Clinical Case Presentation            Majd Hasanin, Bach V, 42620112
Patient’s Personal Data• Age: Twenty-One yrs old.• Gender: Male• Nationality: Saudi• Occupation: College Student• Marital ...
Chief Complaint               “‫”حساسية في كل أسناني‬                “Sensitivity all over”History of chief complaint: Sta...
Medical History   Patient stated that he is medically fit.   Allergies: None.   Hospitalization: Never been hospitalize...
Past Dental History Few extracted teeth (Upper 6’s). Few restored teeth (Lower 6’s).                                     5
Past Dental History                      Few extracted teethFew restored teeth                                            6
Habits and Oral Hygiene Activities   Patient brushes once daily mostly never.   Technique of brushing: Horizontal Scrub....
Pretreatment Photographs                           8
Extra-oral Photographs   Frontal (Non-Smile)   Frontal (Smile)                                           9
Extra-oral Photographs    Lateral (Non-Smile)   Lateral (Smile-45 ْ )                                                  10
Intra-oral Photos “Frontal”                              11
Intra-oral Photos “Upper Arch”                                 12
Intra-oral Photos “Lower Arch”                                 13
Intra-oral Photos “Right Side”                                 14
Intra-oral Photos “Left Side”                                15
Diagnostic Aids                  16
Panoramic Radiograph                       17
Radiographs-BitewingsRt                      Lt                             18
Radiographs-PeriapicalsU Rt                       U LtL Rt                       L Lt                                  19
Mounted Diagnostic Casts                           20
Mounted Diagnostic Casts Rt                        Lt                                21
Diagnostic Casts        Maxillary Occlusal View       Mandibular Occlusal View                                  22
Clinical Examination                       23
Extra-oral ExaminationTransverse “non-smile”: Symmetrical. Nothing Abnormal  Detected.                          24
Extra-oral Examination• Antro-posterior, Vertical: Concave profile. Class I extra-orally. Incompetent lips. Normal NLA...
Intra-oral ExaminationTongue, floor of the mouth, Palate and Mucosa areall with-in the normal limit (WNL).               ...
Intra-oral Examination Lower midline is deviated to the left around 3.0mm in comparison to the upper midline.            ...
Intra-oral Examination Two restored teeth. Multiple carious teeth. Two missing teeth.                            28
Clinical Examination PSR(Periodontal Screening and Recording)       1 = Pocket Depth < 3.5 mm, bleeding upon probing.    ...
Clinical Examination     Gingival Index (GI):                  By: “Leo and Silness,1963”    18   17   16   15   14   13 ...
Clinical Examination     Plaque Index (PI):               By: “Silness & Loe”,1964    18   17   16   15   14   13   12   ...
Clinical Examination     Periodontal Chart (FM) Upper:    B    M-    CEJ    M-BP           333   333        333   333   3...
Clinical Examination     Periodontal Chart (FM) Lower:     B     M-     CEJ     M-BP            333   333   333   333   3...
Clinical Examination Generalized Plaque Accumulation. Calculus Index: 0 “Zero”.                                     34
Clinical Examination                                                             Key:                                     ...
Clinical Examination                                               Key:                                                   ...
Clinical Examination  Pulpal and Periapical Tests for suspected teethTooth # Cold Test        Vertical Percussion   Horiz...
Laboratory Investigations CRT (Caries Risk Test)  Saliva Flow Rate :        12 ml in 5 min = 2.4 ml/min (above standard)...
Laboratory Investigations CRT (Caries Risk Test) Measuring the Acid Production by the  microorganism in the saliva;  Acc...
Laboratory Investigations CRT (Caries Risk Test) Results have revealed the following:  •S.M = 2 < 100,000 CFU Low Risk ...
Diagnosis and Treatment        Planning                          41
Treatment Objectives•Chief Complain.•Oral Hygiene Motivation.•To Restore:   Function.   Structure.   Esthetics.        ...
Preliminary “Emergency”                          43
Preliminary “Emergency”• Diagnosis   Peri-apical radiolucency.   Irreversible Symptomatic Periodontitis.• Proposed Tx.  ...
Phase I, II(Restorative, Endo, Prostho)                               45
Phase I: (Periodontic Therapy)• Diagnosis for the “Periodontium”:    Chronic Generalized Moderate Gingivitis, resulting f...
Phase I: (Periodontic Therapy)• Proposed Tx.   Scaling, by ultrasonic scaling and hand instruments.   Prescribing 0.12% ...
Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:    Includes the demonstration of the right technique in     br...
Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:    Flossing:                                  49
Phase I: (Preventive Therapy)•Based upon the CRT the patient will need:   Diet Alteration (less Sweets,       CHO Balance...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 18:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 17:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 15:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I, II:• Diagnosis for tooth # 14:    Deep Occluso-distal Caries.    Necrotic Pulp.• Proposed Tx.    Conventional ...
Literature Article Supporting Tx Option:           Premolars with MOD restorations were           stronger if reinforced w...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 24:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I, II:• Diagnosis for tooth # 25:    Deep Occluso-mesial Caries.    Necrotic Pulp.• Proposed Tx.    Conventional ...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 27:    Occlusal Caries.    Palatal Pit Caries.• ...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 28:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 38:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 37:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I:• Diagnosis for tooth # 36:    Defective Restoration.    Deep Occluso-distal Caries.• Proposed Tx.    Temporiza...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 35:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 34:    Shallow Occlusal Caries.• Proposed Tx.   ...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 44:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 45:    Occluso-distal Caries.• Proposed Tx.    C...
Phase I, II:• Diagnosis for tooth # 46:    Deep Occluso-distal Caries.    P.A Radiolucency.    Symptomatic Irreversible...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 47:    Occlusal Caries.• Proposed Tx.    Modifie...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 48:    Occlusal Caries.• Proposed Tx.    Modifie...
Tooth #        Treatment PlanPeriodontium   Supragingival Scaling and Polishing# 18           Class I composite or amalgam...
Tooth #   Treatment Plan# 34      Class I composite# 44      Class I composite# 45      Class II composite# 46      Conven...
Phase III (Orthodontic      Therapy)                         72
Orthodontic Consultation                           73
Orthodontic Consultation An orthodontic consultation is needed  to:1.   Correct the lower midline shift.2.   Gain normal ...
Orthodontic Consultation After the Consultation:1. Lower 6’s (# 36, # 46) will be extracted.2. Treatment will take upto 2...
Post Treatment Progress                          76
Pre and Post Photographs                           77
Frontal          78
Occlusal-Maxillary                     79
Occlusal-Mandibular                      80
Lateral-Rt             81
Lateral-Lf             82
Pre and Post Radiographs                           83
Panoramic-Before                   84
Panoramic-After                  85
Bitewings-Rt               86
Bitewings-Lf               87
Periapicals-RCT # 14                       88
Periapicals-RCT # 25                       89
Tooth #        Treatment DonePeriodontium   Supragingival Scaling and Polishing# 18           Class I amalgam# 17         ...
Tooth #   Treatment Done# 34      Class I composite# 44      Class I composite# 45      Class II composite (OD)# 46      C...
Phase IV (Maintenance)                         92
Phase IV (Maintenance)  Recall the patient every 3 months to: •  Do periodontal maintenance. •  Emphasize on the oral hyg...
Thank you all, for your kind attention            Any Questions?
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Case Presentation-Internship!

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This is a case I treated from A-Z which was presented today at the Internship Treatment Plan Seminar, the patient last visited the dental office on the sixth grade!! He was very apprehensive at the initial visits, but thankfully we managed to over come that successfully.

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Transcript of "Case Presentation-Internship!"

  1. 1. Clinical Case Presentation Majd Hasanin, Bach V, 42620112
  2. 2. Patient’s Personal Data• Age: Twenty-One yrs old.• Gender: Male• Nationality: Saudi• Occupation: College Student• Marital Status: Single• Patient’s Attitude: Cooperative (Apprehensive in the initial visits).• Patient’s File number: 25129 2
  3. 3. Chief Complaint “‫”حساسية في كل أسناني‬ “Sensitivity all over”History of chief complaint: Started since more than 3 years ago! Dentists scare me and I never bothered to visit a practitioner ever since the sixth grade. 3
  4. 4. Medical History Patient stated that he is medically fit. Allergies: None. Hospitalization: Never been hospitalized. Medications he is on: None.Family Medical History Not significant. 4
  5. 5. Past Dental History Few extracted teeth (Upper 6’s). Few restored teeth (Lower 6’s). 5
  6. 6. Past Dental History Few extracted teethFew restored teeth 6
  7. 7. Habits and Oral Hygiene Activities Patient brushes once daily mostly never. Technique of brushing: Horizontal Scrub. Uses a “Medium” brush. Doesn’t change his tooth brush very often. Doesn’t floss. Doesn’t visit the dentist nor the hygienist periodically. 7
  8. 8. Pretreatment Photographs 8
  9. 9. Extra-oral Photographs Frontal (Non-Smile) Frontal (Smile) 9
  10. 10. Extra-oral Photographs Lateral (Non-Smile) Lateral (Smile-45 ْ ) 10
  11. 11. Intra-oral Photos “Frontal” 11
  12. 12. Intra-oral Photos “Upper Arch” 12
  13. 13. Intra-oral Photos “Lower Arch” 13
  14. 14. Intra-oral Photos “Right Side” 14
  15. 15. Intra-oral Photos “Left Side” 15
  16. 16. Diagnostic Aids 16
  17. 17. Panoramic Radiograph 17
  18. 18. Radiographs-BitewingsRt Lt 18
  19. 19. Radiographs-PeriapicalsU Rt U LtL Rt L Lt 19
  20. 20. Mounted Diagnostic Casts 20
  21. 21. Mounted Diagnostic Casts Rt Lt 21
  22. 22. Diagnostic Casts Maxillary Occlusal View Mandibular Occlusal View 22
  23. 23. Clinical Examination 23
  24. 24. Extra-oral ExaminationTransverse “non-smile”: Symmetrical. Nothing Abnormal Detected. 24
  25. 25. Extra-oral Examination• Antro-posterior, Vertical: Concave profile. Class I extra-orally. Incompetent lips. Normal NLA (Nasiolabial Angle “90⁰”). Increased lower facial height. 25
  26. 26. Intra-oral ExaminationTongue, floor of the mouth, Palate and Mucosa areall with-in the normal limit (WNL). 26
  27. 27. Intra-oral Examination Lower midline is deviated to the left around 3.0mm in comparison to the upper midline. 27
  28. 28. Intra-oral Examination Two restored teeth. Multiple carious teeth. Two missing teeth. 28
  29. 29. Clinical Examination PSR(Periodontal Screening and Recording) 1 = Pocket Depth < 3.5 mm, bleeding upon probing. 29
  30. 30. Clinical Examination  Gingival Index (GI): By: “Leo and Silness,1963” 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 5” = 2 / Moderate Gingival Inflammation 30
  31. 31. Clinical Examination  Plaque Index (PI): By: “Silness & Loe”,1964 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 5” = 2 / Moderate Plaque accumulation 31
  32. 32. Clinical Examination  Periodontal Chart (FM) Upper: B M- CEJ M-BP 333 333 333 333 333 323 323 322 223 323 333 333 233 333 CALF 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 M- CEJ M-BP 333 333 333 333 333 333 333 333 333 333 333 333 333 333 CALL B 32
  33. 33. Clinical Examination  Periodontal Chart (FM) Lower: B M- CEJ M-BP 333 333 333 333 333 333 323 323 322 223 323 333 333 333 233 333 CALL 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 M- CEJ M-BP 333 333 333 333 333 333 333 333 333 333 333 333 333 333 333 333 CALF B 33
  34. 34. Clinical Examination Generalized Plaque Accumulation. Calculus Index: 0 “Zero”. 34
  35. 35. Clinical Examination Key: Restoration Caries Recurrent PA Leison Dental Charting “Upper Arch”18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 35
  36. 36. Clinical Examination Key: Restoration Caries Recurrent PA Leison  Dental Charting “Lower Arch”48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 36
  37. 37. Clinical Examination  Pulpal and Periapical Tests for suspected teethTooth # Cold Test Vertical Percussion Horizontal Percussion Palpation Test# 14 -ve -ve -ve -ve# 25 -ve -ve -ve -ve# 36 +ve (normal) -ve -ve -ve# 46 +ve +ve -ve -ve (prolonged) Control Teeth# 15 +ve -ve -ve -ve# 24 +ve -ve -ve -ve# 37 +ve -ve -ve -ve# 47 +ve -ve -ve -ve 37
  38. 38. Laboratory Investigations CRT (Caries Risk Test)  Saliva Flow Rate : 12 ml in 5 min = 2.4 ml/min (above standard) Low Caries Risk  Saliva Viscosity : Watery  Saliva Buffer Capacity : Between 4.5-7 PH Low to Medium Caries Risk 38
  39. 39. Laboratory Investigations CRT (Caries Risk Test) Measuring the Acid Production by the microorganism in the saliva; According to the “Standard chart”: 1 and 2 = Low Risk 3 and 4 = High Risk S.M L.B 39
  40. 40. Laboratory Investigations CRT (Caries Risk Test) Results have revealed the following: •S.M = 2 < 100,000 CFU Low Risk •L.B = 3 > 100,000 CFU  High Risk S.M L.B 40
  41. 41. Diagnosis and Treatment Planning 41
  42. 42. Treatment Objectives•Chief Complain.•Oral Hygiene Motivation.•To Restore:  Function.  Structure.  Esthetics. 42
  43. 43. Preliminary “Emergency” 43
  44. 44. Preliminary “Emergency”• Diagnosis  Peri-apical radiolucency.  Irreversible Symptomatic Periodontitis.• Proposed Tx.  Pulp extirpation of the offended tooth, initial instrumentation, placing calcium hydroxide (as an intra-canal medicament) and T.F. 44
  45. 45. Phase I, II(Restorative, Endo, Prostho) 45
  46. 46. Phase I: (Periodontic Therapy)• Diagnosis for the “Periodontium”:  Chronic Generalized Moderate Gingivitis, resulting from local factors “Plaque”, “poor oral hygiene” of the patient (Multi-factorial).• Prognosis: Diagnostic: Good. Therapeutic: Excellent. 46
  47. 47. Phase I: (Periodontic Therapy)• Proposed Tx.  Scaling, by ultrasonic scaling and hand instruments.  Prescribing 0.12% Chlorohexidine mouth wash, incase there was excessive bleeding, during scaling.  Modifying and emphasizing on the Oral Hygiene Instructions.  Re-evaluation in 4-6 weeks.  Maintenance every 6 months. 47
  48. 48. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Includes the demonstration of the right technique in brushing and flossing: Brushing “Modified Bass” technique. 48
  49. 49. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Flossing: 49
  50. 50. Phase I: (Preventive Therapy)•Based upon the CRT the patient will need:  Diet Alteration (less Sweets, CHO Balance , more Protein & Vitamins).  Fissure Sealant (for intact deep fissured sound teeth). S.M L.B 50
  51. 51. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 18:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 51
  52. 52. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 17:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 52
  53. 53. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 15:  Occlusal Caries.• Proposed Tx.  Modified class I composite restoration. 53
  54. 54. Phase I, II:• Diagnosis for tooth # 14:  Deep Occluso-distal Caries.  Necrotic Pulp.• Proposed Tx.  Conventional Endodontic Tx.  Fiber Post and Direct Composite Resto. 54
  55. 55. Literature Article Supporting Tx Option: Premolars with MOD restorations were stronger if reinforced with fibres. 55
  56. 56. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 24:  Occlusal Caries.• Proposed Tx.  Modified class I composite restoration. 56
  57. 57. Phase I, II:• Diagnosis for tooth # 25:  Deep Occluso-mesial Caries.  Necrotic Pulp.• Proposed Tx.  Conventional Endodontic Tx.  Fiber Post and Direct Composite Resto. 57
  58. 58. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 27:  Occlusal Caries.  Palatal Pit Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally and palatally. 58
  59. 59. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 28:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 59
  60. 60. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 38:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 60
  61. 61. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 37:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 61
  62. 62. Phase I:• Diagnosis for tooth # 36:  Defective Restoration.  Deep Occluso-distal Caries.• Proposed Tx.  Temporization with G.I.C. 62
  63. 63. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 35:  Occlusal Caries.• Proposed Tx.  Modified class I composite restoration. 63
  64. 64. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 34:  Shallow Occlusal Caries.• Proposed Tx.  Modified class I composite restoration. 64
  65. 65. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 44:  Occlusal Caries.• Proposed Tx.  Modified class I composite restoration. 65
  66. 66. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 45:  Occluso-distal Caries.• Proposed Tx.  Class II composite restoration. 66
  67. 67. Phase I, II:• Diagnosis for tooth # 46:  Deep Occluso-distal Caries.  P.A Radiolucency.  Symptomatic Irreversible Periodontitis.• Proposed Tx.  Conventional Endodontic Tx.  Temporization with G.I.C.  Ortho Consultation. 67
  68. 68. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 47:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 68
  69. 69. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 48:  Occlusal Caries.• Proposed Tx.  Modified class I composite or amalgam restoration occlusally. 69
  70. 70. Tooth # Treatment PlanPeriodontium Supragingival Scaling and Polishing# 18 Class I composite or amalgam# 17 Class I composite or amalgam# 15 Class I composite or amalgam# 14 Conventional Endo + Fiber Post and Composite Core# 24 Class II composite# 25 Conventional Endo + Fiber Post and Composite Core# 27 Class I composite or amalgam# 28 Class I composite or amalgam# 38 Class I composite or amalgam# 37 Class I composite or amalgam# 36 GIC-To be referred to Ortho# 35 Class II composite 70
  71. 71. Tooth # Treatment Plan# 34 Class I composite# 44 Class I composite# 45 Class II composite# 46 Conventional Endo + GIC-To be referred to Ortho# 47 Class I composite or amalgam# 48 Class I composite or amalgam 71
  72. 72. Phase III (Orthodontic Therapy) 72
  73. 73. Orthodontic Consultation 73
  74. 74. Orthodontic Consultation An orthodontic consultation is needed to:1. Correct the lower midline shift.2. Gain normal anterior bite.3. Close the inter-proximal spaces.4. Gain a proper occlusal relationship. 74
  75. 75. Orthodontic Consultation After the Consultation:1. Lower 6’s (# 36, # 46) will be extracted.2. Treatment will take upto 2 years and a retainer is required to be worn for life.3. Conventional Orthodontic Treatment will be carried out as the patient’s treatment option. (Pt. refused orthognathic surgery as a tx option). 75
  76. 76. Post Treatment Progress 76
  77. 77. Pre and Post Photographs 77
  78. 78. Frontal 78
  79. 79. Occlusal-Maxillary 79
  80. 80. Occlusal-Mandibular 80
  81. 81. Lateral-Rt 81
  82. 82. Lateral-Lf 82
  83. 83. Pre and Post Radiographs 83
  84. 84. Panoramic-Before 84
  85. 85. Panoramic-After 85
  86. 86. Bitewings-Rt 86
  87. 87. Bitewings-Lf 87
  88. 88. Periapicals-RCT # 14 88
  89. 89. Periapicals-RCT # 25 89
  90. 90. Tooth # Treatment DonePeriodontium Supragingival Scaling and Polishing# 18 Class I amalgam# 17 Class I amalgam (Palatal Extension restored with composite)# 15 Class I composite# 14 Conventional Endo + Fiber Post and Direct Composite Build-up# 24 Class II composite# 25 Conventional Endo + Fiber Post and Direct Composite Build-up# 27 Class I composite# 28 Class I composite# 38 Class I composite# 37 Class I composite# 36 GIC-Referred to Ortho# 35 Class II composite 90
  91. 91. Tooth # Treatment Done# 34 Class I composite# 44 Class I composite# 45 Class II composite (OD)# 46 Conventional Endo + GIC-Referred to the Orthodontist# 47 Class II composite (OM)# 48 Class I composite 91
  92. 92. Phase IV (Maintenance) 92
  93. 93. Phase IV (Maintenance)  Recall the patient every 3 months to: • Do periodontal maintenance. • Emphasize on the oral hygiene. • Maintain good relationship with the patient. “Treat the patient as a whole, not a hole…” is very important to always keep in mind.  Recall the patient every 6 months to: • Do full mouth X-Ray, check all restorations. 93
  94. 94. Thank you all, for your kind attention Any Questions?

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