Unseen case revision

What is Erosion??

Chemical means of TSL

Extrinsic - acidic diet

Intrinsic - Diet, bulimia

What is attrition?

Tooth-Tooth contact

Bruxism

Edge to edge contact - Class III

This is shown via flattening

What is Abrasion?

contact other than tooth to tooth

Brushing

tongue piercing

food

What is abfraction?

Flexural forces along the long axis of the tooth

What are the special investigations for toothwear?

Plaque bleeding

OH assessment

Diet analysis - find aetiology

BEWE

Tooth wear index

Clinical photos

Study models

What is the critical pH?

5.5 for enamel

6.2 for cementum

What are the affects of TSL?

Poor aesthetics

Reduced clincial crown height

Yellow teeth

Overclosing - angular cheilitis

Occlusal instability

Loss of function

Pulp inflammation and devitalisation

Difficulty bonding, less enamel

What is important to note in terms of tooth surface loss?

It is multifactorial, ensure that do not tunnel vision on one cause.

What is the tooth wear index?

What does the BEWE measure?

Erosion only but DBO says it is used for toothwear as a whole

What is a facebow?

Device that records the relationship of max arch to horizontal axis of rotation of the mandible. (transfers info to articulator)

How to treatment plan? fixed pros / TSL

- Patient expectations?

- Management of the aetiology

- Periodontal stability - Poor prognosis teeth?

- Pulp and periodontal support

- Tooth tissue? - Suitable for certain treatments? Ferrule?

- Occlusion

What is Canine guidance?

When you slide your jaw to the side with upper and lower canines touching, they should "guide" the rear teeth apart - i.e. slide to the side and your molars should separate immediately.

What is group function?

Multiple contact relations between the max and mand teeth in lateral movements on the working side whereby simultaneous contact of several teeth acts as a group to distribute occlusal forces.

What is ICP?

Centric occlusion

Maximum intercuspation, stable reproducible bite

What is retruded contact point?

First point of tooth contact where the mandible is in the most anterior superior position in the glenoid fossa.

What is RVD?

Resting vertical dimension

Relationship of maxilla and mandible at rest

What is Occlusal vertical dimension?

Relationship of maxilla and mandible during occlsion

What is the average free way space?

2-4mm

RVD - OVD

What can an increased FWS indicate and difficult to manage?

Tooth surface loss

Can have TMJ issues where changing the relationship of the jaws

Indications for fixed pros

Heavily broken down teeth

Cracks and fractures

Post RCT

Tooth surface loss

How to determine whether a tooth is restorable?

- Patient expectations?

-Periodontal stability - Poor prognosis teeth?

- Pulp and periodontal support

- Tooth tissue? - Suitable for certain treatments? Ferrule?

- Interocclusal space

+

tooth restorability index

Tooth tissue for restorabiity:

Clinical crown height - Posterior: 3mm

Anterior: 4mm - Crown lengthing, increased height with comoposite

Supra/ subgingival margins

Biological width - Prep no further than 0.5mm subgingival to avoid this area.

Crack

How to determine prognosis of a crack?

Supraginginval - good prognosis to be saved

Subgingival - Poor prognosis as difficult to get coronal seal,. Isolated deep pocket with sub gingival cracks

If crack extends to pulp floor - unrestorable

What are the principles of crown prep?

Retention and resistance form

Structural durability

Preservation of peridontium

Preservation of tooth structure

Marginal integrity

Why not alginate for crown impressions?

Not dimensionally stable

Can distort and become inaccurate

Types of crowns for GIC cements?

PFM, FGC

Types of crowns for RMGIC?

PFM,. Full metal

Types of crowns for resin cement?

All ceramic, PFM, Full metal

Types of crowns for Zinc poly carboxylate cements?

PFM and full metal

Advantages and disadvantages of PFM crown:

Good aesthetics, Stronger than fullc eramic

Disadvantages:

Wear on opposing teeth

Heavy tooth prep

Advantages and disadvantages of Zirconia crown:

Aesthetic

Heavy tooth prep

Wear to opposing teeth

Advantages and disadvatages of lithium disilicate

Best Aesthetic

Heavy tooth prep

Wear to opposing teeth

Advantages and disadvantages of Non-previous metal crown:

Minimal tooth prep

Best mechanical properties

Least wear on opposing teeth

Poor aesthetics

Describe post-core crown:

Root canal must take place

Finish line must finish on natural tooth

Types

Pre-fabricated

Direct cast

Indirect cast

What is a Nayyar Core?

Posts are not viable and extensive coronal tissue

Remove 3-4mm of GP

Pack amalgam or composite. Then crown prep

Ferrule must be present, margins on tooth structure

Advantages of resin retained bridge?

And disadvantages

Fixed

Minimal prep, Minimally invasive

Replace 1 unit

Dependent on occlusion

Poor aesthetics in spaced

Can debond easily

80% survival 10 years

Advatntages and disadvantages of conventional bridge?

Fixed

Can reinforced heavily restored teeth

Significant tooth prep

Irreversible

Potential Devitalisation of pulp

Replace minimal number of teeth

Poor aesthetics in spaced dentition

72% survival 10 years

Advantages and disadvantages of dentures:

Replaces multiple teeth

Aesthetcis

Can alter facial profile

Protect existing teeth

Plaque trap

Removable

Altered temperature and taste detection

Fungal infections

Trauma

Pre denture assessment?

Expectations, concernsm,

Denture history?

Medical history - Xerostomia? Risk of fungal?

Oral hygiene

Ridge shape, Arch shape

Gag reflex?

Lip line - aesthetics

Periodontal support

Occlusion, excursions, and guidance

Interocclusal space

How does kennedy classi 1 & 2 affect denture?

More likely to be unstable due to unbound saddles

How does Cawood and Howell class affect our dentures?

First 4 months post extraction will be the most resorption which will affect the extensions and retention

What are the stress bearing regions in maxillary complete denture?

Palatal rugae

Residual ridge

Maxillaryu tuberosity

What areas need to be relieved in maxillary complete denture?

Frenal attachments

Insive papilla

Mid palatine raphe

What are the support areas of a mandibular complete denture?

Residual ridge

Buccal shelf

Retromolar pad

What are the relief areas of a mandibular complete denture?

Frenal attachments

Mental foramen

Genial tubercle

Mandibular tori

Mylohyoid ridge

Acrylic denture versus Cobalt chrome

Can easily add poor prognosis / lost teeth

Plaque trap can worsen perio

Tissue supported only

Disturbed temperature perception

Cheaper

Less hygiene, weaker and less tolerable

Co/Cr:

Tissue and tooth supported

More difficult to do additions, need to be planned for before construction of denture

Minimal gingival coverage

More hygienic

More expensive

Better tolerance

How do we get retention in dentures?

Clasps and precision attachmemnts

Indirect retention

Guide plans and friction

Well extended flanges within neutral zone

Peripheral seal

Gravity

How do we get support from dentures?

Tooth borne: Rest seats, milled

Mucosa borne

Implant

Where do we get stability in dentures?

Combination of retention and support

Denture instructions at fit:

Show them how to insert and remove

Advise that it can take up to 6 months to adapt to speech, eating and comfort

Remove the denture at night, brush with a soft bristle brush and soap over a basin of water and keep in sterilising solution

Call back with any concerns.

How should I note down the HPC?

See if socrates is answered for the complaint

And write the differentials

Other considerations for History of case: EO/ IO

Limited mouth opening, nocturnal

Bad taste? Systemic unwell, swelling

What questions to ask about epilepsy?

Last fit?

Any triggers?

What sort of symptoms do they have?

Aura?

How do they want to helped during seizure?

Self limiting?

What should I think if they are taking omeprazole or similar?

GORD, reflux

Aetiology of erosion

Questions regarding asthma?

Stable or unstable

When was the last asthma attack?

Any hospitalisations?

Think varnish, colophony

What should we note regarding social history?

Smoking: How long, how many a day. What type? (chewing). Have they tried to quit before

Drinking: How many units a week? 14 is recommended, Lots of alcohols can be erosive

Combined together - oral cancer risk

Stress? Bruxism, occupation

Recreational drug use.

Past dental history?

Regular?

Only attend when in pain?

Anxiety?

Will they be reliable.

Oral hygiene regime

What to note intraorally from the photographs

Swelling

gingival condition

Inflammation

Recession

Potential areas of caries - even if suspiscious, do not sit on fence

Fractures

Discolouration

Pigmentation

Toothwear

Deficient restoration

Colour - with probing can state

What differential periodontal diagnoses are there?

Gingivitis - localised / generalised

Periodontitis - Localised / Generalised / Molar - incisal

If not full mouth IOPA state this for stage and grading

When to take xrays and why?

Bitewings - investigation of caries, overhangs and plaque retentive factors

IOPA - Apical pathology, horizontal bone levels for perio.

OPG: ID canal, developing dentition, gag reflex. Poor for anterior

How to infer prognosis of teeth?

Bone loss - Perio

Is there enough tooth tissue

Root morphology, infection

How does tooth tissue affect prognosis?

Structure for coronal seal? can it support restroation?

Cracks?

Equ/Sub gingival

Into pulp?

Ferrule

Bone levels

Template of treatment planning?

Emergency Phase

Prevention and stabilisation phase

Restorative

Maintenance and recall

Prevention and stabilisation phase?

DOFF

Periodontal disease

On going carious lesions

Parafunctional habits

Restorative phase:

Indirect and direct restorations

Denture work

Endodontic work

Review periods

Periodontal - 6 to 8 weeks for review of charting, plus 2 years radiographs

Endodontic - 1 year post endo for xray and clinical findings

Caries - high risk 3 months, 6 months radiographs

How to get informed consent?

Give the patient every realistic option

Always offer no active treatment

Risks, benefits and costs

Dentine hypersensitivity:

Exposed dentine tubules causes pulpal hyperalgesia

Cause: TSL, Internal bleaching, Gingival recession

Sharp pain, lasts no longer than a few seconds

Manage aetiology, varnish, ohi and diet advice, desensitising agents

Describe Symptomatic apical periodontitis:

Pain on biting - TTP +ve

Easy to localise

Radiograph:

Widening of PDL, Apical radiolucency +/-

Asymptomatic apical periodontis:

Asymptomatic but has an apical radiolucency

Describe acute apical abscess

Rapid onset of severe pain

Extreme tenderness, suppuration, swelling, fever, systemic

Widening of PDL, apical radiolucencyt +/-

RCT. XLA

Describe chronic apical abscess

Typically asymptomatic, sinus tract formation

Foul or metallic taste

Apical radiolucency

Key indicator diagnosing cracked tooth?

Pain on release of biting

How to investigate cracked tooth syndrome?

Transilumination, dye

Tooth sleuth

Sensibility testing

Occlusal assessment

Radiology - can show bone loss

Mobility

Pocketing

What is emergency treatment for cracked teeth?

Occlusal reduction

Composite splint

Orthoband

Keys to an access cavity:

Straight line access

Able to support restoration

convergent walls

No unsupported enamel

How do we assess endo in review?

Abscence from pain, swelling, sinus with no loss of function, evidence.

Is the GP condense suitably

Is the GP 0-2mm away from the apex

No overhangs, good contour

Indications for surgical endodontics

Evidence of apical pathology that cannot be accessed conventionally

Extruded apical material

Persisting pathology following RCT where Re-RCT inapproapriate

Perforation that cannot be accessed via chamber

Types of surgical endo?

Incision and drainage

Apicectomy and curretage

Root hemisection

What are the risk factors for periodontitis?

Poor OH

Smoking

Increased age

Dentures

Pregnancy

Diabetes

Stress

Genetics

Plaque retentive factors

Medication induced gingival englargement

What are the 5 As of smoking:

Ask: Regularly inquire about your patient's smoking status.

Advise: Strongly and clearly advise all smokers to quit for their health.

Assess: Determine their readiness to quit and their stage of change (e.g., precontemplation, contemplation, action).

Assist: Help them quit by providing support, counseling, and potentially medication or other cessation aids.

Arrange: Schedule follow-up appointments to monitor progress and provide ongoing support.

What is the cage questionnaire regarding alcoho?

Every thought about cutting down alcohol consumption

Ever become angry when questionned on alcohol consumption

Ever felt guilt about drinking habits

Eye opener - do you drink first thing in the morning

What is tunnelling surgery?

Reconoturing furcation to allow cleaning with an interdental brush

Degree 3 furcation

What is resective surgery?

gingival and bone contouring to shift the margins apical and produce a healthy sulcus depth

Reduced PPD and improved hygiene

Recession has to be accepted

Single wall defects or class 1 furcation

What is regenerative surgery?

Regeneration of soft and hard tissues

Guided tissue regernation, bone graft and enamel matrix derivative

Two or three sided wall defects or degree 2 furcations

How is asthma relevant to dental appt

Medical emergency

Allergy to colophony with severe asthma contraindicated

Well controlled

Hospitalised?

Steroid inhaler?

What is preventative stages for caries:

Diet, oral hygiene advice

Smoking cessation

Fluoride - 5000ppm, varnish 2-4x a year

What are 3 factors to create an ideal occlusion?

ICP coincident with RCP

Posterior teeth make initial contact

Anterior teeth provide guidance on excursion and protrusion

When is group function preferred over canine guidance?

When you cannot get canine guidance - class 3, AOB, class 2 div 1

Unfavourable canines

short crown:root

Conseuqences of occlusal interfences ?

symptomatical apical periodontitis

TMJ pain.

Cusp fracture

increase mobility

root fracture

What are 5 principles of post and core prep:

Length if post should be longer than height of crown

4-5mm apical GP

At least 2mm of circumferential ferrule

Post no more than 1/3 diameter of root

Post shouldn't exceed diameter of shaped canal

If there is not enough supragingival tooth for crown, what can be done?

Ortho extrusion, crown lengthen, gingevectomy

What splint should be suggested for a bruxism?

Soft splint first line and mild

Hard acrylic full coverage splint the gold standard

When are antibiotics/steroids used in RCTs?

Vital teeth when haemorrhage control is difficult

Acutely inflamed pulp where analgesia cannot occur

Insufficient time for RCT following pulp exposure

What are the requirements for the ferrule effect?

Axial wall = 1.5-2mm above marginal gingivae and 1mm thick

Parallel axial walls

Margins of prep should sit on sound tooth structure

4-5mm of supra bony tooth structure should be available

What are main reasons for RCT failing?

Accessory canals unfilled

Loss of coronal or apical seal

Root fracture

Perforation

Periodontal pathology

Composition of amalgam and what was added to help with corrosion?

Mercury, Silver, Tin, Copper

Copper was added to help

Factors of composite?

Poor compressive strength

Relatively high tensile strength

Good aesthetics

Adhesive bond

Moderate wear resistance

Staining

Polymerisation shrinkage, - increased filler helps

What aspect of the panavia methods bonds to tooth?

MDP bonds to hydroxapatite