OSCE Book - Restorative and DMS

Question 1

A patient attends for a emergency. They have a ‘broken’ upper right lateral incisor which is a post crown, and the post has fractured. She has an important meeting the next day and is extremely distressed. She is very keen to keep the root. Briefly describe how you will manage this case, and explain to the patient the options available to her including the advantages and disadvantages of each option.

Answer 1

1. Intoduce yourself to the patient
2. Take a history to understand if patient is in pain or if their is infection. Also ascertain the patients concerns regarding aesthetics
3. Assess the patient. See how much of the post is left in the root, what type of post (threaded) and the patients lip line.
4. Take a PA to look for root fracture or perforation, PAP and bone levels.
5. Explain to the patient that this is more complex than just recementing the crown back onto the tooth and that it may be difficult to manage (manage patient expectations)
6. Discuss options with patient
   i) Remove the remaining root and replace the space with temp partial denture or bridge and restore with permanent once bone has healed.
   ii) Remove the fractured post and replace the post crown. Explain to patient that their is risk of perforation or root fracture when removing the post. If this happens options i) would have to be used.
7. As patient is keen to keep the root. Explain that you will use special equipment to remove the post. Ultrasonic to break up the cement and then irrigant to wash it away. Then masserann kit to then extract the post.
8. Once the post is removed can proceed with preperation for a replacemnt post restoration and temp crown. Explain that the temp will need to be replaced by a permenant crown and that the temp wont have as good aesthetics.
9. Ask if she has any questions

Question 2

A F&H patient presents as a NP complaining of sensitivity in the lower right second molar. You take bitewing radiographs and notice that the LR7 has extensive decay with the risk of pulpal exposure. Today the tooth is vital on pulp testing. Please explain the situation to the patient and discuss the treatment option available.

Answer 2

1. Introduce yourself to the patient
2. Explain to the patient that the 47 is heavily decayed and that may be the cause of the sensitivity.
3. Explain that the tooth is in need of treatment of it will worsen. So the decay needs to be removed. Use the radiograph to aid explaination. Using the radiograph explain that the decay extends close to the nerve of the tooth and their is a risk it may extend into it.
4. Explain that you would like to remove all the decay but that you would wish to avoid exposing the pulp.
   Treatment options
5. Step wise technique. This is when you remove most of the decay but leave a small thin layer over the pulp or nerve of the tooth and proceed with a direct pulp cap (using biodentine or dycal). Then restore with GI or RMGI. Returning 2-3months later to remove the residual caries. Reason for doing this is that the pulp will lay down tertiary dentine to protect the nerve and some of the soft dentine will remineralise. Allowing removal without exposing the pulp. Then place a liner and restore as normal. (stepwise technique, Bjorndal and Thylstrup,1998)
6. Pulp exposure and direct pulp cap. If the pulp is exposed, place dam on the patient and then cover the pulp with MTA, biodentine or SCaOH and restore the tooth. Explain that the tooth will need to be followed up with regular pulp testing and radiographs. Warn the patient of the risk of pulpitis and to return if they get symptoms.
7. If the direct pulp cap fails then RCT will need to be carried out.

Ask the patient if they have any questions.

Question 3

Please mix some zinc phosphate cement to be used as a base material.
Why is it mixed on a glass slab?

Answer 3

Question 4

Please take a facebow recording for the patient
Props
Facebow with occlusal fork
Dental wax
Hot water to soften wax
Labels

Answer 4

Introduce yourself to the patient
1. Check you have all the equipment
2. Soften the wax on the occlusal fork in hot water. Check that the was is not too hot before putting it into the patients mouth.
3. Position the occlusal fork onto the occlusal surface of the upper teeth with the central marking in the midline. Allow the wax to cool.
4. Insert the occlusal fork handle into a clamp on the facebow.
5. Adjust the facebow to
i) Locate the condyles, 12mm anterior to the tragus of the ear. Centre the facebow on the face
ii) Record the relationship of the occlusal p,ane to the frankfort plane (warn the patient that you will be passing the orbital pointer towards their eye). Some facebows also record the intercondylar distance.
6. Once the adjustments are complete, tighten the clamp holding the occlusal fork and orbital pointer. Release the condylar rods and remove the facebow from the patient. Check the clamps are tight.
7. Label the facebow with the patients name.

A facebow records the relationship of the upper dental arch to the condylar axis. With the facebow in the top picture the condyle location and centreing of the facebow is acheived by adjusting the condylar rods so that the tips contact the skin overlying the condyle and the readinfs on each rod are equal. the relation of the occlusal plane to the frankfort pane is recorded by positioning the orbital pointer so that the tip contacts the skin overlying the lowest point on the intra-orbital margin.

Question 5

You are a GDP seeing a patient with a patient that wears a chrome upper partial denture. The patient has denture stomatitis on the palate.
Please explain to the patient what the problem is and how you would treat this condition. Please explain the treatment to the patient.

Answer 5

1. Introduce yourself to the patient
2. Candida albicans is a yeast (fungus) that commonly causes these infections in the oral cavity. Reassure patients that this is a common infection and is present in about 40% of the general population. It is not transmissible.
3. Explain that the fungus can colonise dentures especially if they are left in overnight.
4. Explain to the patient that their mouth needs time to recover overnight and so the dentures should be left out. (compare it to sleeping with your shoes on)
5. The dentures are colonised with C.albicans so must be cleaned thoroughly with CHX mouthwash. Do this by brushing and washing the denture for 15mins 2x daily. Then soak dentures in sterodent overnight once infection has gone.
6. A topical anti-fungal cream can be applied to fitting surface of the denture 4x daily also
7. Systemic antifungals should be reserved for patients whos condition doesnt resolve with topical AF
8. **Arrange a review appointment **
9. Ask if patient has any questions

Question 6

A 16 year old girl attends your surgery concerned about the appearance of her front teeth. She has evidence of a loss of tooth substance on the labial and palatal surfaces of her anterior teeth.
How would you manage this patient?

Answer 6

1. Introduce yourself to the patient
2. Take a detailed history and examination to determine the timescale of the tooth substance loss
3. Determine the causes.
   i) Dietary. This is likely to cause erosion on the labial surfaces of incisors first
   ii) Gastric reflux and bulimia. This causes a pattern of wear on the palatal surfaces of the upper incisors, as the gastric acid is thought to strike the palatal surface of the teeth first. However in severe cases the distinction is less obvious.
   iii) Attrition. This is wear of tooth substance by teeth, which could be caused by bruxism. It usually occurs in conjuction with erosion but also abrasion.
   iiii) Abrasion. This is wear of the teeth by surfaces other than teeth like nail biting and toothbrushes.
4. **Take a clinical record for a baseline. This includes photographs and study models. **
5. Discuss prevention of further progression by explanation of the condition and its causes, and the removal of causative factors; referral to a physician for GI problems or a psychiatrist for an eating disorder.
6. Monitor if not severe
7. If severe or the condition progressess, consider composite restorations to imporve aesthetics or full crowns if wear is excessive.
8. Referral to a restorative specialist if complex restorative problem

Question 7

While carrying out a root canal on an upper molar you fracture a file in the canal.
Explain how you would proceed and how you would explain the problem to the patient.

Answer 7

1. Calmly explain to the patient that a fine instrument has seperated within the canal and you will try and remove it
2. If you can see the broken file then attempt to remove with some fine mosquitoe forceps. If you are unable to remove then take a PA of the tooth to locate the broken file.
3. Try to dislodge the broken file by passing a finer file alongside it.
4. If this fails, consider trying a Masseran kit.
5. If this is not successful explain to the patient that it is not possible to retrive the broken file with the equipment here and refer them to an endodontic specailist who will retrive the file +/- complete the root filling also. They may do this with ultrasonic instrumentation and EDTA to soften the dentine and working a small file alongside it. If this doesnt work the endodontist may fill the canal to the level of the blockage depending on its location.
6. Explain that the tooth will need to be keep under observation as it may be necessary to carry out a apicectomy at a later stage.
7. Ask patient if they have any questions and arrange a follow up appointment.
8. Record carefully in the notes the explaination given and the event.

Question 8

You are a GDP. While carrying out RCT on a molar you cause a traumatic perforation. Explain how you would proceed and how you would explain the problem to the patient?

Answer 8

1. Calmly assertain the position and size of the perforation by taking a radiograph.
2. Determin why the perforation has occured. Poor access? correct if possible
3. Once have more information explain to the patient what has occured. Explain that the aim is to seal off the perforation.
4. Discuss the options available and likely outcome and why you think it happened. Tx options depend on where the perforation is.
5. Consider early referral to specailist
6. Record the event and explaination carefully in the notes.

Question 9

Treatment options for a small and large pulp chamber perforation?

Answer 9

Small - If bleeding can be arressted, attempt repair using MTA or GIC
Large - If still restorable, then as above. If not restorable then xla or hemisection of tooth.

Hemisection of tooth is cutting it in half, removing the side of tooth that has the perforation.

Question 10

Treatment options for lateral perforation.
1. Ginigval third
2. Middle third
3. Apical third

Answer 10

1. Incorporate in the final restoration eg diaphragm post and core crown or consider crown lengthening procedure
2. Clean and prepare the remainder of the canal by passing instruments down the wall opposite perforation. Fill the canal using lateral condensation technique and try to occlude the perforation. For larger perforations proceed to fill the root if the bleeding can be arrested. It may require surgical approach and in multi-rooted teeth hemisection/extraction of the tooth may be necessary.
3. Clean well with NaOCl and proceed to fill the root. COnsider vertical compaction technique to attempt to fill both the perforation and the remainder of the canal. If unsuccessful an apicectomy will be required.

Perforations may be induced by iatrogenic causes, resorptive processes or caries. Lateral perforations often occur as a result of poor access. Apical perforations make the obturation of canal difficult

Question 11

Look at this radiograph
1. What complication has occurred?
2. What symptoms might the patient be experiencing
3. What are the other causes of these symptoms?

Answer 11

1. There is a radio-opaque matter in the inferior alveolar canal beneath the 37. This tooth also has some radio-opaque material in the distal canal. A root canal filling was being carried out and material extruded through the apex of the tooth and has ended up in the IAC
2. If the material is in the IAC it is likely to cause the patient to complain of altered sensation in the distribution of the iAN ie lower lip. The altered sensation may be numbness or tingling (paraesthesia) and in some cases pain.
3. Other causes. iatrogenic. truama following surgery eg surgical remvoval of lower 8 or premolars.
   Infection - osteomyelitis
   Degenerative - MS
   Metabolic - tetany, diabetic neuropathy
   Neopastic - space occupying lesion

Question 12

This patient has come to your dental surgery and wants to know about the advantages and disadvantages of composite restorations over amalgam.
Please explain the advantages and disadvantages of composite material to the patient.

Answer 12

1. Intoduce yourself to the patient
   Composite - Advantages
2. Aesthetic
3. Conservative removal of tooth structure
4. Provides insulation, has low thermal conductivity
5. Bonds to tooth structure resulting in good retention, low microleakage, minimal interfacial staining and increased strength of remaining tooth
6. Repairable
   Composite - disadvantages
7. Potential for gap formation as a result of polymerisation shrinkage
8. More difficult, time consuming and costly compared with amalgam.
9. More technique sensitive, require complete isolation from moisture
10. May exhibit greater occlusal wear in areas of high occlusal stress
11. Have a higher linerar coefficient of thermal expansion, resulting in potential marginal percolation if inadequate bonding technique is utilised.

Question 13

This patient has come to your dental surgery and wants to know about the advantages and disadvantages of composite restorations over amalgam.
Please explain the advantages and disadvantages of amalgam material to the patient.

Answer 13

Introduce yourself to the patient
Amalgam - advantages
1. Ease of use
2. High compressive strength
3. Excellent wear resistance
4. Favourable long term clinical research results
5. Lower cost than for composite

Amalgam - disadvantages
1. Not aesthetic
2. No insultation, thermal conductive need to place liner to protect pulp
3. Less conservative have to remove healthy tooth tissue to create undercuts
4. Weakens the tooth structure (unless bonded)
5. Intial microleakage
6. More difficult tooth preperation

Question 14

Please draw the envelope of motion of the mandible from a point on the tip of a mandibular incisor from a side view (ie in the sagittal plane), and explain the movements.

Answer 14

Question 15

Please mix GI cement to use as a luting cement.
Props
- Glass ionomer powder and liquid system
- Mixing pad
- Mixing spatula

Answer 15

Question 16

A 24 year old women presents to your dental practise with discoloured teeth.
1. List 4 causes of intrinsic tooth discolouration

Answer 16

1. Trauma
2. Flurosis
3. Caries
4. Amelogenesis imperfecta
5. Dentinogenesis imperfecta
6. Tatracycline staining
7. Chronological hypoplasia
8. Age changes
9. Pulpalnecrosis and pulpal sclerosis ?

Question 17

A 24 year old women presents to your dental practise with discoloured teeth.
2. The patient wishes to know what treatment options are available - please discuss them with her.

Answer 17

1. Vital bleaching. In surgery bleaching, using 30-35% carbamide or hydrogen peroxide. A dental curing light is often used to activate the bleaching agent.
2. At home bleaching using custom made bleaching trays. Patinets use carbamide peroxide 10% for 6-8hrs a day. They are kept under review to monitor progress. Home bleaching techniques are easily applied and repeatable, but can be unpredictable with tetracycline staining. They are only appropriate when there is minimal to no restoration in the teeth.
3. Non-vital bleaching. This allows bleaching of deeper dentine and has a greater effect on change in colour.
4. Microabrasion - with acid and pumice +/- hydrogen peroxide.
5. Composite resin veneers. SOme tooth prep is needed but is less destructive than crowns. When there is severe dark discolouration the tooth may nee to be bleached before. They provide a good result, but may over time may shrink, stain and wear and so may need replacing after about 4 years.
6. Porcelain veneers - about 0.5mm of tooth substance is removed, but again is less destructive than for a crown prep. They are constructed in a lab and bonded onto etched enamel surface. They provide good aesthetics and are less plaque retentive than composite resin veneers.
7. Crowns - These provide excellent aesthetic appearance and are retentive and strong, but are destructive to tooth substance. They are a good option if the tooth is alreaady heavily restored.

Ask if the patient has any questions

Question 18

What types of post and core are available? and please give the advantages and disadvantages of each type

Answer 18

1. Pre-fabricated or custom made
2. Parallel-sided or tapered
3. Threaded, smooth or serrated

Question 19

1. Please do vitality test of this lower first premolar, explaining what you are doing.

Props
- Cotton wool pledget
- Ethyl chloride
- GP
- Heat source
- Vaseline
- Prophylaxis paste
- EPT

Answer 19

1. Introduce yourself to the patient
2. Explain to the patient what you plan to do. I.E test whether the tooth in question is still alive by applying a stimulus to it and gain their permission.
3. It is useful to test adjacent teeth or contralateral teeth first as a control.

Ethyl chloride
1. This is the application of cold. Spare EC on a CW and hold it against the tooth for several seconds until a temperature change is noticed by the patient.

GP
1. This is the application of heat. Dry the tooth and apply vaseline to it as this will stop the gp from sticking to the tooth. Heat the GP and apply it to the tooth until the pt notices a temp change

EPT
1. Dry the tooth and apply TP or prophylaxis paste.
2. It is necessary to make a circuit, So either the patient hold the wand to the tooth with your guidance.
3. Apply the tip to the tooth on the lowest setting anf slowly increase the power until the patient notes a response. (the reading bears little resemblance to the state of the pulp as it can vary depending on the position it is applied to on the tooth or the amount of power in the battery)

Question 20

2. What could cause a false negative or false positive response?

Answer 20

Possible causes of false positives
1. Multiple root canls containing vital and no. vital pulp at the same time
2. Nervous patient
3. Pus in canal

Possible causes of false negatives
1. Presence of a large restoration that insulates the pulp
2. A vital pulp with a good blood supply but a damaged nervous supply (N.B pulp testing really tests the nervous stimulation of the pulp rather than its blood supply, which is of more importance in maintaining vitality)
3. Secondary dentine insulating the stimulus reaching the pulp. (Sclerosed canals)

Question 21

Please isolate the first permenant molar to commence endodontic treatment and explain what you are doing.
Props
- Phantom head
- Rubber dam sheets
- Assorted clamps
- Dental floss
- Dental wedges
- Gauze squares
- CW rolls
- High speed suction
- Parachute chain

Answer 21

The appropriate method of isolation for endo treatment is application of rubber dam. Other methods are considered inferior, due to the risk of inhalation of instruments, so selecting the parachute chain is wrong.
1. Prior to commencement of the RCT, punch holes in the dam to go over the tooth. For endo treatment is is only necessary to expose the tooth you are working on through the dam, although sometimes adjacent teeth may be exposed.
2. Seclect correct clamp
3. Apply a piece of floss to the clamp going through both holes.
4. Ether put the clamp and floss through the hole in the dam, apply clamp holding forceps and place them all on the tooth together or put the clamp and floss on the tooth first and stretch the dam over the clamp.
5. Floss the dam into the contact points and apply wedges if needed
6. Check seal with CHX and use opeldam if needed. Lightcure this and recheck seal.
6. Place a piece of gauze beneath the rubber and the patients skin
7. Apply the frame
8. Secure the loose floss to the frame

Question 22

1. Please survey these study models
2. What is surveying and why is it done?

Props
- Surveyor with attachments
- Study models

Answer 22

1. Attach the study model to the cast table on the surveyor
2. Orientate the occlusal plane at 90 degrees to the base of the surveyor
3. Place the analyser rod in the surveyor and gently run around the teeth present on the cast. Assess the study model for guide planes and undercuts where clasps could be used to gain retention. It may be necessary to tilt the cast to use some undercuts or even out others
4. WHen the final angle of tilt has been decided, remove the analyser rod and replace with carbon tip. Then run this around the cast to mark all the undercuts on the hard and soft tissues alike.
5. Remember to score the cast with several lines so taht it can be relocated back onto the surveyor with the surveyor table at the correct angulation for this particular cast.

B
Study models are surveyed as part of the denture design process. Surveying involves locating the maximum contour of the individual teeth, alveolar ridges and residual ridges. It is used to identify the path of insertion and withdrawal of the denture. Once this is known it is possible to identify which undercuts need to be blocked out. This will ensure that no part of a rigid denture will lie in an undercut relative to the path of insertion. It will also identify which undercuts can be left to aid retention of the denture, and the amount of horizontal undercut of the teeth selected for clasping can be determined. Surveying is important because it enables a denture to be designed with the easiest path of insertion, coupled with the greatest retention and resistance to displacement.

Question 23

A 35 year old man presents to your surgery as he is concerned regarding the appearance of his teeth. Please take a history from the patient to ascertain their concerns and to determine the likely cause(s) for the appearance of the teeth.

Answer 23

1. Introduce yourself to the pateint
2. Patients complaint. You need to ascertain the chief complaint and write it down in the notes in the patients own words
3. History of present complaint.
   i) is this a new problem or have the teeth always had this appearance
   ii) DId the baby teeth have a similar appearance
   iii) Are there any associated features, such as pain or sensitivity?
4. Ask about possible factors, both enviromental and genetic, which may be responsible, for example
   - Trauma to teeth
   - Systemic illness or infection
   - Exposure to any toxic substance
   - Any high intake of fluoride or tetracycline as a child
   - Any hereditary disorders
5. Check the patients MH, any systemic illness(es) and the age at which they occured.
6. Ask if the patient has any questions

Question 24

What is the most likely cause of the appearance of this patients teeth.

Answer 24

The patient has horizontal bands of yellow/brown discolouration affecting the maxillary and mandibular incisors and canine teeth. It is not possible to see in this picture if his first molars are also affected. The most likely diagnosis is enamel hypoplasia, possibly the result of disturbance during the period of tooth development in childhood. The enamel is reduced in thickness or deficient structure and may present as pits, linear or groove defect along enamel.

Question 25

What treatment may be possible to improve their appearance?

Answer 25

The management of intrinsic staining may be difficult, and depending on severity the restorative options are:
- Tooth bleaching and microabrasion (this may be an option if the defect was localised and minimal)
- Veneers: composite/ porcelain
- Crowns (depending on the extent of tooth involvement)

Question 26

What treatment may be possible to imporve their appearance? Please describe the advantages and disadvantages of each briefly to the patient.

Answer 26

**Microabrasion **(this is a procedure wehre a small amount of the stained tooth substance is removed by using a combination of an abrasive impregnated wheel and dilute acid)
Advantage - no restorative material used
Disadvantage - Useful only if development problem or staining is fairly superfical (several hundred micrometres only)
Bleaching ( this is the use of chemicals to lighten or whiten darken/discoloured teeth)
Advantages - No need for removal of tooth substance. No need for restorative material to be used.
Disadvantage - Effect is not permanent. It will be of limited use in this case as the problem is not only staining as there are also enamel defects to address. Bleaching can make teeth sensitive.
Veneers (composite/porcelain) (A veneer is a facing placed on the surface labial in this case of the tooth. Usually requiring tooth prep.)
Advantages - Veneers are effective for masking substantial hypopastic enamel so would be suitable in this case.
Disadvantage - The enamel thickness needs to be reduced by half on the labial surface. Requires acid etching. Very dark staining may not be masked by the veneer.
Crowns (a crown is a restoration cap that covers the coronal tooth tissue that is present above the gum)
Advantages - USed when there is inadequate tooth structure to support a veneer. Can be used to mask darker staining. Good aesthetics
Disadvantages - Requires tooth prep - more thatn required for veneers.
Ask if the patient has any questions?

Question 27

Intrinsic causes of tooth discolouration?

Answer 27

1. Amelogenesis imperfecta
2. Dentinogenesis imperfecta
3. Porphyria
4. Flurosis
5. Tetracycline staining
6. Enamel hypopasia
7. Neonatal jaundice
8. Non-vitality and root filling

Question 28

Extrinsic causes of tooth discolouration

Answer 28

1. Mouthwashes
2. Discoloured restorations
3. Tea, coffee, red wine
4. Smoking
5. Betel leaf usage

Question 29

You are making a full gold crown for a lower left permenant molar. The crown has come back from the lab. Please go through the stages of trying in a crown and cementing it on the dental manakin using the cement provided. Please treat the manikan as though it was a living patient.
Props
- Dental manikan with crown prep on LL6
- Full coverage crown on die
- Articulating paper
- Cement
- Dental instruments

Answer 29

1. Before the patient arrives into the clinic, the crown should be checked on the model. Things to look at are:
   i) The contact points
   ii) The occlusion with opposing teeth
   iii) The die and adjacent teeth for rub marks
   iv) Check there are no blobs of cast metal on the fit surface, if there are, these neeed to be ground down.
   N.B if it was ceramic crown you would also check the shade but not in this case.
2. Introduce yourself to the patient
   i) Check that there is no change in MH
   ii) Check that the patient has not had any problems with the tooth in question since last visit.
   Give local anesthetic if required. However remember LA will alter the patients perception of the occlusion.
3. Remove the temp crown from 36. Clean the tooth adn remove all the temp cement.
4. Try in the restoration, you may need to check the contacts with floss to help seat
5. Check the margins of the crown; there should be nooverhangs and there should be a smooth transition from restoration to tooth.
6. Check ginigval emergence profile
7. Check the occlusion. Using fine articulating paper. Static and dynamic occlusion must be checked for high spots and heavy contacts then removed. But care must be taken not to make it too thin.
8. Cement the crown to tooth
   i) The prepared surface of the tooth should be cleaned and dried.
   ii) The fit surface of the crown should be cleaned and dried
   iii) The cement should be placed around the fit surface of the crown
   iv) the crown should be seated on the prep with considerable pressure, which will expel excess cement
   v) The pressure should be maintained until the cement is set
   vi) Excess cement should be flicked away from the margin and contact areas should be cleaned with floss
9. Recheck the occlusion
10. Arrange a review

Question 30

A F&H 35 year-old women presents to your clinic. She is wearing a partial denture in the place of a missing lateral incisor. She is keen to have a fixed prosthesis. Please discuss and explain what investigations you need to carry out prior to treatment.

Answer 30

1 Introduce yourself politely to the patient.
2 Ascertain if the missing teeth were ever present in mouth. (Absent maxilary lateral incisors are hereditary in 1-2% of the population).
3. Extra oral examination - Check the smile line. Does patient show any gingival/alveolus?
4. Intra-oral examination - Check the health of oral mucosa. Do a periodontal assessment: oral hygiene, any calculus, pocketing, gingival inflammation.
5. Assess the ridge height and width, and bone quality and quantity by clinical and imaging means. To accommodate a standard implant there should be a minimum of 10 mm bone inciso-gingivally (ridge height) and a minimum of 6 mm facio-lingually. (NB: short and narrow implants are commercially available so ensure there is adequate bone for these if insufficient for standard implants.)
6. Assess the occlusion.
7. Special investigations
- Vitality testing of adjacent teeth to ensure no further treatment is required as they may be used as abutments.
- Radiographs - assess for unerupted teeth, pathology.
- Periapical or standard upper occlusal. OPT is helpful in the assessment of the overall dentition and to assess if there is adequate space between the roots to accommodate an implant. Cone beam CT.
- Study models for occlusal assessment and diagnostic wax-up.
- Clinical photographs.
8 Management of these patients may require a multidisciplinary approach that may include an orthodontist, dental implantologist and restorative dentist. The options for treatment include closure of space by orhtodontic means or a restorative option with maintenance of the space.

Question 31

A F&H 35 year-old women presents to your clinic. She is wearing a partial denture in the place of a missing lateral incisor. She is keen to have a fixed prosthesis. Please discuss her treatment options with her.

Answer 31

1. Closure of space by orthodontic means
   i) Complete space closure - reshape the canine to resemble a lateral incisor
   Advantage - No need for fixed pros
   Disadvantage - Disguising the canine to resemble a lateral incisor is rarely ideal (the tooth will still look bulky and prominent). Also long treatment time compared with restorative option.
   ii) Partial space closure (as too much space for a lateral incisor)
   Advantages: allows correct soze fixed prosthesis. Good aesthetic
   Disadvantage - Requires both orthodontic and restorative team, ie cost implications
2. Restorative options with maintenance of space.
   i) FIxed restorations. Fixed fixed adhesive bridge (RB)
   Advantages - minimal or no tooth prep (conservative). Good aesthetics. Less chairside time and less expensive than a conventional bridge.
   DIsadvantage - Requires a sound aesthetic abutment with healthy enamel to bond to. Requires adequate occlusal clearance on the abutment. If one side debonds can be plaque trap.
   ii) cantilever design
   Advantages - Conservative, minimal tooth prep, good aesthetics and easy plaque control
   DIsadvantage - Leverage on abutment teeth. If abutment debonds then the patient is left with space.
   iii) Conventional bridge
   Advantages - Fixed, good retention, goood aesthetic. Less sensitive cementation technique compared with resin bonded bridge.
   Disadvantages - Greater tooth prep required, risk of pulp death. Failure to decementation, decay of abutment. Cost irreversible. Requires temp crown.
   iv) Single tooth implant
   Advantages - FIxed restoration. Independent of adjacent teeth for retention. Maintains the supporting bone and prevents bone loss.
   Disadvantages - Require adequate bonne and involves a surgical procedure. High intial expense and long treatment time.

Ask if the patient has any questions and allow them time to consider their options before making decision.