33 OSCE Objectives → red bold text = a question we saw on the practice OSCE I am sure this is written deep in the instructions somewhere (like how to mount endo teeth), but Kramer told me the OSCE is HALF!!! removable, half other stuff. So be really comfortable with this first section!

● Removable Prosthodontics (for both partial and complete dentures): 1. Anatomy

a. Retromolar pad: has to be covered by denture for mandibular denture stability and support i. A baseplate was unacceptable b/c it didn’t extend 2/3rd up the retromolar pad ii. There was a model that was missing the retromolar pad on 1 side

b. Buccal shelf: provides primary support for mandibular denture (doesn’t change), ID on a stone

model

c. Incisive papilla: under incisive papilla is nasopalatine nerve and vessel, ID on a stone model d. Hamular notch + fovea palatini: ID on a stone model

i. Error - denture model underextended on the hamular notch area (what do you mean by this?) → i think there was a model or an impression where it didn’t extend far back enough to capture the hamular notch area (someone correct me if I’m remembering wrong) OOH thanks! :)

e. Palatal rugae: ID on a stone model f. Post dam area (posterior palatal seal): used for denture retention and palatal seal via suction, ID on a

stone model g. Palatal vault: describe the palatal vault w/o using Neil/House classification → palate was high/deep

i. Neil's Classification (1-3) → classifies the lateral throat ii. House's Classification (1-3) → classifies the soft palate

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2. Indications and considerations:

a. Monoplane teeth: i. Teeth with zero degree cusps/non-anatomical cusps (use if mandibular ridge is flat) ii. Give unnatural and unesthetic tooth anatomy BUT easy to establish balanced occlusion since all

cusps are flat and there are no cusp inclines to cause excursive or protrusive interferences b. Lingualized occlusion:

i. Several questions on lingualized occlusion 1. If don’t have buccal flare on cusps → will have cheek biting 2. Anatomic teeth in the maxilla and monoplane or semi-anatomic cusps in the mandible

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c. Angular cheilitis:

i. ID an image + ID the cause → overclosing/lost VDO

d. Epulis fissuratum:

i. Tx w/ diode laser

3. Techniques + Instrumentation

a. Fox plane: i. Fox plane on display/picture of one → purpose is for assessing horizontal and vertical

planes of occlusion of wax rim

b. Centric tray:

i. Used for preliminary VDO and CR (use putty)

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c. Bite recorder:

i. Used for final VDO and CR d. Custom tray fabrication:

i. Edentulous (no teeth): 1 layer of wax and no occlusal stops ii. Dentate: 2 layers of wax and occlusal stops

e. Custom tray errors: i. There was a custom tray and we had to identify what was wrong with it → was missing a handle

ii. Custom tray had a handle too straight out (90 degrees), so it was made wrong (can’t capture anterior border)

1. Handles should be L-shaped so they come up over the lip and out the front of the mouth 2. Allows the PT to close and you have easier access to mold the soft tissues

f. Choosing a stock tray:

i. Opt for a larger one over too small → fits better

g. Impression errors:

i. Hole in the palatal of PVS impression was a VOID → NOT palatal tori ii. Voids in 2 or three areas of a border molding impression (vestibular area)

h. Model error: i. Retromolar pad was missing on one side of a model - Model needs to extend 2/3rd up the

retromolar pad for denture stability and support ii. Maxillary model not usable for denture fabrication due to large bleb on palatal iii. Frenum areas need to be relieved

i. Base plate (aka record base) vs custom tray: i. Base plate is made with NO wax ii. Base plate has NO handle

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j Wax rim error:

iii. There was a maxillary wax rim with anterior too thick/wide or too flared/too round

j. Denture fabrication error:

i. Central groove of mandibular posterior teeth should be centered over alveolar ridge ii. There was a denture where you had to ID what was wrong

1. Teeth on posterior lower right were off center k. Beading and boxing:

i. What is the purpose/advantage of the beading and boxing? → create an all-in-one cast with land area → stronger

l. Denture repair:

i. There was a repaired denture, and we had to identify what was wrong → had 2 acrylic blebs on the intaglio surface (which would cause pain/sores)

m. Surveyors: i. There was a picture of a surveyor which asked, “What was it measuring?” (HOC)

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ii. Surveyors are used to select path of insertion & select guiding planes - a survey line is drawn on

a tooth or teeth for the purpose of determining the proper location/type of various clasps n. Remember how pressure-indicating paste is used(PIP)-> shows areas with excess pressure o. Lynal is a material that can be used for a functional impression reline. p. A master cast base should be at least ½ inch thick & the landing area should be at least 3-5 mm wide

4. Treatment planning a. Immediate dentures:

i. Healing time after placing immediate dentures: 5-6 months healing time after immediate dentures

CAD/CAM: 1. List the steps for completing a CAD/CAM restoration in one visit.

a. Proper patient/case selection b. Proper preparation geometry c. Standard isolation d. Digital impression e. Design restoration f. Mill restoration g. Occlusion and fit check (CMO) h. Finish restoration (glaze and polish) i. Prepare for bonding (clean, etch, silane coupler) j. Delivery

2. Recognize errors in CAD/CAM scanning a. Scanner not in proper orientation → causes initial orientation of scan to appear off (not in center of distal

and mesial OR tipped out of horizontal alignment)

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b. Light/dark blue in interproximal areas (lack of data in this spot) → would cause overbuilt

restoration in the contact area and will have to be adjusted manually

3. Recognize errors in CAD/CAM design

a. Marginal ridge too high

b. Yellow on crown design indicates crown is too thin in that area (due to underprepped and under

contoured → results in overmilling of crown)

c. Concentric circles on intaglio surface of crown is due to overmilling from sharp ridge → thin

spot/thin restoration warning→ fracture

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4. Describe material requirements/limitations for CAD/CAM restorations.

a. Lithium disilicate (e.max) i. 2.0 mm occlusal reduction ii. 1.0 mm radial shoulder margin

b. Leucite reinforced (Empress) i. 2.0 mm occlusal reduction ii. 1.2 mm radial shoulder margin

c. Zirconia i. 1.5 mm occlusal reduction ii. 0.5 mm chamfer margin

5. Describe milling requirements/limitations for CAD/CAM restorations. a. The sharper the angles → the greater the overmill → and leads to fracture b. Because of bur size, any roughness in the prep will be over-milled → preps must be very smooth and

rounded to avoid thickness (or technically thinness) issues c. Sirona: will NOT over-mill, but instead ignores the roughness → leads to open margins d. PlanFit/E4D: WILL over mill the roughness → leads to open margins

Bicon dental implants

1. Identify all parts/instruments in the Bicon advanced surgical/restorative

a. Pilot drill: 6mm, 8mm, 11mm, and 14mm markings → standard and extended size

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b. Paralleling pins: normally use 0 degrees, 15 and 25 degrees used for misaligned teeth or anterior teeth c. Latch reamers: used to increase diameter + collect bone for bone harvesting/bone

typing, inactive tip

c d. Hand reamers: maxillary arch only, active tip

e. Threaded straight handle + threaded offset handle (for posterior) f. Seating tips g. Inserter retriever: for implant placement into osteotomy → green, purple, blue color (question had

an inserter retriever pulled out from the kit)

h. Guide pins: used to check osseointegration (healing) of the implant

2. List steps of the osteotomy preparation technique for Bicon implants

a. Pilot drill at 1100 RPM with irrigation to 6mm b. Check trajectory with paralleling pins c. Prepare osteotomy to depth (pilot drill, 1100 RPM, irrigation) d. Increase diameter of osteotomy using latch reamers at 50 RPM by increments of 0.5mm until final

diameter is reached → (inactive tip, no irrigation) i. Fluted design for bone grafting → use bone in last latch reamer to type the bone

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ii. If in type 4 bone, under prepare by 0.5mm 3. Recognize errors in the osteotomy preparation and/or implant placement (i.e. position trajectory, etc.)

a. Did not prep osteotomy so implant will be 2mm subcrestally → question showed an implant that was supra-crestal

b. Did not use paralleling pins to check trajectory c. Stopping the handpiece inside the osteotomy → can cause bone to break d. Increasing the depth using the hand reamer (due to active tip) e. Touching the implant body f. Not tapping the implant down the long axis of the tooth → remember to use offset threaded instrument in

posterior g. Cutting the black healing plug anywhere besides the crest of the bone.

4. Describe the various impression techniques used for Bicon implant crown fabrication. a. Direct abutment level impression:

i. Place the abutment ii. Take impression

b. Indirect abutment level impression: i. Place the abutment ii. Snap on impression sleeve iii. Take impression iv. Insert abutment transfer die

c. Implant level impression(for IAC): i. Place impression post ii. Place impression sleeve iii. Take impression iv. Insert implant analog

5. Identify the Bicon implant system parts used during the restorative phase. a. Healing plug removal instruments b. Guide pins to confirm osseointegration of the implants and to check parallelism. c. Check depth of soft tissue to determine height of abutment d. Crown tapped in

Threaded Root-form Implants (Straumann/Hiossen)

1. Id all parts/instruments in the Hiossen surgical kit. a. http://hiossen.com/about-us/surgical-kits/drill-kits/taper/

2. List steps of the osteotomy preparation using the Hiossen surgical kit. 3. Recognize errors in the osteotomy prep and/or implant placement (i.e. depth, position, angulation, etc.).

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a. Need 1.5 mm in M-D space b/w implant & its neighbor (so 3 mm between two adjacent implants)

4. Distinguish between a bone level and tissue level implant and explain indications for each.

a. Bone level is more esthetic because of the emergence profile and tissue collar is not visible. b. Tissue level better for cementation? Because the margin is more coronal. → google says tissue level is

good b/c the cement is higher up from the bone (in simple terms) and that keeps to prevent bone loss? -Tissue level implant may be preferable for implant-supported dentures

5. Explain the importance of properly torquing the abutment and state the correct torque for the Straumann/Hiossen abutment placed during the implant lab rotation.

a. Straumann: 35 ncm (Newton centimeter)/ Hiossen: 30 ncm b. For immediate loading, the torque of the abutment must be less than the torque of the implant because

the implant has an active tip and will continue to penetrate the bone. 6. Describe advantages and disadvantages of a custom abutment versus a stock abutment.

a. Stock (direct) i. Conventional crown and bridge technique ii. Snap-on impression at abutment- level iii. Freedom to position the restorative margin iv. Possibility to adjust occlusal height v. All parts included in a kit for prosthetic and laboratory

procedures b. Custom (anatomic)

i. Better emergence profile and esthetics ii. Preservation of the papilla iii. Less gold used in final restoration iv. Uniform thickness of restoration v. Can make up for poor placement of the implant body vi. Better retention and resistance vs stock abutments vii. More expensive than stock abutment

7. Distinguish between the abutment level impression and the implant (fixture) level impression & id the impression parts used in each technique

a. For a stock abutment → take abutment-level impression i. Abutment is in ii. Put the impression cap over top iii. Put in the impression cylinder iv. Take the impression & the impression cylinder sticks in the material v. Then the lab can use an implant analog & abutment, which will transfer to the model when poured

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b. For custom abutment → take implant-level impression b/c you don’t have the abutment yet

i. Put the analog in the implant ii. Put the impression coping over it iii. The impression coping will get picked up in the impression

8. Discuss pros and cons of screw-retained versus cement retained crowns

a. Screw retained i. Advantages

1. Non parallel implants 2. Retrievability if repairs are needed 3. Retrievability if one of multiple implants fail 4. Ability to re-tighten abutment screws that may become loose

ii. Disadvantages 1. Esthetics 2. Leakage at composite/ tooth interface 3. Nearly 10X more likely to have porcelain fx’s due to the screw hole

b. Cement retained i. Advantages

1. Esthetics 2. Better control over emergence profile 3. Easier to replace if crown fails 4. Mimics conventional crown and bridge (Ease of use) 5. Lower fx rate (4% vs 38% @ 5 yrs)

ii. Disadvantages 1. Possibility of residual cement/crestal bone loss 2. Difficulty of removal if screw loosens

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Radiography

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

Don’t forget to specify right/left and maxillary/mandibular for radiographs

2. Identify teeth (by number/letter) on a given radiograph a. Practice test had us ID a primary tooth on a radiograph (it was #T)

3. Identify radiographic technique errors from resulting radiographic images a. FMX errors:

Large vertical angle: foreshortening Small vertical angle: elongation Incorrect horizontal angle: contact points are overlapped –

can’t see proximal surfaces

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b. Pano errors:

i. Pt’s head rotated/twisted: teeth narrow on side closest to the film sensor, teeth too wide on the other side, noticeable in anterior teeth due to narrower image layer

ii. Pt’s head too far back: teeth wide/blurry, TMJ areas not seen- horizontal magnification will be

greater.

iii. Pt’s head too forward: teeth appear narrow/blurry, may see cervical vertebrae- smaller horizontal

magnification

iv. Pts chin too high:

1. Max anterior teeth look wide/blurry + mandibular anterior teeth look fine, 2. Anterior teeth moved up + posterior teeth move down → frown

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3. Hard palate superimposed on roots of maxillary anterior teeth 4. TMJ not seen

v. Pts chin too low:

1. Mandibular anterior teeth look wide/blurry + maxillary anterior teeth look fine 2. Anterior teeth moved down + posterior teeth moved up → smile appearance 3. Prominent overlapping of teeth 4. Cervical vertebrae seen

vi. Pts head slumped forward: cervical vertebrae make radiopacity on middle of film, superimposed

spine

vii. Tongue improperly positioned (not against palate): can see image of palatoglossal air space as

broad radiolucent band across maxilla → obscures apices of maxillary teeth roots or alveolar process

viii. Ghost images: always on the opposite side of the object, higher up (due to negative vertical

angle) and more blurred (because farther away)

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ix. Thyroid collar vs. cervical spine: thyroid collar will obstruct the image completely because it is

lead while cervical spine is bone

4. Identify radiographic technique errors from a photograph of sensor holder assembly and sensor placement

a. I’m guessing it will be a photo of a backwards sensor (backwards CMOS)

5. State the recommended series type and recommended exposure intervals for both new and recare

children and adults who are at high caries risk and low caries risk, according to the 2012 ADA guidelines.

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6. Recognize proper Rinn assembly for BW and PA sensor placement in all areas of the mouth.

Molar and Premolar PAs: Upper right = the same as lower left Upper left = the same lower right (Just think about how it would fit to take an upper PA - the cord must come out of the mouth)

Canine/Lateral and Incisor PAs: Bitewings:

Endodontics

1. Describe the basic pulp chamber anatomy, root morphology, number of roots/pulp canals for all teeth a. # of roots/canals:

i. Maxillary: 1. Centrals, laterals, canines: 1 root, 1 canal 2. PM1: 1-2 roots, 2 canals 3. PM2: 1 root, 1 canal

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4. M1: 3 roots, 4 canals 5. M2: 3 roots, 3 canals

ii. Mandibular: 1. Centrals, laterals, canines, PM1, PM2: 1 root, 1 canal 2. M1, M2: 2 roots, 3 canals

b. Access shape: i. Maxillary:

1. Centrals, laterals: triangle 2. Canines, PM1, PM2: oval 3. M1, M2: rhomboid

ii. Mandibular: 1. Centrals, laterals, canines, PM1, PM2: oval 2. M1, M2: rhomboid

2. Recognize and explain errors in endo access prep (location, shape for specific teeth, size, etc.) for all

teeth. Understand the rationale of the shape of each access opening. a. Access Prep:

i. Shape of pulp chamber/location of pulp horns/# of roots dictate the shape of the access opening ii. Un-roof pulp chambers done ONLY with upward bur stroke iii. All pulp tissue must be removed

b. Incorrect endo access prep: i. Do not get straight line access → had to choose which line on a pic represented straight line

access + had to ID a mistake on a radiograph where they perf’d the tooth because they didn’t follow straight line access

ii. Canals can be overlooked iii. Infected material left in root canal iv. Increase risk of perforation v. Weakened tooth structure

3. Recognize common endo instrumentation and obturation errors and explain their causes. a. Gutta percha extending out apex of tooth may happen for 3 reasons:

i. Too small of a gutta percha ii. Over-instrumenting the minor constriction iii. Didn’t feel tugback

4. Id number, name, sequence and purpose of radiographs commonly required during endo therapy. a. Pre-op: diagnosis

i. Size & depth of canals, morphology & number of roots, pathology ii. Allows you to see how large pulp chamber is (will you feel a “drop”?)

b. 10 File: testing to affirm the file has gone to WL (can be 0.5 mm short of apex) i. Apex locator used in clinic

c. Master cone gutta percha: testing to see if gutta percha cone goes to WL & is wide enough for canal → do not want it going past the apex

d. Post obturation: testing to see that there are no voids in the gutta percha & that the fill has gone to WL 5. Be familiar with the WaveOne Protocol, including instruments, purpose and settings.

a. Had an xray where an endo file was broken off in a canal

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6. Identify armamentarium used in endodontic therapy.

● Side vented needle irrigation ● Hand files ● EDTA (RC Prep) → dissolves inorganic material ● NaOCl → dissolves organic material

Anesthesia

1. Name and locate landmarks used for the following injections: PSA, MSA, ASA, IO, NP, GP, IAN, IN. Describe the injection technique, including appropriate anesthetic amount for: PSA, MSA, ASA, IO, NP, GP, IAN, IN. Describe which hard&soft tissues are anesthetized for: PSA, MSA, ASA, IO, NP, GP, IAN, IN.

Dr. Van said that some questions will be models that have teeth colored in and we will have to pick which injection it is that will do that → 4-5 questions on anesthesia total → there can be multiple correct answers

Landmarks: Technique: Anesthetic amount: Tissues anesthetized:

PSA: - Maxillary tuberosity, 2nd max molar - Penetrate @ height of

- 45-degree angle inward, upward, and backward - 25 or 27 short

½ - 1 cartridge - Max molars & associated supporting structures, excluding

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mucobuccal fold, just distal to 2nd molar

- Deposit in vicinity of PSA foramina, near apex of 3rd molar - ½ - ⅝” deep (12-16 mm)

MB root of 1st molar - Buccal soft tissues

MSA: - Maxillary 2nd PM, zygomatic arch - Penetrate @ mucobuccal fold above 2nd PM

- Parallel to long axis of 2nd PM - 27 or 30 short - Deposit 1-3 mm above apex of 2nd PM - ¼” (6 mm) deep

½ - ¾ cartridge - Maxillary PMs, MB root of 1st molar & associated supporting structures - Buccal soft tissues

ASA: - Max lateral & canine - Penetrate @ mucobuccal fold above lateral or just mesial to canine

- Advance at angle toward mesial side of canine - 27 or 30 short - Deposit 1-3 mm above apex of canine - ¼ - ½” (6-12mm) deep

⅓ - ½ cartridge - Max anterior teeth & associated supporting structures on facial - Facial soft tissues, upper lip

IO: - Maxillary 1st PM, IO notch, ridge, depression, foramen - Penetrate @ mucobuccal fold over 1st PM

- Parallel to long axis of 1st PM, in line w/ foramen; contact bone & apply pressure during & after - 25 or 27 long - Deposit @ IO foramen, below IO notch - ½ to ⅔” (12-16 mm) deep

½ - ⅔ cartridge - Max centrals through PMs & associated supporting structures - Facial soft tissues, lower eyelid, side of nose, upper lip

NP: - Maxillary central incisors, incisive papilla - Penetrate @ either side of incisive papilla

- Angle under papilla, toward foramen w/ pressure throughout - 27 or 30 short - Deposit @ incisive foramen, beneath incisive papilla - 4 mm deep

⅛ - ¼ cartridge, just until papilla blanches

Anterior ⅓ of hard palate, from distal of canine to distal of canine

GP: - Junction of maxillary alveolar process and palatine bone, border between hard and soft palate, 2nd molar, GP foramen - Penetrate just anterior to GP foramen

- Approach from opposite corner of mouth, pressure throughout - 27 or 30 short needle

⅛ - ¼ cartridge, or until significant blanching occurs

-Posterior ⅔ of hard palate from distal of canine and up to midline -Palatal tissues overlying posterior ⅔ of hard palate from distal of canine to midline

IAN: - Coronoid notch, pterygomandibular raphe, corner of mouth - Penetrate @ apex of pterygomandibular triangle: 7-8 mm above occlusal plane, lateral to & hugging the raphe

- Approach from opposite corner of mouth w/ syringe over PMs & parallel to mandibular occlusal plane & needle hugging raphe and contacting bone - 25 or 27 long - Deposit slightly above mandibular foramen - 1” (20 - 25 mm) deep - ⅔

¾ - 1 cartridge All mandibular teeth to midline & overlying facial tissue anterior to mental foramen (from 2nd PM to midline)

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of a long needle

IN (incisive):

- Mental foramen, 2nd mandibular PM - Penetrate @ mucobuccal fold just anterior to mental foramen

- Advance horizontally @ depth of vestibule; apply pressure after for 1-2 min - 27 or 30 short - Deposit just distal to mental foramen - ¼” (6 mm) deep

⅓ cartridge - 1st or 2nd PM to midline & associated supporting structures - Facial tissue & lip anterior to mental foramen

2. Identify all local anesthetic syringe parts a. Syringe components:

i. Needle adaptor → do not throw away syringe barrel ii. Finger grip & finger bar iii. Thumb ring iv. Piston v. Harpoon → not present in self aspirating syringes

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b. Gauge Sizes: 25 (red), 27 (yellow), 30 (blue) i. The smaller the gauge #, the larger the barrel ii. Long 32 mm, short 20 mm

3. Recognize errors in the local anesthetic syringe assembly. a. Most needle breaks are w/ a 30 gauge → NEVER bend them (Blue Breaks) b. Never force a needle or bend a needle prior to use c. Needles should never be inserted into their hubs, they break at the hub→ weakest point d. Needle problems are typically operator problems

4. List all dental anesthesia armamentarium for a proper tray set-up. a. Syringe b. Needle c. Cartridge d. Antiseptic e. Topical anesthetic f. Cotton tip applicator g. Saliva ejector h. 2x2 cotton gauze i. Hemostat or locking pliers

Other:

1. Centric Relation according to MWU: a. Comfortable, Reproducible and Loadable

Information we wrote down from our practice OSCE that need to be added above still:

1. Dentures a. Bite Registration w/ wax rims and bite recorder are ordered from the lab and used to establish

vertical relationship of ridges, establish centric relationship of ridges, choose mold and shade of tooth, then sent back to the lab with final denture prescription.

b. Voids in 2 or three areas of a border molding impression 2. Implants

a. Be able to pick implant systems parts out of a line up. i. Ex: what part is this? (abutment)

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