 24)
o Requires excellent oral hygiene from patient
o Good alignment of abutment teeth required


3. Removable prostheses (denture) - pt wanted fixed
• Advantages:
o Can replace other missing teeth in the same arch
• Disadvantages:
o Compromises dental and periodontal health (especially if high
caries risk and poor oral hygiene)
o Difficult to maintain
o Can cause trauma to soft tissues
- Less hygienic

c) State your preferred tx option and outline the tx execution sequence
in detail (20 min)

The preferred tx option is resin-bonded bridge for this patient.
1. History and examination, radiographs
a. Health, space, cost
b. Pt expectations
c. Occlusion
d. Shade selection
 2. Examine abutment teeth
a. Pulpal/perio health à good oral hygiene and favourable
periodontal status desired
b. Sufficient enamel
c. Minimally restored
d. Minimal wear
e. Minimal translucency
f. Ovoid/square form (Avoid triangular/conical form)
g. Angulation à path of insertion
h. Vertical length of abutment à consider crown lengthening

3. Preparation of abutment teeth
RBB w/ multiple abutments are more likely to debond due to differential
a. One wing on tooth 34 movement of the abutment teeth
i. Single abutment better than double
ii. Abutment tooth should be sound or minimally restored
iii. Occlusion should be stable
b. Tooth prep includes
i. Creating large palatal bonding area with proximal wrap
ii. Definite, single path of insertion
iii. Occlusal, incisal or cingulum rest seats
iv. Proximal grooves/slots
c. Strength of bonding to prepared and etched enamel is greater than
etched but unprepared enamel
d. Preparation should cover as large as area as aesthetically possible
i. Sufficient proximal and palatal surface reduction
ii. At least 180 degree wraparound for resistance
e. Cervical margin within enamel and supragingival
f. Preparation should ensure precise insertion path
4. Study models (articulated)
5. Frame work fabrication (lab)
a. Master cast duplication
b. Resin coping fabrication
c. Wax pattern
d. Investing and casting
6. Bonded with resin cement
a. Isolation of abutment teeth by RD à avoid contamination
b. Clan abutment tooth with pumice and rubber cup
c. Etch, rinse, dry
d. Prime
e. Resin
7. Post-operative care
a. Regular recall exams
b. Attention to periodontal health is critical (plaque retention)
c. Calculus removal with hand scalers rather than ultrasonic to avoid
debonding


Endo

 a) Describe management of endodontic emergencies (30 min)

• “Endodontic emergency” = pain and/or swelling, caused by various stages
of inflammation or infection of the pulpal and/or periapical tissues.
• Causes:
o Caries
o Deep, defective restorations
o Trauma
• 85% of dental emergencies come from pulpal or periapical disease
o either exo or endo to relieve symptoms
Diagnosis
• methodical, subjective, and objective evaluation is imperative before
developing a proper tx plan

Types of endodontic emergencies:
1. Irriversible pulpitis and normal periapex
2. Irriversible pulpitis + acute apical perio
3. Necrotic pulp + acute apical perio, with no swelling
4. Necrotic pulp + fluctuant swelling, with drainage
5. Necrotic pulp, fluctuant swelling, with no drainage
6. Necrotic pulp, diffuse facial swelling, with drainage through canals
7. Necrotic pulp, diffuse facial swelling, with no drainage

Emergency Endo Management
• Pain is both psychological and physical entity
• Management should consider both physical symptoms as well as
emotional state of pt
o Needs, fears, coping mechanisms understood with compassion
o Build rapport
• Accurate dx
o Chief complaint
o Medical hx
o Special investigations
• Once decided endo tx is necessary, manage the acute dental emergency
• Inform pt recommended tx plan, alternatives (benefits, risks, prognoses)
and obtain informed consent
o Endo or exo
• For emergency, tx depends on
o pulpal and periapical status
o intensity and duration of pain
o diffuse or fluctuant swelling

Vital Teeth Reversible - Conservative removal of irritant and resto
pulpitis - If recession and root exposure, topical
desensitising agents to reduce dentin
hypersensitivity
Irreversible - symptomatic often emergency
pulpitis - requires immediate tx with
intermittent/spontaneous pain
 - initiating root canal tx with complete pulp
removal and total cleaning of the root canal
system
- Sources of infection (caries + defective
resto) needs to be completely removed to
prevent recontamination of root canal
system
- time constraint in emergency visits à may
not achieve total cleaning
- pulpotomy for multirooted teeth
AB not recommended
Pulpal No swelling - Complete instrumentation of root canals
necrosis whether swelling or no swelling
with acute - trend toward not leaving tooth open for
apical drainage
abscess - calcium hydroxide medicament in between
visits
- careful not to push necrotic debris beyond
apex à promotes post-tx discomfort
- electronic apex locator can help with WL
single visit RCT not recommended
Swelling - Drainage & remove source of infection
- Establish drainage through root canal or by
incision (fluctuant)
- If localised swelling, drainage via root canal
preferred
- Complete canal debridement and
disinfection important
- Tissue swelling à acute periradicular
abscess at first visit or could be flare up or
post-endo complication at later visits
- Swelling can be localised or diffuse,
fluctuant or firm
AB
Symptomatic - technically challenging and time consuming
with (crown, bridgework, posts and cores, etc.)
previous - goal still management of necrotic teeth à
endo tx remove infection from RC system and
establish patency to achieve drainage
- remove posts and obturation
- carefully assess ability, practicability, and
feasibility to re-treat beforehand
Flare-ups - acute exacerbation of periradicular pathosis
after initiation or continuation of
nonsurgical RCT
- reasons: prep beyond apex,
overinstrumentation, debris past apex,
incomplete removal of pulp, chemical
irritants, root fractures, etc.
 AB prophylaxis controversial
Cracked and - difficult to locate and diagnose
fractured - removal of filling, dye solutions,
teeth transillumination, selective loading of cusps
can help detection
- sharp pain in vital teeth, dull ache for
nonvital or obturated teeth from
mastication
- management: bonded restoration, full
coverage crown
- often require endo or exo



b) Discuss traditional hand and contemporary rotary NiTi canal
preparation (30 min).

Please look at Parashos lectures!