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maxillary 2 molar tooth anatomy and anomalies and endodontics management..

maxillary 2 molar tooth anatomy and anomalies and endodontics management..

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  • 1. MAXILLARY
    II MOLAR
    SUBMITTED BY
    O.R.GANESAMURTHI
    1 YEAR M.Sc.D ENDODONTICS
  • 2.
  • 3. INDEX
    • EXTERNAL ANATOMY OF TOOTH
    MORPHOLOGY OF TOOTH
    • INTERNAL ANATOMY OF TOOTH
    PULP CHAMPER
    ROOT CANAL SYSTEM
    • ANOMALIES OF TOOTH
    • 4. ENDODONTIC CORELATION
    • 5. CASE REPORT
    • 6. REFERENCE
  • INTRODUCTION
    The maxillary second molar is the tooth located distally from both the maxillary first molars of the mouth but mesial from both maxillary third molars. This is true only in permanent teeth.
    In deciduous teeth, the maxillary second molar is the last tooth in the mouth and does not have a third molar behind it.
    The function of this molar is similar to that of all molars in regard to grinding being the principle action during mastication. There are usually four cusps on maxillary molars, two on the buccal and two palatal
  • 7. MAXILLARY II MOLAR
    Class traits
    • 3 or more cusps
    • 8. At least 2 buccal cusps
    • 9. One or more lingual cusps
    • 10. In general 2 or 3 roots
  • CHRONOLOGY OF SECOND MOLAR
    • Average time of eruption : 11 to 13 years
    • 11. Average age of calcification : 14 to 16 years
    • 12. Average length : 20.0 mm
  • CHRONOLOGY OF SECOND MOLAR
  • 13. Arch traits
    • 3 roots: 2 Buccal & 1 Palatal
    • 14. Crown: Buccolingual > MesioDistal
    • 15. Cusps
    3 major cusps
    MP, MB & DB
    Arranged in a tricuspid-triangular pattern
    Lesser-sized DL cusp & sometimes missing
    • Oblique ridge: MP to DB cusp
    • 16. Buccal cusps are of unequal size
    • 17. MP cusp is larger than DP
  • Buccal aspect
    Smaller crown size
    Less prominent DB cusp & narrower MD
    Distally inclined BUCCAL roots
    Lingual aspect
    DL cusp is smaller in width & height
    LINGUAL root is narrower MD & slightly Distally inclined
    No cusp of Carabelli
  • 18. Mesial aspect
    Less numerous Marginal ridge tubercles
    MB & Lingual roots are less divergent
    Distal aspect
    Smaller Distal cusps
    A greater portion of the occlusal
    aspect is visible
  • 19. Occlusal aspect
    • MB & DL angles are more acute
    • 20. ML & DB angles are more
    obtuse
    • More variable pit/groove pattern
    • 21. More numerous supplementary
    groove
    • Crown is more constricted MD
  • INTERNAL ANATOMY
    Pulp
    MesioDistal section
    2 horns, MB is higher
    Pulp chamber, roof & floor
    Canals, narrow
    Canal orifice
    BuccoLingual section
    Pulp chamber is wider
    2 horns of equal height
    Cross -section
    3 canals
  • 22. INTERNAL ANATOMY
    PULP CHAMBER
    • THE PULP CHAMBER OF MAXILLARY 2 MOLAR IS SIMILAR TO THAT OF THE MAXILLARY 1 MOLAR EXCEPT IT IS NARROWER MESIODISTALLY
    • 23. PULP HORNS- 4
    1.MESIOBUCCAL
    2.DISTOBUCCAL
    3.MESIOPALATAL
    4.DISTOPALATAL
    • ROOF– MORE RHOMBOIDAL IN CROSS SECTION
    • 24. FLOOR- OBTUSE TRIANGLE IN CROSS SECTION
  • PULP CHAMBER ANATOMY
  • 25. ROOT CANALS
    if 3 roots are present usually we can see 3 canals
    1. mesiobuccal
    2. distobuccal
    3. palatal
    if 4 canal is present
    it is in mesiobuccal root but less frequently than in the 1 molar
  • 26. ROOT CANAL ANATOMY
  • 27. ROOTS AND ROOT CANALS
    63 % straight
    PALATAL ROOT
    37 % buccal curve
    78 % distal curve
    MESIOBUCCAL
    ROOT
    22 % straight
    83 % straight
    DISTAL ROOT
    17 % mesial curve
  • 28. ROOT CANAL AND APICAL FORAMINA IN
    MAXILLARY 2 MOLAR MESIOBUCAL ROOT
  • 29. ROOT ANOMALIES
  • 30.
  • 31.
  • 32.
  • 33. ANATOMY RALATIONSHIPS IN SITU
    The maxillary 2 molar usually is more
    closely related to the maxillary sinus than
    the maxillary 1 molar
    This close relationship may produce
    Soreness In the maxillary teeth due to
    Maxillary sinusities
  • 34. ENDODONTIC
    CORRELATION
  • 35. Significance of average time of eruption, age of
    calcification, tooth length & root curvature:
    IT HELPS IN DIAGNOSIS AND TREATMENT PLAN
    TREATMENT IS DIFFERENT IN ADULT AND YOUNG
    NECROTIC PULP
    RCT
    ADULT
    Irreversible Pulpitis
  • 36. YOUNG
    Irreversible Pulpit's
    Necrotic Pulp
    Reversible Pulpit's
    Pulp Capping or
    Pulpotomy
    Closed Apex
    Open Apex
    Apexification
    Obturation
    Apexogenesis
    RCT
  • 37. ENDODONTIC CORELATION
    AN IMPORTANT AID FOR LOCATING ROOT CANAL IS THE
    DENTAL OPERATING MICROSCOPE (DOP).
    IT IS USED TO IDENTIFIED CANAL
    THE NUMBER OF 2 MESIOBUCCAL CANALS IDENTIFIED IN
    MAXILLARY 2 MOLAR INCREASED FROM
    51 % NAKED EYE
    82 % MICROSCOPE
    93.7 %DOM
  • 38. DENTAL OPERATING MICROSCOPE (DOP).
    The operating microscope is an indispensable tool for state-of-the-art endodontic treatment. The specialty practice should not be without a microscope; this instrument is useful in all phases of endodontic treatment from diagnosis to placement of the final restoration.
  • 39. Loupes give excellent magnification and illumination
    An operating microscope.
  • 40. ENDODONTIC CORELATION WITH
    PULP CHAMPER
    DIAGNOSTIC MEASURES ARE IMPORTANT AIDS IN THE LOCATION OF ROOT CANALS ORIFICES
    THESE MEASURES
    OBTAIN MULIPLE PRE TREATMENT
    RADIOGRAPHS
    EXAMINING THE CHAMBER WITH SHARP
    EXPLORER
  • 41. 3. TROUGHING GROOVES WITH
    ULTRASONIC TIPS
    4. STAINING THE CHAMBER WITH 1 %
    METHYLENE BLUE DYE
    CHAMPAGNE BUPPLE TEST
    5. VISUALIZING CANAL BLEEDING
    POINT
  • 42. PRE TREATMENT RADIOGRAPHS
    The palatal canal is centered between the mesiobuccal and distobuccal roots in maxillary molars.
    When a second mesiobuccal canal (MB 2 ) is suspected, a mesial radiograph is often required to identify it. However, as the
    horizontal angulation increases, the clarity of the radicular anatomy decreases. A 20 degree mesial shift is sufficient to separate the canals while limiting distortion.
  • 43. Endo-Ray II film holder.
    the operator places the film parallel to the tooth and perpendicular to
    the central ray and as far apical as possible
  • 44. digital radiography system
  • 45. CONVEX PULP CHAMBER
    FLOOR OF PULP CHAMBER
    MARKEDLY CONVEX
    CANAL ORIFICES SLIGHT FUNNAL SHAPE
    IN THIS CASE
    REMOVAL OF A LIP OF DENTIN
    CANAL CAN BE ENTERED MORE IN
    A DIRECT LINE WITH THE AXIS
  • 46. ROOT CROSS SECTION OF THE
    MAXILLARY 2 MOLAR
  • 47. ROOT CROSS SECTION-ENDO CORRELATION
    PALATAL, MB 2
    FLAT SHAPED
    CIRCULAR, FLAT
    MB 1
    DISTOBUCCAL
    CANAL
    FLAT,RIBBON SHAPED
    NEAR APEX
    BALANCE FORCED INSTRUMENTATION METHOD
    ROTARY NiTi FILES ALLOWED CONTROLLED
    PREPARATION OF THE BUCCAL AND LINGUAL
    EXTENSIONS OF OVAL CANALS
  • 48. The Balanced Force action.
    This instrumentation technique uses clockwise/ anticlockwise rotational motion to remove dentine with flexible stainless steel files or nickel-titanium files. It is useful for rapidly removing dentine in curved canals whilst maintaining curvature (files are not precurved)
  • 49. ROOT CANAL ORIFICES
    1 CANAL SEPARATE IN TO 2 CANALS
    RELATIONSHIP OF THE
    2 CANAL ORIFICES
    DIVISION IS BUCCAL
    AND PALATAL
    CLOSER 2 CANAL ORIFICES
    PALATAL CANAL SPLITS
    FROM THE MAIN CANAL
    AT SHARP ANGLE IT IS
    VISUAL CONFIGURATION
    AS LOWER CASE LETTER h
    GREATER CHANCE OF 2 CANALS
    JOIN AT SOME POINT IN
    THE BODY OF THE ROOT
    BUCCAL CANAL IS STRAIGHT
    PORTION OF THE h
  • 50. Examination of pulp chamber floor can reveal clues to the location of orifices and to the type of canal system present
    Rotary NiTi files must be used cautiously with the type of anatomy because instrument separation can occur as the files traverses the sharp curvature in to the common part of canal
  • 51.
  • 52. ROOT CANAL WITH ENDODONTIC CORRELATION
    TEETH WITH FUSED ROOTS
    THESE PARALLEL ROOT CANALS
    ARE FREQUENTLY SUPERIMPOSED
    RADIOGRAPHLY BUT THEY CAN
    IMAGED BY EXPOSING RADIOGRAPH
    FROM DISTAL ANGLE
    OCCASINALLY 2 CANALS
    1 BUCCAL AND 1 PALATAL
    BOTH EQUAL LENGTH AND DIAMETER
  • 53. 3 CANAL ORIFICES
    2 CANAL ORIFICES
  • 54. ACCESS CAVITY PREPARATION IN DIFFERENT CANAL
    ACCESS OUTLINE FORM
    2 CANALS
    4 CANALS
    3 CANALS
    RHOMBOID
    SHAP
    ROUND TRIANGLE WITH BASE TO BUCCAL
    OVAL AND WIDEST
    IN BUCCO
    LINGUAL
  • 55. WORKING LENGTH DETERMINATION
    Modern electronic apex locators are reliable instruments that can help the clinician determine the working length
    Successful treatment depends on the anatomy of the root canal system the dimension of the canal walls and the final size of enlarging instruments
  • 56. J. Morita Root ZX electronic apex locator.
  • 57. Analytic Endo Analyzer electronic apex locator and electronic pulp tester
  • 58. WORKING LENGTH
    SIZE OF ROOT CANAL INSTRUMENTATION
    CANAL CLEANLINESS
    DISADVANTAGES
    INCREASED RISK OF PROCEDURAL ERRORS
    ROOT FRACTURES
    IRRIGANT VOLUME
    NUMBER OF INSTRUMENT CHANGES
    DEPTH OF PENERATION OF IRRIGANT
    NEEDLES
    LESS
    IMPORTANT
    FACTOR
  • 59. ACCESSORY CANALS AND ENDODONTICS
    CORRELATION
    ACCESSORY CANALS
    FILLED
    THERMOPLASTIC
    GUTTAPURCHA
    ACCESSORY CANALS
    REMOVED
    SURGICAL
    PROCDURES
    APEX SHOULD BE RESECTED 2 TO 3 mm
    REMOVES MOST OF THE UNPREPARED
    UNFILLED ACCESSORY CANAL
    ELIMINATING A POTENTIAL RESERVOIR OF PATHOGENS
  • 60. ROOT RESECTION FOR REMOVAL
    OF ACCESSORY CANAL
    Root end resection a bevel perpendicular to the long axis of a root exposes a small number of microtubules
  • 61. root resection with 45-degree bevel exposes significantly grater number of tubules increasing the chance of leakage into and out of the root canal to prevent this root end cavity preparations should extend coronally to the height of the bevel
  • 62. ACCESSORY CANAL ELIMINATION
  • 63. TEETH WITH MINIMAL OR
    NO CLINICAL CROWN
    • Short crown may be developmental
    defect
    • Caries left untreated
    • 64. Fracture under heavily occlusal force
    • 65. External trauma
    • Before starting the procedure
    clinician should study their root
    angulations on Preoperative
    radiograph
    • Examine the cervical crown
    anatomy with an explorer
    • Pulp chamber located at the
    center of the crown at the level
    Of the CEJ
  • 66. TEETH WITH MINIMAL,NO CLINICAL CROWN
    Depth of penetration bur to reach the pulp canal is
    measured on a Preoperative radiograph
    clinician reaches this depth without locating the canal 2
    radiograph Should be taken before procedure
    Straight radiograph
    Angled radiograph
    Preparation deviating in a
    Mesial or distal side
    Preparation deviating in a
    Buccal or lingual side
    The clinician redirect the penetration angle if necessary
  • 67. Teeth with calcified canal
    Endodontic correlation
    Causes of calcified tooth
  • Management of calcified tooth
    • Use of magnification and
    transillumination
    • Search canal orifices after completely
    preparing the pulp chamber
    • And cleaning and drying its floor ( 70 %
    denature ethanol )
    • Chamber floor is DARKER in color than
    its wall
  • 71.
    • Developmental grooves
    connecting orifices are LIGHTER
    in color Than the chamber floor
    • Staining the pulp chamber floor
    with1 % methylene blue dye
    Performing the sodium
    hypochlorite “CHAMPAGNE
    BUPPLE “test
    • Searching for canal bleeding point
  • Management of
    calcified tooth
    • Dentin must slowly be removed
    down the root
    • Use long thin ultrasonic tips under
    high magnification of a DOM to
    avoid removing too much tooth
    structure
  • 72. The Analytic ultrasonic gold nitride tips are available in sizes #2 through #5, and NiTi tips are available in sizes #6 through #8. Pictured left to right are #2, #3, #6, #7, and #8. Many other configurations are available
  • 73. The Spartan ultrasonic handpiece has been specifically "tuned" to work the CPR tips.
  • 74. ULTRASONICS
    The CPR tips are available in nitride (gold-yellow) and NiTi (green, blue, and purple).
    The extremely fine tips coupled with the small handpiece allow unprecedented visibility Ultrasonic tips can be used to remove pulp stones and to cut dentin while locating additional canals.
  • 75. As the search moves apically
    • Two Radiographs must be taken
    1. straight on direction
    2. angled directions
    • Very small pieces of lead foil placed
    at the apical extent of the penetration
    Can provide a radiograph references
    • Use first a small file K FILE ( #6, #8,
    or #10 ) coated with a chelating agent
  • 76. Management of calcified tooth
    Coated with a chelating agent should be introduced In to the canal to determine patency
    This file should be removed until canal enlargement It should be used in short up and down movement and In a selective circumferential filling motion with most of the
    Lateral pressure directed away from the furcation
    This safely enlarge the coronal canal and moves it laterally To avoid the furcation
  • 77. LIMITATIONS
    Stop excavating dentin if a canal orifices cannot be found to avoid Weakening the tooth structure
    Serious error can arise from inappropriate attempt canals
    Root wall or furcation perforations can occur
  • 78. Rotated teeth
    This case altered crown root relationship
    Management of rotated teeth
    • Radiograph examination is crucial
    • 79. Initial outline form occasionally can
    be created without dental dam
  • 80.
    • Positioning of bur with long axis of
    the tooth
    • Bur penetration for both depth and
    angulations should be confirmed
    Frequently with radiographs
  • 81. CASE REPORTS
  • 82. Endodontic Miscellany : Maxillary 2 molar
    with two canals in the palatal root
    During pre-clinical Endodontic on extracted teeth, a maxillary second molar was found to have a palatal root with two canals.
    While locating the canals, because of eccentric location of the instrument in the palatal canal, a second canal was suspected.
    Placement of another instrument easily verified the presence of the second canal..
  • 83. The palatal root canal system was characterized by two canal orifices and two canals that appeared to unite in the apical third of the root.
    which constitute type II canal configuration according to Vertucci's classification 8 Most of the clinical literature on the fourth canal in maxillary molars reports an additional mesiobuccal canal (MB2)3,4,5. But an anomalous root morphology that occurs Infrequently
  • 84. Table 1: Canal Configurations of
    Maxillary second Molar
    Year Author Canal configuration
    P MB DB
    1979 Slowey 2 1 1
    1979 Thews 2 1 1
    1982 Cecic 2 2 1
    1983 Martinez- 1 3 2
    Berna
    1984 Beatty 1 3 1
    1988 Bond 2 2 2
    1991 Wong 3 1 1
    1994 Jacobsen 2 1 1
    1997 Hulsmann 1 1 2
  • 85. Two canals in a single palatal root may
    present in one of the following types
    a. Two separate orifices, two separate
    canals and two separate foramina.
    b. Two separate palatal roots, each
    with one orifice, one canal and one
    foramen.
    c. One palatal root, one orifice, a
    bifurcated canal and two foramina
  • 86. To investigate properly the possibility of additional canals, the dentist should:
    # understand the complexity of the morphology of the tooth involved
    # take additional off-angle radiographs
    # ensure adequate “straight-line” access to improve visibility
  • 87. # examine the pulpal floor for “lines” to areas where additional canals may be located
    # remove a small amount of tooth structure that often may occlude a canal orifice.
    The dentist should be suspicious of additional canals if endodontic files are not well centred in the canal on the radiograph or if endodontic files are not well centred in the canal clinically.
  • 88. Discussion
    Having the information observed from the
    radiographs and knowing what combinations of internal anatomy are possible, the dentist should be able to determine what type of canal configuration is present. An examination of the floor of the pulp chamber offers clues to the
    type of canal configuration present.
  • 89. A Five-canal Maxillary Second Molar*
    May 2007, Volume 4, No.5 Journal of US -China Medical Science , ISSN1548-6648 USA
    CASE REPORT
    The patient was a 35 years old male who presented with a severe spontaneous pain in the maxillary right area which had been constant for one day. The medical status was unremarkable. Clinical examinations revealed that tooth-2 had deep mesio-occlusal caries without pulp exposure and was very sensitive to cold test.
  • 90. Radiographic examination disclosed an unusual anatomical configuration of the roots, suggesting that four roots might be present.
    A diagnosis of acute pulpitis was made for tooth-Following local anaesthesia an endodontic access opening was made and the pulp chamber was exposed clearly.
  • 91. Preoperative radiograph of tooth
  • 92. Examination of the chamber floor with an endodontic explorer (DG-16) revealed five canal orifices
    1.mesiobuccal canal (MB1),
    2.mesiobuccal 2nd canal (MB2),
    3.mesiopalatal canal (MP),
    4.distopalatal canal (DP)
    5.distobuccal canal (DB)
  • 93. The orifice of the mesiopalatal canal was large, well formed, and located at the mesiopalatal corner of the pulp chamber.
    The distopalatal canal was also large and well developed and more distal to the chamber than a single palatal root would be expected.
    The MB2 orifice was found nearly on the imaginary line between the MBl and MP orifice, and about 1.5mm palatal to the MBl orifice
  • 94. Occlusal view of seating of master point, displaying five root canal orifices
    Occlusal view of the access opening showing MB1, MB2, DB, and MP canal orifices
  • 95. All canals were easily negotiated, and the working length was determined by using electronic apex locator Root ZX
    The root canals were cleaned and shaped using K-type files and Gates Glidden drills #2, #3, and #4 with passive step-back technique.
    Apical preparations in the buccal canals were enlarged to a master file size of 30, and in the palatal canal to size of 45.
  • 96. The root canals were copiously irrigated with 3% H2O2 solution.
    Then the canals were obturated with AH-Plus sealer and gutta-percha using a lateral compaction technique.
    A temporary restoration with IRM was placed and a permanent restoration was advised. At the 3 month recall examination, the tooth was asymptomatic with normal periapical
  • 97. Post obturation occlusal view of the pulp chamber floor showing all five root canal orifices
    Postobturation radiograph (RVG) displaying five root canals
  • 98. DISCUSSION
    Peikoff classified the anatomical root and canal variations into six categories:
    Three separate roots and three separate canals;
    (2) three separate roots and four canals (two in the mesiobuccal root)
  • 99. three roots and canals whose
    mesiobuccal and distobuccal canals combine to form a common
    buccal with a separate palatal
    two separate roots with a single
    canal in each
    one main root and canal
    four separate roots and four
    separate canals including two palatal.
  • 100. This study also revealed that occurrence of ‘standard' configuration,
    3 roots with 3 or 4 canals, was the
    most frequent (88.6%).
    In addition to Yang et al. result found that the maxillary second molars had a C-shaped root in 4.5% and C-shaped in Chinese population.
  • 101. QUINTESSENCE INTERNATIONAL VOLUME 39 • NUMBER JANUARY 2008
    A maxillary second molar with 6 canals: A case report
    A 31-year-old man presented to the dental clinic with a chief complaint of a fractured amalgam restoration on the maxillary right second molar. The patient’s medical history was non contributory. A preoperative radiograph taken after removing the fractured amalgam. Although the cavity was deep, there were no clinical symptoms. Therefore, the tooth was restored with a gold crown
  • 102. One month later, the patient returned, reporting prolonged pain to cold on the restored maxillary right second molar, and root canal treatment was indicated
    Before the access opening was prepared,
    we assumed from the preoperative radiograph that it had two divergent palatal roots. Immediately after obtaining access, two mesiobuccal canals were apparent. When we located one distobuccal canal, its isthmus suggested the presence of a second canal.
  • 103. We established the root canal anatomy to be as follows: 2 canals in the mesiobuccal root with one apical foramen, 2 separate canals in the distobuccal root, 1 canal in the mesiopalatal root, and 1 canal in the distopalatal root On the first visit,we determined the working lengths from the radiograph using a Root Zx . On the second visit, the six root canals were instrumented with a Profile Ni-Ti rotary file and irrigated with 1mL of 2.5% sodium hypochlorite after each change of file size
  • 104. At the third visit, all of the canals were obturated by a combination of lateral and vertical compaction compaction
    using gutta-percha and Sealapex.The final radio-graphs and photograph srevealed the unusual anatomy of six canals filled with gutta-percha
    Preoperative radiograph
  • 105. All 6 canal orifices in view
    Two mesiobuccal canals.
    2 distobuccal canals
    1 mesiopalatal canal
  • 106. 1 distopalatal
    canal
    Working length determination
    of all canals.
  • 107. a
    b
    c
    d
    Post treatment radiographs (a, b) and photographs (c, d) of the maxillary right second molar with 6 canals.
  • 108. DISCUSSION
    The use of microscopes during endodontic treatments in dental clinics has become more widespread, and this practice has made the detection of hidden accessory canals easier, especially for mesiolingual canals of the maxillary molars. it is not necessary to use a microscope to detect every hidden root canal orifice in the pulp chamber. There are many studies of the configurations of apical canals that help practioners to predict the anatomy and positions of the pulp chamber and root canals before access preparation.
  • 109. However, the average number of canals in a tooth is merely an indication when dealing with an individual case. Based on a study involving 500 pulp chambers of extracted teeth, Krasner and Rankow recently proposed new rules for locating root canal orifices. The rules state that the orifices of root canals are always located at the junction of the walls and the floor, at the angles in the floor-wall junction, and at the termini of the root developmental fusion lines.
  • 110. With sufficient knowledge of tooth anatomy and an awareness of possible root canal variations, careful inspection of preoperative radiographs
    and the dentinal map of pulpal floor should decrease the possibility of missing canals, even without using microscopes, and therefore result in lower failure rates of endodontic treatment
  • 111. CONCLUSION
    For successful endodontic treatment, it is helpful to keep in mind that there is a chance
    of encountering a maxillary second molar with more than 3 or 4 canals, or even 6, as this case.
  • 112. REFERENCES
    1
    2. ENDODONTICS Fifth Edition
    JOHN I. INGLE, DDS, MSD
    LEIF K. BAKLAND, DDS
    3. ROOT CANAL MORPHOLOGY
    4. May 2007, Volume 4, No.5 Journal of
    US -China Medical Science ,
    ISSN1548-6648, USA
    5. QUINTESSENCE INTERNATIONAL
    VOLUME 39 • NUMBER 1 •
    JANUARY 2008
    6. Journal of Endodontic 11, 308-10.
    Endodontics
    Problem-Solving in Clinical Practice
    TR Pitt Ford, BDS, PhD, FDS RCPS
    JS Rhodes, BDS, MSc, MRD RCS,
    7.
  • 113. THANK YOU ALL

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