OSCE LEARNING OBJECTIVES

CAD/CAM

1) List the steps for completing a CAD-CAM restoration in one visit.

a) Scan
i) Scan prep and adjacent teeth as indicated
ii) Data density view, erase extra information
iii) Scan opposing and buccal
iv) Verify bite alignment (pop-pop)
v) Set orientation
vi) Trace margin
b) Plan
i) rotate/resize/move crown
ii) Freeform, rubber tooth, move tools
iii) Goal: help to expedite autogenesis
c) Design (T-O-P order)
i) Adequate material thickness
ii) Occlusion & Anatomy: bite registration, view and refine contacts, embrasures
iii) Interproximal: hide model, smooth surface or dropper to create ideal contact
d) Milling
i) Sprue position--away from margins, contacts, occlusion
ii) Send to mill
e) Remove sprue, adjust, patient try-in
f) Stain & glaze
g) Crystallization and cooling
h) Bonding/cementation
i) Check occlusion and adjust as needed

2) Apply the sequence and key tools for a CAD/CAM workflow, from preparation to final delivery in a
one-day appointment.
a) Prep
i) Healthy soft tissues
ii) Rounded/smooth angles
iii) Supragingival margins
iv) Continuous, smooth margins
b) Chairside scanning
i) Laser based system, full color video
ii) Start with scanner parallel to occlusal plane, touching tooth
iii) Use continuous movement
iv) Adequate scan
(1) Posterior: prep tooth, 1 anterior, 1 posterior, 3-5mm buccal tissue
(2) Anterior: prep tooth, canine to canine, 3-5mm buccal tissue
(3) Opposing: occlusal surface, 3-5mm buccal tissue
(4) Buccal bite: proper occlusion in MI
c) Design

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 i) Library method: anatomic information is taken from adjacent cuspal reference points
and automatically placed on the design proposal
ii) Correlation method: a contoured surface is used as reference to be overlapped in
new design, overlapping pre-saved anatomy (pre-op scan) onto design proposal
d) Milling
i) 100 um cement space
ii) Standard mill mode: crowns
iii) Detail mode: inlays, onlays
e) Stain & glaze
i) Hemostat, cement spatula, composite placement instrument
ii) Crystal glaze, yellow stain (cervical), blue stain (cusp), white stain (cusp tip)
iii) Suspend crown on pin, place onto firing tray, begin crystallization
f) Delivery

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3) Recommendations gnize and describe the steps in selecting and using library versus correlation
methods in different clinical situations.
a) Library method: anatomic information is taken from adjacent cuspal reference points and
automatically placed on the design proposal
i) STEPS
b) Correlation method: a contoured surface is used as reference to be overlapped in new design,
overlapping pre-saved anatomy (pre-op scan) onto design proposal
i) STEPS

4) Recognize and correct errors in CAD/CAM scanning, orientation, margination and design.
a) Tip always faces distal, gently sit on teeth, do not tilt B/L
b) Reflection and scatter of light: dry field, proper isolation, turn off external lights, Scan Model
Mode for metal surfaces
c) Black hole: scanner is too hot, cable malfunctioned, right USB port

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 d) Color off: calibrate scanner
e) Part of model missing: start scan on incisal edge, not lingual
f) Blue area: underscanning, insufficient data to be able to make restoration
g) Speckled/artifacts: overscanning, activate Active/Delete and scan over site quickly
h) models are not popping into place: use refine buccal bite tool or drag buccal bite scan into
place

5) Differentiate the two milling modes for a single restoration and their clinical applicability.
a) Smooth preps allow more uniform intaglio milling.
b) standard mode: crowns, quicker and larger bur, may be detrimental if we have sharp cusp
tips. If we mill standard mode with irregularities on the prep, the bur mills on the intaglio to skip
them - more overmilling.
c) detail mode: inlay, onlay, takes longer but uses smaller bur, more precision and less structure
taken away for sharp cusp tips, undercuts, or other errors in the prep/design. If we mill detailed
mode with irregularities on the prep, intaglio has less overmilled surface.

6) Describe material requirements/limitations for CAD/CAM restorations.

a) PMMA block (acrylic)
i) for long term provisional, single crown, FPD
ii) Contraindicated for permanent restorations
b) Feldspathic
i) For veneers, inlays, anterior crowns (select cases)
ii) Contraindicated for FPD, posterior crowns, bruxers
c) Leucite
i) for veneers, inlays, anterior crowns (select cases)
ii) Contraindicated for FPD, posterior crowns, bruxers
d) Lithium Disilicate
i) For veneers, inlays, onlays, single crowns, anterior 3 unit FPD, posterior 3 unit FPD up
to 2nd premolar as terminal abutment
ii) 1 mm radial shoulder, 0.5 mm supragingival margin, 2.0 mm occlusal reduction,
functional cusp bevel, 6-10 degree taper, axial reduction as needed
iii) Contraindicated for bruxer, surveyed crowns for RPD, 3+ units for FPD (1+ pontic)
e) Zirconia: OXIDE ceramic
i) For monolithic single crowns and monolithic FPD
ii) 0.5 mm radial chamfer, 0.5 mm supragingival margin, 1.5 mm occlusal reduction,
functional cusp bevel, 6-10 degree taper, axial reduction as needed
iii) Contraindicated for veneers, inlays

7) Describe milling requirements/limitations for CAD/CAM restorations.

a) Cement spacer is 100 um, margin ramp 25 um, thickness based on manufacturer
b) Material thickness should be yellow only around the margin (not red)

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 c) Occlusion: flattened, minimal geometry with no excursive interferences

IMPLANTS

1) Identify the parts/instruments in the surgical/restorative kit and their used in placement and
restoration of the Bicon brand of press-fit implants.
a) Pilot drill – used to initiate osteotomy
- Drill to depth that allows implant to be placed 2mm subcrestally
b)Latch reamers – different diameters/lengths - finalize osteotomy for implant size
c) Electric drill system w high torque handpiece
d)Hand driver – allow us to screw implant parts w ends specifically shaped for them
e) Open/closed tray impression coping – capture exact 3D dimensional spatial position of an
implant in the mouth and transfer it to the impression then to a cast
f) Implant analog – has same inner screw workings as implant in the mouth
i) Acts as the implant for the cast
g) Healing abutment – guide soft tissue healing around implant and allow access later
h) Guide pin – confirms proper angulation of osteotomy
i) Curette and dappen dish – used to harvest autogenous bone and confirm intact walls of
osteotomy
j) Threaded straight handle and implant inserter-retriever – to insert and retrieve implants
(mallet also used for retrieval)
k) Healing plug – to insert the implant (don’t touch a sterile implant); guides soft tissue healing
during implant integration and permits access to implant for restoration
l) Threaded straight handle, seating tips, and mallet – fully seat implant into osteotomy
m) Healing plug cutters – trim healing plug
n) Healing plug remover or hand driver – remove healing plug after uncovering
o) Threaded straight handle and sulcus former – to shape the crestal bone after uncovering and
create space needed for restoration

2) Recall the steps for performing the osteotomy and placement of a press-fit implants.
a) Use Vacupress surgical guide or use adjacent teeth as landmarks to guide preparation
b) Pilot drill – used to initiate osteotomy
i) “Bicycle grip” recommended by manufacturer
c) Confirm proper angulation using guide pin
i) Paralleling xray recommended
d) Latch or hand reamers – different diameters/lengths - finalize osteotomy for implant size to
adequate diameter and depth
e) Use curette to harvest bone and confirm osteotomy walls are intact
f) Use healing plug or implant inserter-retriever to insert implant into osteotomy site
i) Healing plug: insert a seating tip into the healing plug and tap implant with mallet until
seated
ii) Inserter-retriever:

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 (1) push implant to place using hand pressure only
(2) Twist upper knob counter clockwise to release implant
(3) Use seating tip to tap implant into place
(4) Re-insert black healing plug into implant
g) Cut healing plug at level of bone crest using healing plug cutters

3) Recognize errors in the osteotomy preparation and/or implant placement (e.g. position, angulation,
etc.)
a) No external irritation w osteotomy – frictional heat damages bone
b) Using wrong speed
i) 1100 RPM for pilot
ii) 50 RPM for latch reamers
c) Guide pin should be parallel to adjacent teeth
d) Implant should be placed subcrestally (roughly 2mm subgingivally)
e) Buccal/lingual pin position approximates central grooves of adjacent teeth

4) Describe the design features of the Bicon brand of press-fit implant that improves crestal bone
maintenance.
a) Micro-textured surface – speed osseointegration to stimulate/guide cellular activity and
maintain crestal bone
b) Slow speed drill used – decreases chance of overheating and destroying bone
c) Passively engage w bone
d) Sloping shoulder – more room over implant which supports crestal bone and interdental
papillae
e) Plateau tapered design - 30% more surface area than other threaded implants
f) Platform switching – by moving the interface of implant and abutment away from the crestal
bone, you reduce the inflammatory response and maintain more bone
g) Microthreads in collar and conical interface btw implant and abutment – reduce stress
transmitted to crestal bone
h) 1.5 degree locking taper – provides bacterial seal and 360 degrees of abutment positioning

5) Describe the treatment benefits of primary implants stability associated with threaded implants.
a) Threaded implants undergo active bone engagement --> good primary implant stability at
time of surgical placement
i) Good primary stability is good predictor of osseointegration success
ii) Osseointegration = no fibrous soft tissue between bone and implant surface – direct
bone to implant interface
b) Can perform 1 stage implant surgery w threaded implants
c) Can immediately provisionalize

6) Describe the various impression techniques that can be used to restore both implant systems: the
Bicon brand of press-fit implant and threaded implant.

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a) Impression techniques for PFM crowns
i) Direct abutment level impressions
(1) Clean implant well with sterile water then dry
(2) Place and tap universal or non-shouldered abutment into place
(3) Mill abutment w carbide bur (???)
(4) Inject impression material around abutment and place impression into tray to make
impression just like natural tooth
(5) Do not remove abutment after final impression in order to prevent changes in
orientation
ii) Implant level impression – can be done during uncovering procedure or after soft tissue
healing
(1) Use impression post, impression sleeve, and implant analog
(2) Inject impression material around sleeve
(3) Impression sleeve comes off w impression tray
(4) Impression post must stay inside implant well and be removed by dentist
(5) Insert universal or abutment analog into sleeve (in impression)to send to lab
(6) Lab fabricates soft tissue model while pt soft tissue heals
(7) Milled abutment and crown are cemented together extraorally
(8) That whole unit is tapped into implant
b) Closed tray impression: popular for single and short unit restorations
i) Screw the closed tray impression coping on to the implant (the hex end fits precisely into
the implant) using light finger pressure only
ii) Cover the access hole with a little periphery wax to keep impression material out of the
access hole
iii) Inject light body material around the impression coping, completely cover
the impression coping with impression material
iv) Load the tray with heavy body material
v) Insert the tray and remove the set impression after 5 minutes
vi)Unscrew the impression coping and screw it on to the implant analog
vii) Plug the assembly into your impression (align the orientation fin with the groove in your
impression; you will feel or hear it snap into place)
c) Open tray impression: popular for longer unit and full arch restorations (Especially useful for
multiple divergent implants)
i) Screw the open tray impression coping on to the implant (the hex end fits precisely into
the implant
ii) Modify a stock impression tray by cutting a hole (to allow you to unscrew the coping after
making the impression)
(1) If the hole is too big: customize with periphery wax
iii) Block out the coping access hole with periphery wax to keep impression material out of
the access hole and make the coping easier to find
iv) Practice inserting your tray before filling; then inject light body material around the
impression coping (don’t cover the screw post with impression material this time)

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 v) Load the tray with heavy body material and insert it into the mouth so that the coping
screw comes through the hole you made in the tray (expose the impression coping screw
using a finger or instrument before the material sets)
vi) Unscrew the coping to remove the impression (you will feel/hear a clicking noise)
vii) Remove the impression (the coping will be locked within the impression material)
viii) Screw an implant analog on to the coping
d) Virtual impressions
i) “Scan body” impression coping is screwed on to the implant
ii) Scan the site making a virtual impression

7) Explain the advantages of cement-retained vs. screw-retained restorations for threaded implants.
a) Bicon implant and abutment are friction retained – cementless and screwless –
i) Abutment and crown are either milled as one unit (integrated abutment crown) oR
cemented together extraorally and delivered as one unit
ii) decreases chance of implantitis from excess cement or broken screw in implant
b) Screw retained implants - the retaining screw enters through the crown and engages with the
implant
i) Restoration requires filling screw hole with removable material and then composite on
top – can look less esthetic but allows for later retrieval of implant
ii) Indicated for posteriors
c) Cement retained implants - abutment still engages with the implant through a screw. Crown is
cemented onto abutment
i) Retrieval of implant cannot occur without destroying the implant crown but there is
no access hole so esthetics are superior
ii) Indicated for anteriors

8) Recall the steps for placing implant overdenture attachments into a prosthesis that will be retained
by threaded implants. - see Implant Rotation II for 2020-2021 in 1632L
a) Implants are already placed in the mouth and integrated
b) Use locator core tool to screw locator abutments into the implants
c) Remove metal housings from prosthetic overdenture
d) Place white locator blockout spacer over each abutment in the mouth – to keep the
processing material from locking on to the abutments
e) then place processing attachments into each implant abutment
f) Drill holes in the prosthetic overdenture to accommodate the new metal housings
g) After processing attachments are set in the prosthesis, remove the black part from the metal
housing and replace w final blue attachments using locator core tool
h) Now they snap on to the abutments in the mouth – yay

9) Describe the steps in delivery of screw-retained implant crown on a threaded implant.

a) After implant osseointegration and impression and crown fabrication: remove healing cap
b) Place abutment into implant

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 c) Place implant crown over abutment and use hand driver to screw in retaining screw
d) Fill void with plumbers tape, then with composite

RADIOLOGY

1) Recognize types of radiographs (BW, PA, PANO, Occlusal, etc.)

a) Periapical (PA) – surrounding the apex of tooth

● Full length of the roots and at least 2 mm of periapical bone must be visible.

b) Bitewing (BWX) – interproximal, used to look for caries

● Should demonstrate each posterior proximal surface at least once.

c) Occlusal – show roof or floor of mouth; used to identify extra teeth, unerupted teeth, jaw
fractures, cleft palate, cysts, abscesses, foreign objects, etc.

d) Panoramic (PANO) – tube rotates around pt head to provide single film of the entire oral
cavity; used to view 3rd molars, analyze mixed dentition, and evaluate pathology/trauma

2) Identify teeth (by number/letter), dental materials, and restorations on a given radiograph.

a) Amalgam: distinct, irregular borders, highly radiopaque

b) Composite: distinct, irregular borders, moderately radiopaque

c) Liners/bases: distinct RO/RL from restorative material

d) Gold: smooth marginal outline, highly radiopaque

e) Stainless steel: smooth marginal outline, highly radiopaque but less so than amalgam or gold

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 f) Ceramic (general): slightly radiopaque, similar to dentin

g) eMax Ceramic: slightly radiopaque, cement line usually identifiable

3) Recognize and identify abnormalities on a given radiograph (presence of caries, periodontal disease,
radiopacities, etc.)

a) Cervical burnout: ring of RL at cervical; do not confuse with decay

b) Shape of carious lesion: triangle with broad base at tooth surface spreading along enamel
rods, when lesion reaches DEJ forms second triangle with apex towards pulp chamber
c) Health

i) PDL space: thin RL line, continuous and uniform

ii) Lamina dura: dense RO line around tooth

iii) Alveolar crest: 1-2mm apical to CEJ of adjacent teeth, thin and pointed in anterior

d) Disease

i) use periapicals, paralleling technique to record crestal bone accurately

ii) see amount of bone present, condition of alveolar crests, bone loss in furcation areas,
width of PDL space, local irritating factors contributing to periodontal disease
iii) Early bony changes: loss of cortical density, rounding of crest
iv) Horizontal v. vertical bone loss

4) Identify radiographic technique errors from resulting radiographic images.

a) Intraoral errors (PA, BWX, Occ)

i) Horizontal angulation incorrect
(1) Overlapped contacts
ii) Vertical angulation incorrect
(1) Larger positive vertical angle (cone too close to head above occ plane)
(a) Foreshortening

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 (2) Larger negative vertical angle (cone too close to chest below occ plane)
(a) Elongation
iii) Underexposure
(1) Inadequate time – image appears light
iv) Overexposure
(1) Excessive time – image appears dark
v) Cone-cut
(1) Improper alignment results in xray beam not exposing entire sensor
b) Panoramic errors
i) Teeth too anterior (on bitestick)
(1) Blurring and narrowing of anterior teeth
ii) Teeth too posterior (on bitestick)
(1) Blurring and widening of anterior teeth
iii) Head turned
(1) Teeth appear smaller on side to which head is turned
(2) Teeth appear wider on opposite side
iv) Head tipped down
(1) Mandibular incisors appear shortened
(2) Mandible is V-shaped (exaggerated smile)
v) Head tipped up
(1) Mandible “squared off”
(2) Hard palate superimposed over maxillary teeth
(3) Reverse smile
vi) Lead apron on back of neck
(1) Large RO shadow of apron
vii) Pt not standing straight
(1) Cervical vertebrae block beam, resulting in RO area in middle of pan
viii) Tongue not kept against palate
(1) Palatoglossal air space
ix) Failure to remove appliances, tongue ring, glasses, etc.

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 x) Pt movement→ Blurred image
5) Identify potential radiographic technique errors from a photograph of sensor holder assembly and
sensor placement.
a) Standard protocol to avoid errors
i) receptor is parallel to long axis of tooth
ii) central ray of xray is perpendicular to long axis of tooth
iii) maxillary arch parallel to floor, side to side and front to back
iv) film reasonable distance away for patient to close and still remain parallel
v) bite completely on biteblock, teeth contact it
vi) cotton roll in edentulous region, against opposing arch
6) Recognize proper Rinn assembly for BW and PA sensor placement in all areas of the mouth.

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ENDODONTICS

1. Describe the basic pulp chamber anatomy (location, size, shape, canal orifice location), root
morphology (number and shape of roots/pulp canals) for all teeth. Correlate these principles
with appropriate access preparation.

2. Identify number, name, sequence and purpose of radiographs commonly required during
endodontic therapy.

· Pre-op Radiographs (1)

o Taken with XCP radiograph holders that permit use of the paralleling technique (less
distortion).
o To document…
§ Existing pathosis

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 § Root length / curvature
§ Axial inclination
§ Calcification of canals
§ Areas of resorption

· Working Radiographs
o Working Length Radiograph (2)
§ Taken with a small size file (#10 file) to verify the WL determined by the electronic
apex locator.
o Cone Fit (Master Cone) Radiograph (3)
§ Take with a master gutta-percha cone inserted to WL.
§ Confirms that the master GP cone was adapted to the prepared canal length.
o Obturation Check (4)
§ Confirms that the canal was adequately obturated.

· Final Radiograph (5)

o Taken with XCP holding device.
o Rubber Dam off.
o Temporary in place
o Baseline for evaluation of healing at subsequent recall appointment.

3. Identify the armamentarium (equipment and instruments) and their purpose and protocols, for
use in endodontic therapy. See 1622 WK7 L4 &5 Chuti Notes Endodontic Instruments
a. Access to pulp chamber – drilled opening in occlusal surface overlying pulp chamber
i. 169 L bur – 5 mm long, 1 mm wide
1. Used create access 3 mm wide 1 mm deep
b. Unroofing pulp chamber
i. Endo z bur – refine a tapered access opening into pulp chamber
ii. 9 mm long, 1 mm wide, non end cutting
iii. Use at slow speed, rest the non cutting tip on the internal facial wall
c. Removing coronal pulp – large and small endo spoon excavators remove pulp
i. After removal, use endo explorer to make sure U can smoothly enter canals
d. Achieving straight line access –
i. Open orifice w vortex opener – coronal 1/3 of canal to remove dentin triangle
ii. req for cleaning, shaping, obturation
iii. Less file fatigue, better canal visualization, easier removal of pulp
e. Cleansing and shaping
i. Establish WL w 10 file
ii. Establish glidepath w Gold Glider rotary file used to WL w IRI
1. Develops smooth radicular tunnel to apical constriction
iii. Shape canal w WaveOne rotary file w IRI
1. 3 strokes in coronal third, middle third, apical third w IRI between each
2. Repeat until WL achieved

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 iv. Confirm WL w radiograph
f. Obturation
i. Dry canals w paper points
ii. Fit GP to WL, confirm w radiograph
iii. Apply sealer to GP and fit into canal
iv. Use system B to burn off end of GP
v. Condense GP apically w plugger

4. Recognize and explain errors in endo access preparation (location, shape for specific teeth, size,
etc.) for all teeth. Understand and rationale of the shape of each access opening.
Maxillary
i. Central
1. Pulp chamber anatomy – 1 canal 100%
2. Root morphology – 1 root 100%
3. Access - triangular
ii. Lateral
1. Pulp chamber anatomy - 1 canal 100%
2. Root morphology - 1 root 100%, distal curve apical 1/3
3. Access - oval
iii. Canines
1. Pulp chamber anatomy - 1 canal 100%
2. Root morphology - 1 root 100%
3. Access - oval
iv. 1st Premolars
1. Pulp chamber anatomy – 2 canals 90%
2. Root morphology – only premolar more likely to have 2 roots
a. 1 root 40%
b. 2 roots 60% - B and L T1 100%
3. Access - oval
v. 2nd Premolars
1. Pulp chamber anatomy and Root morphology
a. 1 root 90% - T1 50%
b. 2 roots 10% - B and L T1 100%
2. Access - oval
vi. 1st Molars
1. Pulp chamber anatomy and Root morphology – tooth most likely to have
4 canals
a. 3 roots – 100%
i. P – T1 100%, apical curve towards
ii. MB – T1 40%, T2 50%, T3 10%
iii. DB
iv. MB2
2. Access - triangular
vii. 2nd Molars
1. Pulp chamber anatomy and Root morphology

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 a. 2 roots – 10%
b. 3 roots – 90%
i. Has MB2 40%
c. 25% have root fusion
2. Access - triangular
b. Mandibular
i. Central
1. Pulp chamber anatomy – 1 canal 66%, 2 canals 33%
2. Root morphology – 1 root 100%
3. Access - oval
ii. Lateral
1. Pulp chamber anatomy – 1 canal 55%, 2 canals 45%
2. Root morphology – 1 root 100%
3. Access - oval
4.
iii. Canines
1. Pulp chamber anatomy
2. Root morphology – 1 root 95%, 2 roots 5%
3. Access - oval
4.
iv. 1st Premolars - most likely of any tooth to have a T4 canal
1. Pulp chamber anatomy and Root morphology
a. 1 root 100%
i. T1 75%, T4 25%
2. Access - oval
v. 2nd Premolars
1. Pulp chamber anatomy and Root morphology
a. 1 root 100%
i. T1 85%, T1-2-1 15%
2. Access - oval
vi. 1st Molars
1. Pulp chamber anatomy and Root morphology
a. 2 + roots 100%
i. M – 2 canals 100%: T2 40%, T3 60%
ii. D – T1 70%, T2 20%, T3 10%
2. Access – rectangular/trapezoid
vii. 2nd Molars
1. Pulp chamber anatomy and Root morphology
a. 2 roots 100%
i. M – T1, T2, T3 – 30%
ii. D – T1 90%, T3 10%
b. C shaped canal
c. High rate root variation/fusion
2. Access - triangular
5. Recognize common endodontic instrumentation and obturation errors and explain their causes.
● Failure to obtain straight-line access increases the possibility of …

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 o File separation
o Ledging
● An artificial irregularity created on the surface of the root canal wall that
impedes the placement of instruments to the apex of an otherwise
patent canal.

RPD AND COMPLETE DENTURES

1. Identify Kennedy Classifications and Applegate’s modifications/rules.

· Class I
o Bilateral edentulous space located posterior to natural teeth.
o Tooth-tissue support
o Only anterior teeth remaining
· Class II
o Unilateral edentulous area located posterior to the remaining natural teeth.
o Tooth -tissue support
o Same as Class I but unilateral
· Class III
o Unilateral edentulous area with natural teeth remaining both anterior and
posterior to it.
o Tooth support only
· Class IV
o Single, but bilateral (crossing midline) edentulous area located anterior to
remaining natural teeth.
o Tooth support only

· Applegate’s Rules:
o Classification should follow, not proceed any extractions of teeth that might alter
the original classification.
o If a M3 is missing and not to be replaced, it is not considered in the classification.
o If a M3 is present and is used as an abt, it is considered in the classification.
o If a M2 is missing and is to be replaced, it is not considered in the classification.
o The most posterior edentulous area/areas always determine the classification.
o Edentulous area other than those determining the classification are referred to as
modifications and are designated by their number.
o The extent of the modification is not considered only the number of additional
edentulous areas.
o There can be no modifications areas in Class IV arches (the class IV would be
considered a MOD)

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 2. Identify the parts and components of an RPD and explain their purpose.

3. Recognize the need for indirect retention, and identify acceptable location(s) for this purpose.

4. Identify anatomy of maxillary and mandibular edentulous arches.

5. Evaluate and identify errors in models, custom trays, bare plates, wax rims and denture setups.

6. Identify the critical landmarks area of edentulous casts and their clinical significance.

7. Identify the armamentarium used in denture fabrication and describe its proper usage.

ANESTHESIA
1) Select the appropriate anesthesia technique (main and supplemental), anatomical landmarks
and amount of anesthetic needed during restorative and endodontic procedures in relation to
tooth location. (PSA, MSA, ASA, NP, GP, LB, IAN/LN, IN)
a) Maxillary techniques: 27 gauge short needle
i) Posterior superior alveolar
(1) Nerve: posterior superior alveolar nerve branches
(2) Areas: maxillary molars (#1-3), NOT the MB ROOT OF MAX 1st MOLAR (#3)
(a) Stay in height of vestibule of the most distal tooth of the arch
(3) Do NOT enter infratemporal fossa (hematoma and IV injection possible)
(4) Infiltration
(5) Insert: height of mucobuccal fold above max 2nd molar distal to malar process
(zygomatic process)
(a) 45 degrees to both MD and BL planes
(b) 5mm at height of vestibule
(c) Landmarks
(i) Mucobuccal fold, max tuberosity, zygomatic arch
(6) Amount: 0.5 to 1 ml
ii) Middle superior alveolar
(1) Nerve: middle superior alveolar and terminal branches

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 (2) Areas: pulp and buccal periodontal tissues and bone of max 1st and 2nd premolars
and MB root of 1st molar
(3) Infiltration
(4) Insert: height of mucobuccal fold above max 2nd premolar
(a) Minimal risk of hematoma or iv injection, no major vessels in this area
(b) Insert: 5 mm
(5) Target: max bone above apex of max 2nd premolar
(6) Solution amount: 0.5 ml to 1 ml
iii) Anterior superior alveolar
(1) Nerves: anterior alveolar nerve
(2) Areas: max central incisor – canine
(a) Pulp, bone, and periodontal tissues
(b) Will also anesthetize the maxillary perioral muscles (lip)
(3) Infiltration
(4) Insertion: height of the mucobuccal fold directly above area to receive care
(a) Insert: 5mm
(b) Landmarks: mucobuccal fold
(5) Amount: 0.5 to 1 ml
iv) Greater palatine (GP)
(1) Can be achieved atraumatically
(2) Nerve: GP
(3) Areas: posterior portion of the hard palate up to canine
(4) Insertion: halfway between midpalatal suture and the distal of the 2nd molar
(a) Anterior to the greater palatine foramen
(b) 5mm until bone is contacted--must be inserted enough to completely bury the
bevel of the needle elumen
(5) Infiltration
(6) Amount 0.25 ml only a few drops
v) Nasopalatine (NP)
(1) Nerve: nasopalatine nerves bilaterally
(2) Areas: anterior portion of hard palate from L to R 1st premolars

19
 (3) Infiltration
(4) Insertion: palatal mucosa just lateral to incisive papilla
(a) <5mm
(5) Target: incisive foramen (approach at 45 degree angle to papilla)
(6) Amount: 0.25 ml
vi) supplemental: Intranasal technique
(1) Does not anesthetize lip, good for esthetic procedures
(2) Soft tissue anesthesia in buccal and labial fold
(3) No extraoral anesthesia
(4) Premolar to premolar soft tissue anesthesia
(a) 4-13; a-j
(5) Dosing
(a) Adults
(i) 2 sprays 0.2 ml/each 4-5 min apart
(ii) Initiate procedure 10 min post 2nd spray
(iii) 1 additional spray if adequate anesthesia to initiate dental procedure 10 min
after 2nd spray
(b) Children
(i) >40kg
(ii) 2 sprays 4-5 apart ipsilateral to the part of the max tooth on which the
dental procedure will be performed
(iii) Initiate dental procedure 10 after 2nd spray
a) Mandibular techniques
i) Inferior Alveolar Nerve Block (IANB)
(1) Be cautious:
(a) Possible bifid foramen: usually vertically stacked
(b) Better to aim superiorly in case of a high insertion into the mandibular foramen
or bifid config
(2) Areas
(a) Mandibular teeth to midline of side of injection
(b) Body of mandible

20
 (c) Inferior portion of ramus
(d) Buccal mucoperiosteum
(e) Mucous membrane anterior to mandibular first molar (mental nerve)
(f) Anterior 2⁄3 of tongue
(g) Floor of oral cavity (lingual nerve) lingual soft tissues and periosteum (lingual
nerve)
(3) Procedure
(a) Palpate coronoid notch→ draw imaginary line to pterygomandibular raphe to
determine height of injection
(b) Insert needle along this line 3⁄4 distance of coronoid notch to deepest portion of
pterygomandibular raphe, slowly insert needle until contact with bone, withdraw
needle 1mm (avg depth 20-25 mm)
(c) Barrel should be over premolars on opposite side
(d) Deposit 1.5 ml over 60-90
(4) Seat the pt upright
ii) Lingual nerve block
(1) After successful LA deposit to IAN, 1⁄4 carpule injection at halfway of withdrawing
needle to provide anesthesia to lingual nerve→ tongue symptoms and lingual mucosa
symptoms
(2) For IAN anesthesia, pt must also exhibit lip and mucosa symptoms
(3) Caution
(a) When performing IANB/LN a barbed needle drawn across the lingual nerve can
lead to paresthesia
(b) If you contact the ascending ramus when starting the IANB, withdraw and
replace needle
(c) Never reuse >4 times
iii) Long buccal injection
(1) Areas: soft tissue and periosteum buccal to mandibular molar teeth
(2) Procedure
(a) Insert needle in soft tissue just distal and b of the most distal molar
(b) Needle should be parallel with occlusal plane, insert about 2mm, aspirate,
slowly inject 0.3 ml over 10 sec
iv) Incisive canal injection

21
 (1) Areas: buccal mucosal membrane anterior to mental foramen usually from second
premolar to midline
(a) Lower lip and skin of chin
(b) pulpal nerve fibers to the premolars, canine, incisors
(2) Position: sit in front of pt so that syringe may be placed into mouth below the pt’s
line of sight
(3) Procedure:
(a) request pt to slightly close mouth: greater access to injection site
(b) Place thumb or index finger on mucobuccal fold against body of mandible in first
molar area and move slowly anterior until you feel the bone become irregular and
somewhat concave
(i)Mental foramen usually between apices of the premolars
(c) Insert needle at canine or first premolar directing needle to formen but DO NOT
ENTER FORAMEN
(d) Advance need 5-6 mm, aspirate, slowly deposit 0.6 ml over 20 sec while applying
finger pressure
(i) A vascular area; bleeding/hematoma may occur
(e) After injecting, apply FIRM FINGER PRESSURE to injection site for 2 min to help
force anesthesia into foramen
b) Additional techniques used in LA admin
i) PDL injection
(1) 2% lido with 1:100,000 epi
(2) Significantly better in achieving pulpal anesthesia than using anesthesia without
vasoconstrictor
(3) Use on teeth with IRREVERSIBLE PULPITIS
(4) Do NOT use same needle for PDL injection for a tissue penetration injection
(a) Bacteria from sulcus creates risk for needle tract infection
(5) Risk of discomfort after injection (several days)
ii) Single tooth anesthesia
(1) Wand
(2) Flow rate is computer controlled and consistent
(3) Operator able to focus on position of needle tip while motor delivers anesthetic at
preprogrammed rate of flow

22
 (a) Slow: 0.5 ml/min
(b) Fast: 1.8 ml/min
(4) Release foot pedal→ automatic aspiration
(5) Less painful PDL, palatal, attached gingiva injections
iii) Intraseptal injection
(1) Injection done into papilla
(2) Diffusion of anesthetic via medullary bone
(3) Limited pulpal anesthesia
iv) Intraosseous injection
(1) Very successful in mandibular molars
v) Intrapulpal injection
(1) Directly into pulp chamber of pulpally involved teeth
(2) Most common on mandibular
(3) 25 or 27 short needle, may need to bend
vi) Gow gates/akinosi
(1) Gow gates
(a) True V3 open mouth block technique
(b) The ONLY true mandibular nerve block
(c) Mouth open, aim for neck of condyle, low aspiration risk
(d) Area: Mandibular teeth to the midline
(e) Indication
(i) Poor pain control
(ii) IANB failure
(f) Contra: when pt cannot open mouth
(g) Requires practice
(2) Akinosi: closed mouth
(a) Limited opening
(b) Few post-op complications
(c) No bone contact
(d) Requires practice

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2) Identify the necessary armamentarium for providing anesthesia.
a) Syringe
i) Aspirating
(1) Has “harpoon” that engages the stopper
(2) Aspiration is done by gentle backpressure
(3) Aspiration is in 2 planes: ensures anesthetic is not deposited in a vessel at the
injection site
(4) If any blood is aspirated then injection stops and syringe needle is withdrawn, new
needle and cartridge are loaded and used
ii) Self aspirating
(1) No harpoon
(2) Back pressure caused by diaphragm of cartridge resting on small disk at injection
end of syringe
(3) When thumb pressure is released, negative pressure is created in cartridge resulting
in aspiration
b) Needle
i) Bevel
ii) Shaft
iii) Hub
iv) Syringe adaptor
v) Cartridge/penetration end
vi) Gauges
(1) Smaller number= larger hole
(2) 25 = red
(3) 27 = yellow
(4) 30 = blue
vii) Length
(1) 32mm adults (adults have 32 teeth)
(2) 20 mm short (kids have 20 teeth)
viii) Red dot marks bevel position
c) Cartridge/carpule

24
 i) silicone rubber plunger: seals tube, engages with harpoon to aid in aspiration
ii) aluminum cap: holds thin diaphragm in position
iii) diaphragm: semipermeable membrane
iv) mylar strip: protection if glass breaks, info about drug
d) Additional equipment
i) topical anesthetic, 2x2 gauze, cotton tip applicator, suction, safety glasses
3) Recognize errors in the syringe assembly, local anesthetic administration and its clinical
manifestations.
a) Proper handling of cartridges and disposable needles
i) Never reuse for different pts→ contamination
ii) Change needle after 3-4 injections
iii) Always cover in protective sheath
iv) Always pay attention to position of uncovered needle
v) Recap using scoop method; never hand to hand
vi) Never discard in trash—use sharps container
b) Loading
i) Do NOT engage harpoon into stopper with palm of hand
(1) Use countertop: preferably soft surface
c) Delivering LA: vessel considerations
i) Caution: vessel proximity to target nerve
(1) ie max artery runs with V2 branch in pterygopalatine/infratemporal fossae
ii) Aspiration is necessary
(1) 2 planes needed bc vein is flaccid
iii) Spasm of artery when touched can lead to facial blanching
(1) Artery is prominent
iv) When administering maxillary LA: pterygopalatine fossa and infratemporal fossa
communicate
(1) the maxillary artery and pterygoid venous plexus are in the two fossae
(2) also includes various nerve plexus
(3) communicates with the cavernous sinus: no valves and increased potential for
infection

25
 4) Describe which hard and soft tissues are anesthetized for: PSA, MSA, ASA, NP, GP, LB, IAN/LN,
IN.
a) Identified above
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
COMPREHENSIVE INTEGRATED CRITICAL THINKING – Oral Exit Interview

1. A. Explain the rationale for gingival retraction and describe the MWU protocol for gingival retraction.
Gingival retraction exposes the margin that would otherwise be covered by healthy tissue prior
to impressions
o Dries gingival sulcus of saliva, heme, and crevicular fluid
o Creates temporary space between gingiva and prep margin
· Hemostatic agents also help with preventing heme accumulation
o AlCl3 - clear, Fe2(SO4)3 – brown and cannot be used when it would show through
· Retraction cord – absorbs crevicular fluid from the gingival sulcus
· One cord technique
o Select the largest diameter cord that will conveniently fit into the sulcus
o Pack cord and wait 8-10 minutes; remove before impression
· Two cord technique – ideal for multiple preps and/or compromised tissue health
o Place 00 cord (smallest diameter) into sulcus first
§ Vertical placement; controls moisture
§ Leave in place during impression
o Place larger diameter cord (1 or 2) with hemostatic agent on top of 00
§ Provides horizontal displacement
§ Wait 8-10 minutes
§ Wet and remove; take impression immediately after removal
o Don’t forget to remove 00 cord after impression
I
B. List alternative methods of exposing subgingival prep margins.
· Retraction paste
· Electrosurgery – electric current directed along an electrode, cutting soft tissue
o Inner epithelial lining of gingival sulcus is removed, exposing subgingival tooth
structure
o Not safe for patients with pacemakers
· Laser troughing – uses light at 840nm wavelength for soft tissue ablation
o Enhances the accuracy of impressions
o Safe for patients with pacemakers
· Crown lengthening – increases the extent of supragingival tooth structure for restorative
or esthetic purposes; remove bone away from restorative margin; generally used only in the
posterior; requires a flap procedure and osseous recontour

26
 · Gingivectomy – excision of gingiva; greater than 3mm soft tissue between bone and
gingival margin with adequate attached gingiva only

2. A. Describe the differences between a varnish, a liner and a base and discuss their indications with
respect to clinical indications and uses.
· Goal is to always achieve a Remaining Dentinal Thickness (RDT) of 1.5-2mm whether
with natural dentin or via liner/base.
o Pulp exposure direct pulp cap
o <0.5mm RDT indirect pulp cap
o 0.5-2mm RDT base needed
o >2mm RDT no pulp protection needed
· Varnish – very thin (2-5 microns), provides physical barrier between dentinal tubules and
restoration material. It does not bond to tooth structure; therefore, it is not used with resin
restorations, and is only used with metallic restorations. Not indicated for use any more.
· Liners – thin (less than 0.5mm) layer placed between pulp and restorations that protects
and seals dentin. Protects pulp (thermally and electrically). Used mainly for amalgams, cast gold,
and other non-bonded restorations that are not insulating. Can be used with resins if it doesn’t
contain eugenol.
· Bases – thicker than liners (1-2mm) and placed between restoration, dentin, and pulp.
Provides thermal insulation to pulp and distributes local stresses. Some bases release fluoride.
Used to replace lost dentin under restorations.

B. Identify and discuss the materials that can be used as liners and bases. List and discuss the criteria for
proper clinical applications and limitations.
· Materials used as LINERS:
o Gluteraldehyde and HEMA (GLUMA "desensitizer")
§ Not considered a traditional liner
§ Blocks dentinal tubules, decreasing fluid flow, decreasing sensitivity
o Calcium Hydroxide (Dycal) – direct and indirect pulp capping
§ High pH of 12, alkaline/basic antimicrobial
§ Local basic environment causes cell necrosis within 1mm, allowing
inflammatory process to create reparative dentin and formation of dentinal
bridge
§ Only used in deep areas with <0.5mm RDT or when there is a small pulp
exposure
§ Advantages:
· Antimicrobial properties due to high pH
· Stimulates formation of reparative dentin
· Low cost
· Protects pulp from chemical irritation
§ Disadvantages:

27
 · Low in compressive strength—should not be used on its own;
use with a base for support
· High solubility—becomes weaker if exposed to moisture
· Does not bond to dentin
· Does not provide thermal insulation
· Materials used as LINERS and BASES:
o Zinc oxide eugenol (ZOE) – liner, base, temporary restoration cement
§ Advantages:
· Obtundant (soothing) to pulp despite acidity
· Provides excellent seal
· Low modulus of elasticity
· Antiseptic properties
§ Disadvantages:
· Difficult to mix properly
· No chemical bond with dentin
· Low compressive strength
· Not used with bonding agent for resin restorations
o Glass Ionomers – restorations, bases, liners, and cements
§ Chelates with calcium ions within tooth structure
· Provides good marginal seal
§ Advantages:
· Fluoride release for up to 5 years
· Creates chemical bond with dentin
· High compressive strength
· Low shrinkage
· Low solubility
· Thermal insulator
§ Disadvantages:
· Sensitive to water exposure – leakage and discoloration

C. Identify liner/base materials that are chemically incompatible with selected final restorative materials.
· ZOE – eugenol inhibits the bond of resin; used primarily with amalgam
· Calcium hydroxide – must be covered with another liner for protection from acid etching
and/or displacement. GI/RMGI is traditionally used to cover.
· Varnish – cannot be used with resin bonding; occludes dentinal tubules.

3. A. Describe the indications for Total Etch and Self-Etch/Selective-Etch bonding procedures.
· Total Etch is indicated for enamel and has a high bond strength. Self-Etch is indicated for
dentin and will reduce the risk of post-op sensitivity. For a lesion that is in both enamel and
dentin, use only Self-Etch and selectively etch only the enamel. The selective etching technique
provides the advantages of both systems.

28
B. Describe the steps for each procedure.

· Total Etch:

o Using 35-37% phosphoric acid, etch enamel for 15s and dentin for 10s. Rinse
thoroughly (at least 5s), dry enamel and gently dry dentin. Apply desensitizer on dentin
surface only. Leave for 30s. Repeat procedure. Gently air dry. Scrub primer/bond
adhesive for 10s. Gently air dry to eliminate pooling areas and secure a regular film.
Light cure for 20s.

· Self-Etch with Enamel Selective Etching:

o Using 35-37% phosphoric acid, etch only enamel for 10s. Rinse thoroughly (at least
5s). Air dry. Apply desensitizer on dentin surface only. Leave for 30s. Repeat procedure.
Gently air dry. Scrub primer on dry enamel and dry dentin. Leave for 20s. Gently air dry.
Apply bond on enamel and dentin. Leave for 20s. Gently air dry to secure a regular film.
Light cure for 20s.

4. A. Discuss the essential principles of a proper endodontic access preparation.

Essential Principles of Endodontic Access:

1. Conceptualization and pre-planning:
· Radiographic analysis to determine pulp chamber width M-D and measurement from
occlusal table reference point to roof and floor of pulp chamber
· Know the anatomy of the tooth and shape of the access
2. Completely un-roof the pulp chamber:
· Follow the law of color change: the pulp chamber floor is always darker than the walls
3. Completely remove pulp tissue from chamber
· Use endodontic excavators and NaOCl to dissolve organic matter
4. Achieve straight line access to the canal:

29
 · Remove dentinal triangles using an orifice opener
· Decreases stress on rotary files
· Decreases the chance of file separation
· Decreases the chance of ledging
· Decreases the chance of transporting the canal

Law of CEJ – the most consistent repeatable landmark for locating the position of the pulp chamber
Law of Centrality – the floor of the pulp chamber is always located in the center of the tooth at the level
of the CEJ
Law of Concentricity – the walls of the pulp chamber are always concentric to the external surface of the
tooth at the level of the CEJ

Straight line access:

· Remove dentinal triangles using an orifice opener
· Decreases stress on rotary files and chance of file separation
· Decreases chance of ledging or transporting canal

B. Explain the possible adverse outcomes of performing an incorrect endodontic access preparation.

· Lack of straight line access:

o Canal transportation: relocation of the path and shape due to tendency of files to
restore their original linear shape during canal preparation

o The zip: ellipticity of the apical foramen

o Ledging: artificial irregularity created on surface of roto canal wall

o Increase in cyclic fatigue of the hand file→ increased risk of separation

o Increase chance of ledging or transporting the canal

· May fail to find all canals→ cause failure of the RCT

· May fail to remove all pulp tissue from the chamber, especially pulp horns

· May perforate through the crown or the furcation

C. Define working length and explain its role in endodontic canal preparation and obturation.

· Working Length: the distance from the coronal reference point to minor apical
constriction

30
 o Measured 1mm to 0.5 mm short of the radiograph apex (age dependent) if no apex
locator is available

o All canal shaping should terminate at WL

o Only size #10 files should be passed 0.5 mm beyond the WL to check patency

o During obturation, gutta percha master cone should have tug back at WL

o Final obturation should end at WL

o Purpose: Determination of the lengths needed for instrumentation

5. Describe the radiographs that are routinely taken during endodontic therapy and explain their
purpose.

· Pre-op radiograph

o PA: used for diagnosis, treatment planning

§ Approximates length of tooth and long axis

§ Degree of canal calcification

§ Number and curvature of roots

§ Surrounding anatomy

o BWX: used to measure

§ M-D width of pulp chamber

§ occlusal table to height of pulp chamber

§ occlusal table to floor of pulp chamber

· Working length radiograph – taken with #10 file in place

o used to confirm that canal(s) is/are patent and file reaches to minor apical
constriction

o determination/verification of Working length

o locating canals, identification of undiscovered canals

· Master cone fit radiograph – cone placed at WL minus 1mm

31
 o ensure that GP cone reaches to working length and is properly adapted to the shaped
and cleansed canal

o ensure proper seal of canal by GP cone

· Fill check radiograph

o confirm adequate seal and obturation of canal, adaptation of GP cone to canal after
removal of excess gutta percha

o confirm that canal is neither over or under filled

· Additional: final obturation radiograph with rubber dam removed and access cavity
closed

o documents completion of RCT

o serves as baseline to evaluate healing

6. A. Describe periodontal and peri-implant diagnosis according to the 2018 American Academy of
Periodontology (AAP) stage and grade systems.
· Periodontal Health, Gingival Diseases, and Conditions
- Perio health and Gingival Health
- Gingivitis: Dental-Biofilm Induced
- Gingival Diseases: Non-Dental Biofilm-Induced
· Periodontitis
- Necrotizing Perio Diseases
- Periodontitis
- Periodontitis as a Manifestation of Systemic Disease
· Other Conditions Affecting the Periodontium
- Systemic diseases or conditions affecting the periodontal supporting tissues
- Periodontal abscesses and endo-perio lesions
- Mucogingival deformities and conditions around teeth
- Traumatic occlusal forces
- Tooth and prosthesis related factors
· Peri-Implant Diseases and Conditions
- Peri-Implant Health
- Peri-Implant Mucositis: Inflammation of gingiva around implant with no bone
loss (similar to gingivitis)
- Peri-Implantitis: Inflammation in the peri-implant connective tissue and
progressive loss of supporting bone; often caused by residual cement
- Peri-implant soft and hard tissue deficiencies

32
 · Staging – classifies severity and extent of current tissue loss, including tooth loss due to
perio; incorporates an assessment of the level of complexity of management of the patient’s
condition

· Grading – defined on the basis of observed and/or inferred rate of perio progression

B. Describe recommended periodontal treatment sequences for patients exhibiting periodontal health,
gingivitis and periodontitis. Include recommended maintenance intervals for each.

· Periodontal health - Recall every 6 mos for regular visit, eval, and prophy
· Gingivitis - Pt. to visit for deep cleaning with detailed OHI and re-evaluation of gingival
status every 4-6 months depending on patient risk factors for developing periodontal disease (ie.
genetics, social habits, medications, systemic disease, etc.)

33
 · Periodontitis - Pt. to visit for SRP with re-eval. At 3 months. If perio not resolved, perio
surgery with adjuvant therapy (antibiotic rinses, perio chip, arestin, etc.) at non-healing sites can
be accomplished to attempt to arrest CAL and improve probing depths.

**A perio patient is a perio patient for life and you will continue to see this person every 3 months
for perio maintenance even after you stabilize their periodontal tissues.

7. A. List the important points to consider when deciding when to treat and when to refer an orthodontic
case.

Selecting A Case
· Select an easy case to familiarize yourself with Invisalign to build confidence
· Criteria:
o Class I skeletal pattern
o Class I molar & canines (no elastics needed)
o Mild crowding (1-3 mm)
§ Easily corrected by minor proclination of teeth or interproximal reduction
o Mild spacing (1-3 mm)
o Timeline goal: < less than 1 year

When to Refer
· If there is a true skeletal discrepancy
o Class II or Class III
· Malocclusion Class II or III that would require elastics or auxiliaries

34
 · Malocclusion that has moderate to severe crowding
o Extractions may be necessary
· Anterior open bite
· Deep bite
· Posterior or anterior crossbites
· Impacted teeth

B. Know the indications for use of a space maintainer.

· Early loss of primary teeth

o primary teeth (any) bilaterally on maxilla
o Primary canine→ may cause midline shift
o Unilateral loss of maxillary primary molars
· Premature loss of first or second primary molar, isolated unilateral loss
o Premature loss of primary 2nd molar before 1st permanent molar erupts→ Can result
in significant loss of space
· Trauma, caries, ankylosis of primary tooth, ectopic eruption that causes space loss
· Purpose of space maintenance is to maintain leeway space, the size difference between
primary molars and their permanent successors
o Maxilla 1.5 mm/side, mandible 2.3 mm/side

8. A. Describe the technique for fabricating dentate and edentulous custom trays.

Edentulous:
· preliminary alginate impression
o modification with periphery wax if necessary
o Patient in upright position, hold impression until it sets
o Evaluate the impression: no tears, deficiencies, burn through; all landmarks recorded
o cast pour up, base addition; trimming cast preserving 2-3 mm land area
· Draw on cast:
o Black line to depth of vestibule, red line 2 mm short of black
o Need to be 2mm short of periphery--frenums, etc
· Block out undercuts with wax
· Block out non-denture bearing areas with 1 layer of wax: selective pressure technique.
o Maxilla:
§ Thin keratinized mucosa, Mid-palatal suture, incisive canal and rugae, tori,
flabby tissue areas on very resorbed ridges, nerve entrance/exits
o Mandible
§ Thin keratinized mucosa, tori, non-denture bearing areas, flabby tissue on the
crest of the alveolar ridge

35
 o Crest of ridge that has very thin bone
· Vaseline cast
· Apply Triad and trim to the red line 2mm short of periphery, apply tray handle are cure 4
min
· Trim rough edges

Dentate:]
· Preliminary alginate impression, pour up, trim preserving land area, black line to
vestibule and red line 2 mm short of vestibule
· Wax
o Block out teeth with 2 layers of wax,
o block out other undercuts
o Block out non denture bearing areas with wax (like for complete denture custom tray)
o Stops on unprepared teeth
· Vaseline
· Make tray as you would for complete denture
o Apply triad, trim 2 mm short of vestibule when muscle is in function
o Handle not to interfere with border molding anterior areas that will have a denture
base
· Cure

B. Describe clinical procedures for which dentate and edentulous custom trays are used.

· Custom trays are made off the preliminary cast to help us make more accurate final
impressions. They are for getting better fit and function of denture prostheses.
o Dentate custom trays
§ Usually for implant or FPD, extensive rehabilitation where you need a very
accurate registration for occlusion
§ More accurate, pt comfort, less flexible compared to stock tray, use less
impression material
§ Disadvantage: more expensive in materials and time
o Edentulous custom trays
§ Complete denture
· Produce master cast, use master cast to make record bases
· Important for capturing anatomy of the periphery/border
molding
· Final impressions for dentate patients can utilize selective pressure. Custom trays give a
more accurate impression and more accurate master cast. This is needed for Kennedy class I and
II RPDs.

9. A. Describe the technique for fabricating record bases (base plates) and wax rims.

36
Record Bases are made off master casts (which are made from final impressions)
· Draw a black line to the depth of the vestibule on both maxillary and mandibular casts.
o On the maxillary cast also draw a black line hamular notch to hamular notch. Trim
Triad to black line.
· Block out undercuts with wax.
· Apply Vaseline to cast.
· Apply Triad material and trim to black line (depth of the vestibule).
· Set the Triad unit timer for 4 minutes and cure the tray.
· Trim borders for smoothness to prevent patient discomfort or injury.

Wax rims
· Apply preformed wax rim (use a papillameter to apprx.)
o Maxilla:
§ Posterior: Centered over ridge
· Height 8-10 mm
§ Anterior: 5-9mm anterior to incisive papilla
· Height 22mm from labial notch.
o Mandible:
§ Posterior: height is 2/3rds up retromolar pad
§ Anterior: height is 18mm from mandibular frenum
§ Centered over ridge anteriorly and posteriorly
o Wax rim is 6-10 mm wide
· Place wax rims/record bases on articulator.
o Even out wax rims so they touch evenly across Articulator Pin at 0 (balanced
occlusion)
o Wax rims should be evenly touching throughout, occlusal plane even, lip support
good

B. Describe the function of record bases and wax rims.

· Record base function: retains the wax rim

o Needs to be stable, well adapted to master cast
· Wax rim functions:
o Helps to determine jaw relations
o Establish facial contours
o Aid in tooth selection
o Establish and maintain vertical dimension of occlusion
o Make interocclusal records (i.e. bite registrations)
o Provides a substrate upon which to arrange denture teeth
o Verification of the correct master cast mounting on the articulator

37
 o Establish a wax up mold of the external surface of the denturem

10. Compare the design, placement technique and indications of the Bicon brand of press-fit implants
versus any brand of threaded implants.

Bicon Design:
· sloping shoulder, plateau, 1.5 bacterially sealed connection, 360 of positioning
o Sloping shoulder: more room over implant which supports interdental papillae,
improving gingival esthetics, distributes stress away from the crestal bone
o Plateau: 30% more surface area for osseointegration than threaded implant of same
dimensions
o Locking taper connection
§ 1.5 degree locking taper→ bacterial seal and 360 degrees of abutment
positioning
Placement technique:
· Bicon press-fit implants are “tapped” into the prepared bone site
o Osteotomy performed using slow speed drilling
§ Does not overheat bone; can harvest autogenous bone during surgery
§ More controlled
o Bicon press-fit implants include a geometry designed to “passively” engage prepared
osteotomy bony walls, creating a frictional fit in bone
· Threaded implants are “screwed” into the prepared bone of the osteotomy
o Threaded implants include a geometry that results in “active” engagement of the
prepared osteotomy bony walls
§ Creates a clamping pressure within bone

Indications:
· Bicon press-fit implants (easier and faster to place, less expensive)
o Sites where there is minimal bone volume with space available only for short implants
o Close proximity of vital anatomic structures to planned implant sites
o Personal preferences regarding implant systems
· Threaded implants (takes more time to place, more expensive)
o Situations where enhanced primary stability is desirable
§ 1-stage surgery desired
§ Immediate provisionalization using implant retention desired
o Sites where there is “sufficient” bone volume for the size of threaded implant
available
o Personal preferences regarding implant systems

11. Compare the process of restoring a Bicon brand of press-fit implants versus any brand of threaded
implants.

38
Abutments
· Healing abutment: available in titanium or polyether ethylene ketone (PEEK) resin
o Select temporary healing abutment size that corresponds to the diameter in which
the sulcus was formed
· Bicon abutments are press-fit, cold weld; tapped in
· Abutments for threaded implants are cement or screw retained
· Restoration abutments: can be used with any material to make restoration
· Universal abutments
o Stock abutments with well defined shoulder margins
o Impressions
§ Direct abutment level impression
§ Indirect abutment level impression
· Snap impression sleeve onto abutment, inject impression
material around sleeve
· Sleeve stays in impression
· Insert universal abutment analog into sleeve to send to lab to
fabricate restoration
§ Digital scan
· Non shouldered abutments
o Stock abutments that can be custom prepped like a tooth or used as is
o Seating: tapped into implants in your patient's mouth
§ Have to use extraction forceps to remove if needed
§ Tap in place using seating tips, mallet, straight threaded handle: 3 taps when
connecting metal to metal
o Impress using:
§ Direct abutment level impression
· Direct impression of abutment, prepared or not
§ Indirect abutment level impression (only with non prepped abutments)
· Impression sleeve remains in impression, screw in abutment
analog and

Crown Placement
· Cemented

o Crown is separate from abutment - place abutment and cement crown onto it

§ Both threaded and bicon can have individual crown and abutment
components

· Screw Retained

39
 o Threaded implants only - Crown and abutments are one unit

o Screw crown/abutment into implant fixture to torque required by manufacturer

o Place Teflon tape on top of screw

o Fill screw opening with composite

· Pressfit

o Bicon Integrated Abutment Crown – Bicon only

■ IAC comes as a unit from the lab ready for deliver, screwless/cementless
retrievable, can be made using any restorative material
■ Clean implant well with sterile water and dry well
■ Clean abutment post with alcohol
■ Insert IAC and check interproximal and occlusal contacts
■ For posterior: definitively seat by having patient bite down on cotton or tapping
using plastic abutment attached to threaded handle
■ For anterior: use a seating jig (assures that the seating force is directed along the
long axis of the implant)
■ 5 taps
■ Take restoration insertion PA radiograph
12. A. Describe the phases of treatment planning according to Stefanac and Nesbit.

· Systemic Phase
o Assessment of the patient’s overall general health
o Determines any effect existing health conditions may have on the delivery of dental
care and outcome of treatment.
o Ensure the best possible state of physical health for the patient before, during, and
oooooooooo treatment.
· Acute Phase
o Incorporates diagnostic and treatment procedures aimed at solving urgent oral
problems.
o Ex: controlling pain and swelling, addressing a broken tooth
· Disease Control Phase
o Establishes a stable foundation for future reconstruction
o Eradicate active disease and infection, to arrest occlusal, functional, and esthetic
deterioration, and to address, control, or eliminate causes and risk factors for future
disease.
· Definitive Phase
o The core of virtually every treatment plan

40
 o All active restorative, periodontal, and orthodontic therapy is addressed for patients
who do not warrant a disease control phase or have completed this phase.
o Can also include cosmetic dentistry, elective procedures, replacement of missing
teeth, extractions and pre prosthodontic surgery.
· Maintenance Phase
o Remaining issues will be addressed and previously rendered tx will be reevaluated.
o Can last as long as the dentist-patient therapeutic relationship exists.
o Development of an organized, practice-wide system of periodic care serves as the
backbone of a successful and productive dental practice.
o Prevention of future problems is the guiding principle.
o Significant patient education and the reinforcement of OHI.

B. Understand the concepts of information gathering and the reasons why a patient presented for
treatment.

· Accurate health and dental history may provide important and valuable information for
the dentist prior to beginning tx
o Health conditions/illnesses that may affect/be affected by dental tx
§ Diabetics: need to have adequate blood sugar
§ Hypertension
§ Does pt need antibiotic prophylaxis (infective endocarditis)
o Medications that pt is taking that may have a potential drug interaction with LA or
other prescribed drugs by the dentists
o Need to know the reason the patient is seeking care (Chief Complaint)
o Assessment of ASA
§ Need to know if stress reduction protocol needed
o Important to ask open ended questions
§ When was your last medical appointment and what was it for?
§ What specialists do you see and for what reason?
§ Are you taking anything that is not listed on your medication list, if so, what
for?
o Photos
o Never assume the patient is telling you everything
§ Look for missing answers
o Data collection
§ Chief concern
§ Health history
· Should be updated at every appointment
§ Head and neck exam
§ Dental exam: missing, impacted teeth, conditions, decay
§ Caries risk assessment

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 § Periodontal charting and probing
§ Study casts
§ Radiographic review
o Why is this important for dentistry
§ Informed consent
§ Treatment plans
§ Financial concerns
§ Decision making
§ Documentation for insurance company

13. A. Explain the effects of placement technique and curing time on the photopolymerization of
composite resins.

· Placement technique
o If the composite thickness exceeds 1.5 to 2mm, the light intensity can be inadequate
to produce complete curing, especially with darker shades of composite
§ Darker shades of composite can cause light scattering or absorption that
would decrease the effect of photopolymerization
o Incremental placement
§ Placement and polymerization of Small incremental layers less than 2mm
helps to decrease polymerization shrinkage that could create stresses between
the adhesive bond and tooth
§ Reduces the impact of C factors by altering the ratio of bonded/unbonded
surface
§ Polymerization shrinkage can cause restoration failures: gap formation,
secondary caries
o Access to interproximal areas is limited and may require special technique to
guarantee adequate light curing
· Curing time (increased light exposure)
o Increased depth of cure
o Increased polymer conversion
o Increased hardness
o Standard exposure time is 20 sec but more opaque/dark composites should be cured
for 30 sec especially if they are >1 mm from light source
o The success of the light cured composite depends on the access of high intensity light
to cure the matrix material

B. Explain the clinical effects of the various types of curing lights.

· Quartz-tungsten Halogen (QTH)

o Low cost

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 o Widely used
o Quartz bulb with a tungsten filament in a halogen environment
o Broad bandwidth (covers a lot of initiators but also generates heat)
§ Wavelength emitted is 400-500 nm
o Inefficient- 99% wasted energy
· Light Emitting Diode (LED)
o Solid state
o Semiconductor: nitride electrode
o Narrow bandwidth (less heat generation), low power consumption
§ LED has more focused wavelength emission; usually at 470 nm
o More efficient- 93% waste
o 10,000 hours of life on average
o Can be battery operated
o HIGH cost
· Tip size
o Larger tip: lower irradiance
o Small tip: higher irradiance
o Intensity of the tip output falls off from the center to the edges
§ Smaller tip→ more uniform intensity

C. Explain the effects of light distance and angle on composite polymerization and their effects on clinical
outcomes.

· Depth of cure: the depth of a light cured composite that can be converted from
monomer to polymer when exposed to light; the degree of polymerization at given depths from
the surface
· Depends on
o Concentration of scattering elements (fillers, pigments)
o Concentration and appropriateness of photosensitizers
o Light source parameters: wavelength and power
· The closer to the light source, the higher is the conversion
· How to improve depth of curing
o Hold tip of light maximum of 1 mm away from surface of composite to provide
optimum exposure
o Standard exposure time is 20 sec but more opaque/dark composites should be cured
for 30 sec especially if they are >1 mm from light source
· Access to interproximal areas is limited and may require a special technique to
guarantee adequate light-curing energy
· Intensity of the light is proportional to the distance from the fiber optic to the composite
surface

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D. Explain the effects of composite composition/type on the photopolymerization process.

· Filler particles and color agents tend to scatter or absorb the curing light in the first 1 to
2mm of material
· Glass fillers transmit light better
o Hybrids transmit better than flowable
· Darker shades and microfill composites are more difficult to cure
o They scatter light

14. Distinguish the clinical and radiographic differences between reversible pulpitis, irreversible pulpitis,
acute apical periodontitis and chronic apical periodontitis and the classic symptoms accompanying each
diagnosis.

15. Discuss the purpose and indications for using a facebow transfer to mount patient models.

· Facebow purpose
o Attaches the maxillary cast in the same A-P position on the articulator as the maxillary
arch is located in the oral cavity in relation to the horizontal hinge axis

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 o Orients the maxillary cast superiorly/inferiorly to the same horizontal reference plane
as seen with the maxillary arch
o Transfers the midline of the maxillary teeth to the articulator
o Overall: allows us to mount the max cast on the articulator in the same
tri-dimensional spatial position and orientation as the maxillary arch in the oral cavity
o Initiates the process for establishing endpoints of mandibular movements:
§ Centric occlusion or centric relation
· Indications
o Usage of a semi adjustable or fully adjustable articulator
o Fabrication of larger and/or more complex restorations
§ More accuracy in fit of restoration
§ Less time needed to adjust restoration at delivery
§ Saves time and money
o Fabrication of complete dentures
o Rehabilitations that include vertical dimension issues

16. Describe the critically important steps in producing high quality, same appointment CAD/CAM
restorations including clinical diagnosis, case selection, preparation, scanning, margin location, plan,
design and milling issues.

· Clinical Diagnosis
o Restoration compatible with CAD/CAM system
§ Indirect restorations: Inlay/Onlay/Crown/Veneer
· Case selection
o Materials: lithium disilicate or zirconia
o Parameters of acceptable optical impression:
§ Healthy soft tissues
§ Rounded, smooth angles
§ Supragingival margins
§ Continuous smooth margins
o Avoid: subgingival margins + hemorrhagic tissues
§ Can also manage tissues for main goal of dry sulcus and temporary space for
scan: use of hemostatic agents, compression/pressure, retraction cord (double
cord technique), lasers/electrosurgery (troughing)
· Cord should not be visible
· Saliva Management: with retraction/isolation/suction. Can manage systemically with
anticholinergic medications (block parasympathetic innervation of salivary glands) such as
glycopyrrolate, scopolamine, or atropine
o Systemic medications contraindicated in patients with: glaucoma, obstructive
uropathy, GI motility disorders, myasthenia gravis, and elderly with multiple
comorbidities

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· Preparation – NO SHARP ANGLES, adequate reduction
o Lithium Disilicate
§ 2.0 mm occlusal reduction
§ 1.0mm radial shoulder margin
§ 0.5mm supragingival
§ 6-10 degree taper (~3 degree each wall) Functional cusp bevel
o Zirconia
§ 1.5mm occlusal reduction
§ 0.5mm radial chamfer margin
§ 0.5mm supragingival
§ 6-10 degree taper (~3 degree each wall) Functional cusp bevel
o Tips:
§ Head of handpiece parallel to occlusal plane
§ Bur parallel to long axis of tooth Avoid undercuts
§ No J-margins
§ Use depth cuts
· Ideal Preparation Scan
o Scan <60 seconds
o Prep/margins captured circumferentially at high density
o 3-5mm of buccal tissue and 3mm of lingual gingiva
o Distinct separation between margin and proximal soft tissue
o Capture 100% of adjacent teeth and contact areas
o 3 teeth scanned in posterior – 1 tooth posterior & 1 tooth anterior
o Canine-to-canine scanning in anterior
· Ideal Opposing Scan
o Scan <30 seconds
o Capture 100% corresponding opposing teeth surfaces
o Capture minimum 3-5mm of buccal soft tissue
· Ideal Buccal “Bite” Occlusal Alignment Scan
o Patient in MI
o Capture within 20 seconds
o Bite alignment displays green dot with proper intercuspation/consistent with intraoral
scheme
o Interocclusal clearance: 1.5mm for zirconia, 2.0mm for ACC
· Some Common Scanning Errors and Resolutions
o Scanning PFM/Metal: turn “scan model mode” on to decrease reflection and scatter
of light
o Scan shows that color is off: calibrate color scanner
o Poor scanner position: scanner must be in contact with teeth and always facing distal

46
 o Data density shows blue (data missing): make sure all data on margins and prep are
scanned sufficiently, there are areas away from prep that are not necessary to re-scan is
insufficient
o Black dots on scan: overscanning, use active delete to remove unwanted data
o Bite does not “pop” or dot is red: bite registration can be dragged in place
· Margin Location
o Supragingival
o Geometry: circumferential radial shoulder (Lithium Disilicate) or chamfer (zirconia)
o Texture: smooth
o When tracing the margin:
§ Use the tool that highlights the “sharpness” or the external edge of the margin
§ Margin should be placed on the outer edge of the green
· Plan
o Position proposal to aid autogenesis
o No more than 45 seconds
· Design (remember TOP order)
o Thickness
o Occlusion and anatomy
o Proximals
· Milling
o Check material thickness -> can lead to milling issues
o Sprue position
o Block selection

17. Discuss RPD Kennedy classifications and Applegate’s rules.

· Class I: bilateral edentulous space located posterior to natural teeth

o Tooth-tissue support
o Only anterior teeth remaining
· Class II: unilateral edentulous area located posterior to the remaining natural teeth
o Tooth tissue support
o Same as class I but unilateral
· Class III: unilateral edentulous area with natural teeth remaining both anterior and
posterior to it
o Tooth support only
· Class IV: single, but bilateral (crossing midline) edentulous area located anterior to
remaining natural teeth
o Tooth support only
· Applegate’s modifications
o Rule 1: classification should follow, not precede any extractions of teeth that might
alter the original classification

47
 o Rule 2: if a third molar is missing and not to be replaced, it is not considered in the
classification
o Rule 3: if a third molar is present and is used as an abutment, it is considered in the
classification
o Rule 4: if a second molar is missing and is not to be replaced, it is not considered in
the classification
o Rule 5: the most posterior edentulous area/ areas always determines the
classification
o Rule 6: edentulous areas other than those determining the classification are referred
to as modifications and are designated by their number
o Rule 7: the extent of the modification is not considered only the number of additional
edentulous areas
o Rule 8: there can be no modifications areas in class IV arches (the class IV would be
considered a mod)
18. Summarize the ALARA protocol for deciding what radiographs should be taken before beginning
dental treatment on a new patient and recare patient; i.e. child, teen, adult, good oral health and poor
oral health.

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49
19. A. Describe the indications and uses for different types of lasers and its wavelengths (Diode, Erbium,
CO2).

· Diode
o 445-1064 nm
o Soft tissue only
§ Gingival recontouring and crown lengthening
§ Wound healing
§ Frenectomies
§ Removal of hyperplastic tissue
§ Uncovering impacted or partially erupted teeth
§ Photodynamic therapy for malignancies
§ Photostimulation of herpetic lesion
§ Caries detection
§ Incise, excise, and coagulate oral soft tissues
· Erbium
o 2780nm (chromium), 2940nm (YAG)

50
 o “All tissue” lasers
§ Treatment of dentinal hypersensitivity Caries removal
§ Tooth preparation
§ Osseous remodeling
§ Incise, excise, and coagulate oral soft tissues-limited function in hemoglobin
§ DO NOT use for removal of amalgam
· CO2
o 9,300nm (enamel), 10,600nm (soft tissue)
§ Soft tissue
· Incise, excise, and coagulate oral soft tissues
· Frenectomy

B. Describe the safety measures that must be employed when using hard and soft tissue lasers during
patient care.

· Laser controlled area warning sign

o Must be placed at every entrance into the NHZ (Nominal Hazard Zone/Operatory)
o Laser Classification: dental lasers are 3 or 4
o Laser Radiation Symbol
o Potential Danger / Harm
o Should only be displayed when laser is in use
o Must identify needed eyewear (O.D. for WL)

51
 o Must identify Wavelength and Maximum Power
· Laser protective eyewear
o Equipment such as eyecups, face shields, goggles, eye shields, spectacles and visors,
intended to protect the eyes from overexposure to laser radiation
o Often referred to as “laser safety glasses”
o Must have the laser filtration / Optical Density visibly noted for the appropriate
wavelengths on the LPE
· Infection control
o Fibers and handpieces must be autoclaved between each patient.
o Never use an alcohol gauze to wipe the fiber (risk of fire and/or explosion)
§ Alcohol fires are very hard to see
o Disposable tips (canulas) must be properly discarded after each patient.
o Bending tool and cleaving tools must be autoclaved if contaminated.
o The cleaved end of the fiber is considered a sharp and must be discarded in the
sharps container
· A well fitted surgical mask and High Volume Evacuation (HVE) should always be used
when a laser is in use!

20. A. List the types of permanent crown materials.

· Complete Cast Crown (CCC)

o Usually gold alloy
· Porcelain Fused to Metal (PFM)
· Glass ceramic
o Feldspathic porcelain
o Leucite
o Lithium disilicate
· Oxide ceramic
o Zirconia

B. List the ideal preparation parameters for occlusal/incisal/axial reduction and margin design.

· CCC
o Margin: 0.5mm chamfer
o Axial reduction: satisfies material requirements (~1mm)
o Occlusal reduction:
§ 1.5 mm functional cusp in 2 planes
§ 1.0 mm non functional cusp
· PFM
o Margin:
§ 1.2 mm buccal shoulder extends 1mm lingually past contact

52
 § 0.5 mm lingual chamfer
o Axial reduction: satisfies material requirements (~1mm)
o Occlusal reduction: 2 mm in 2 planes, functional cusp bevel
· Leucite (anterior only)
o Margin: 1.2 mm shoulder
o Axial reduction: satisfies material requirements (usually 1mm lingual, 1.2 facial)
o Occlusal reduction: 2 mm
· Lithium disilicate
o Margin: 1 mm shoulder
o Axial reduction: satisfies material requirements (~1 mm)
o Occlusal reduction: 2 mm in 2 planes, functional cusp bevel
· Zirconia
o Margin: 0.5 mm chamfer
o Axial reduction: satisfies material requirements (~1mm)
o Occlusal reduction: 1.5 mm in 2 planes, functional cusp bevel
· Any anterior requires
o Adequate ferrule > 1.5mm

C. Explain the reasoning and clinical implications of each parameters as it relates to the materials.

· CCC: 0.5mm chamfer margin, 1-1.5 mm occlusal reduction

o CCC requires the least amount of tooth reduction because the material provides good
fracture resistance with less material thickness
o Chamfer margin design used for good marginal visualization and minimally reduced
tooth structure
· PFM: 1.2mm shoulder, 0.5 mm chamfer margin, 2mm occlusal reduction
o Buccal shoulder margin of 1.2 mm allows for 0.2mm of metal framework and 1 mm of
layered porcelain for esthetics
o Lingual 0.5 mm chamfer margin allows 0.3 mm of porcelain because there is no
esthetic need on the lingual; allows a more conservative prep to preserve healthy tooth
structure
· Lithium disilicate: 1mm shoulder margin, 2mm occlusal reduction
o Reduction allows for adequate material thickness for the fabrication of the crown:
fracture strength, esthetics.

21. A. Identify the types of cements and luting agents used for seating indirect restorations in a clinical
setting.

· Temporary (hint: anything containing “oxide” is a temp cement)

o Acid-base reaction:
§ Zinc oxide and eugenol

53
 § Non eugenol
· CaOH (calcium hydroxide)
· Zinc oxide + resin
o Chemical reaction: Resin-based
· Definitive
o Acid base reaction
§ Zinc phosphate
§ Polycarboxylate
§ Glass ionomer
o Polymerization reaction
§ Self cure
· RMGI/Resin modified glass ionomer
§ Photocure
· Resin cement
§ Dual cure resin cement
· Adhesive
· Self adhesive

B. Describe and explain the proper procedures to prepare the intaglio surfaces of glass ceramics (lithium
disilicate, leucite and feldspathic), zirconia crowns and PFM crowns, according to each cement.

· Glass ceramics
o DUAL CURE resin based cement: Inlays, onlays, crowns
o Intaglio needs to be etched and primed
§ Etch and rinse: Porcelain etch hydrofluoric acid then ceramic
primer/monobond plus (contains MDP, silane)
§ Self etch: Monobond etch and prime: ammonium poly fluoride (etch) and
silane (ceramic primer)
o Variolink esthetic DC: dual cure resin based cement (adhesive cement)
§ Intaglio: etch and rinse (hydrofluoric acid) → ceramic primer monobond
plus→ rinse and dry→ apply cement on intaglio
o Multilink: dual cure resin based cement (adhesive)
§ Intaglio: self etch monobond etch and prime → rinse and dry→ apply cement
to intaglio
· Zirconia crowns
o Intaglio: sandblast with aluminum oxide
o <4mm poorly retentive prep: Multilink dual cure resin based cement (primary use)
§ Intaglio: Sandblast zirconia→ rinse and dry→ monobond plus (silane and
MPD)→ dry→ apply cement to intaglio
o <4mm poorly retentive prep: Speedcem plus self adhesive cement

54
 § Intaglio: sandblast→ rinse and dry→ ivoclean 20 sec (cleaning paste) → rinse
and dry→ apply cement to intaglio
§ Don’t need to apply monobond--is self adhesive
§ (mainly used for cementing fiber posts)
o >4 mm preps: RelyX RMGI luting plus
§ Intaglio: Sandblast 1 bar AlO3→ rinse and dry→ apply cement
· PFM crowns and CCC
o Intaglio
§ Sandblast
o RelyX RMGI luting plus
§ Intaglio: Sandblast 1 bar AlO3→ rinse and dry→ apply cement

22. List the remaining tooth structure requirements for post preparation, identify proper file and post
sizes and describe the steps for cementation of a fiber post.

· Remaining tooth structure requirements for post preparation

o Pulp chamber >4 mm = don’t need post
o Retain 5 mm of gutta percha at apex
o Post length should at least equal the clinical crown length

55
 o Post should not be any more than 1⁄4 the width of the root
§ Want to retain as much dentin as possible in the canal space
o Ferrule effect: there should be at least 2mm of tooth structure circumferentially
o Placement is indicated if both the following clinical conditions exist:
§ Remaining total tooth structure is inadequate for retention of a foundation
restoration
§ There is sufficient root length to accommodate the post while maintaining an
adequate PA seal (~5mm)
· Proper file and post sizes
o Size of post should be the size of the canal--fit the size of the post to the canal, not
the canal to the post
· Cementation steps
o GP at 5 mm
Flush canal with endogel and NaOCl, then water. Dry canal with paper points
o Coat post with monobond prime and etch for 20 sec, allow to air dry
o Place speedcem (self adhesive resin cement) on post and into the canal and place the
post in the canal. Tack cure for 20 seconds and follow up with circumferential cure of 3 x
10 sec.
o Allow dark cure for 2 min.

23. Discuss canine guidance, group function, balanced occlusion and lingualized occlusion and how they
relate to dentate versus edentulous dentitions.

· Canine guidance
o Only the canine guides lateral movement
o No posterior contacts should be present during lateral movement
· Group function
o Simultaneous pathway tracing between canine and premolars
o No molar contacts should be present during lateral movement
· Balanced occlusion:
o Bite is even throughout/all teeth touch at the same time in centric and eccentric
movements
o You never have canine rise/guidance with complete dentures! (edentulous dentition)
· Lingualized occlusion:
o Good for edentulous patients with severely resorbed ridges, displaceable tissues, and
class II or III skeletal relationships
§ Good esthetics, mastication
§ Eliminates lateral interferences
o Maxillary lingual cusp (fxnl cusp) functions in central fossa with no contact of the
mandibular buccal cusp (fxnl cusp) and the occlusal incline of maxillary buccal cusp

56
 o Sharp maxillary lingual cusp that occludes into the central fossa of the mandibular
tooth. The mandibular functional cusp does not make contact with the maxillary central
fossa
§ Both mandibular lingual and buccal cusps become non functional a. No lateral
interferences
§ The only functional cusp is the maxillary molar lingual cusps

24. A. Describe the American Society of Anesthesiologists (ASA) physical status classification for overall
health.

· ASA-E: Emergency operation of any variety (used to modify any of the other
classifications)
· ASA I: Normal and healthy patient with little or no anxiety and little or no risk. “Green
flag” for treatment.
· ASA II: Patient has mild to moderate systemic disease or is an ASA I patient with more
extreme anxiety and fear toward dentistry. “Yellow flag” for treatment. Ex: well-controlled
non-insulin controlled diabetes, epilepsy, asthma, and/or thyroid conditions; ASA I with a
respiratory condition, pregnancy, and/or active allergies.
· ASA III: Patient has severe systemic disease that limits activity but is not incapacitating.
For dental, stress reduction protocol and other treatment modifications are indicated. “Yellow
flag” for treatment. Ex: angina pectoris, myocardial infarction or cerebrovascular accident
history, insulin dependent diabetes, congestive heart failure, COPD.
· ASA IV: Patient has severe systemic disease that limits activity and is a constant threat to
life. Distress at rest with significant risk. Whenever possible, elective dental care should be
postponed until medical condition has improved to at least ASA III. “Red flag” for treatment. Ex:
unstable angina pectoris, myocardial infarction or cerebrovascular accident within the last six
months, high blood pressure, severe congestive heart failure or COPD, uncontrolled epilepsy,
diabetes, or thyroid condition.
· ASA V: Patient is moribund (in terminal decline) and is not expected to survive more
than 24 hours with or without an operation. Patient is usually hospitalized and terminally ill.
Elective dental treatment is contraindicated. Emergency palliative dental treatment may be
necessary. “Red flag” for treatment and care is done in a hospital situation.
· ASA VI: Clinically dead patient being maintained for harvesting of organs.

B. Describe the MWU CDMI protocols for antibiotic prophylaxis prior to dental treatment.

· Joint replacements – ADA recommends no prophylaxis, AAOS recommends it

o Antibiotic recommendation and script should be written by orthopedic surgeon!
· Potential for Infective endocarditis – prophylaxis for dental procedures are
recommended ONLY for patients with underlying cardiac conditions associated with the highest
risk of adverse outcome from infective endocarditis. These high risks of adverse outcomes,
include:

57
 o Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
o History of IE
o Congenital heart disease (CHD)
§ Unrepaired cyanotic CHD, including palliative shunts and conduits
§ Completely repaired CHD with prosthetic material or device, during the first 6
months after the procedure
§ Repaired CHD with residual defects at the site or adjacent to site of prosthetic
patch or prosthetic device (which inhibit endothelization)
o Cardiac transplantation recipients who develop cardiac valvulopathy –
§ **Except for conditions listed above, antibiotic prophylaxis is no longer
recommended for any other form of CHD
· Dosing:
o Amoxicillin:
§ Adult – 2 g
§ Child – 50 mg/kg
o Clindamycin:
§ Adult – 600 mg
§ Child – 20 mg/kg

1.

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