Clinical examination and occlusal analysis
Introduction :
The preservation and restoration of occlusoarticular function remains a permanent and major concern in odontostomatology .
In many situations of either disorders of the masticatory system or extensive prosthetic projects, a rigorous clinical examination and a careful clinical occlusal analysis are necessary to clarify the diagnosis and establish the treatment plan.
- THE CLINICAL EXAMINATION :
The clinical examination of the masticatory system allows the practitioner to detect possible pain and dysfunctions, to arrive at an occlusal diagnosis and to establish a therapeutic strategy.
I.1 Contact and collection of information:
Welcoming and listening to the patient during an interview constitutes the first stage of the clinical examination.
First of all, this involves collecting the patient’s identity and all of their socio-professional contact details:
- Name, first name, address.
- Sex: which can have a significant impact from a psychological and aesthetic point of view.
- Age: A young patient has requirements that are mainly aesthetic, while an elderly patient has essentially functional motivations.
- Professional activity: certain professions impose postures that are pathogenic to the head (violinist, switchboard operator).
- The reason for consultation.
- The patient’s state of health and their history (rheumatic diseases, ligament hyperlaxity, etc.).
- The patient’s lifestyle allows us to detect parafunctions which can be considered as etiological factors of dysfunctions (clenching teeth at night? during the day , grinding teeth, etc.).
- Highlighting of certain behavioral disorders: psychological disorders, excessive stress.
- Search for direct or indirect trauma, Surgical history (extraction of wisdom teeth under local anesthesia (prolonged mouth opening).
I.2 The exorbital examination:
- Examination of the face in the frontal plane allows certain facial asymmetries to be detected.
- Assessment of the shape, contour, tone and color of the integuments.
- Equality of the levels of the face: the intensity of the nasolabial and labiomental furrows. The position, the shape of the lips, in relation to the narrowness of the oral orifice, as well as the presence of angular cheilitis associated with a lowering of the corners, are noted and put in relation with a loss of vertical dimension.
- The examination of the profile (flat, rounded and convex, concave) is defined first. The reduction of the DV can be objectified as well as anomalies of inter-arch relationship: Prognathia, retrognathia.
- TMJ and muscle examination: Look for joint and facial pain, muscle tightness and/or headaches in the head and neck region may be a sign of TMJ.
Digital palpation of the masseter, temporalis, lateral and medial pterygoid muscles can detect any tenderness or contracture that may be a sign of neuromuscular dysfunction.
I.3 Examination of the mouth opening:
- Amplitude: Less than 40 mm, it indicates an anatomical, muscular, articular or occlusal pathology. Greater than 50 mm, it indicates ligament laxity.
- Path: The presence of a laterodeviation of the mandibular interincisal point indicates the existence of a muscle spasm on the side of the deviation. This spasm results, most of the time, from occlusal disorders due to uncompensated dental movements.
- Digital palpation of the TMJ, the normality of which is characterized by harmonious and bilateral condylar play, absence of limitation of opening and closing and laterality and by the absence of joint noises and pains (clicking, cracking, crepitations).
I. 4 the intraoral examination:
- Oral hygiene : Good, average or poor, the presence of bacterial plaque and tartar should be noted.
- Examination of the mucous membranes , looking for any changes within the oral mucosa and for an inflammatory, infectious or tumor focus.
- Periodontal examination to assess the condition of the supporting tissues and the bone support. Probing is used to highlight the depth of the pockets and the loss of attachment (recession, suppuration and furcation damage) using a graduated periodontal probe.
- Gingival examination : Clinical signs of gingival inflammation include changes in color, appearance, volume and consistency as well as a tendency to bleed.
- Dental examination : This diagnostic element consists of establishing a complete dental diagram bringing together the maximum amount of information:
– The Dental Formula.
-Diagnosis of carious infections and pulp pathologies, dentin hypersensitivity.
– Distribution of edentulism and their etiologies (impacted teeth, agenesis, extractions).
– Assessment of dental mobility.
– Presence of anterior or lateral overlaps, ectopias, malpositions, rotation and localized versions.
– Localization of wear surfaces, signs of bruxism or occlusal trauma.
- OCCLUSAL ANALYSIS:
Occlusal analysis is an important step in the occlusal and prosthetic diagnostic process. It completes the interview and clinical examination.
It constitutes the set of techniques which precisely determine the dental or joint anomalies which hinder occlusion.
II-1- Intra-arch examination:
- The examination of the dental arches aims to identify all dento-dental or dento-maxillary disharmonies and occlusal curve disharmonies in the sagittal, horizontal and frontal planes.
- Dystopias and dental position anomalies (versions, rotations, egressions) can promote occlusal interferences.
- However, continuous dental arches (free of diastemas or edentulousness) respond to an Organization aimed at maintaining a certain stability of the occlusion.
II-2- Inter-arch examination:
- Examination of maximum intercuspation occlusion (MIO) : “Contact stability”
- Palpation of the elevator muscles provides selective information on the simultaneity of contraction during the passage into OIM and, therefore, on the simultaneity of contacts.
We look for asymmetries and asynchronies of muscular activity which indicate the inequality of intercusp contacts between the left and right sides.
- Rapid teeth chatter: Normally, the intercuspation position is reproducible; the movements are rapid and performed regularly. In the case of imprecise intercuspation, the movements are irregular in form and speed of execution.
- Dental contacts should be made in a single, clear sound that reflects the precision of intercuspation and the absence of hesitation. A pre-contact, on the contrary, produces a splitting, sliding or galloping sound.
- Angle classes and bad frontal and vertical relationships.
- The alignment (or offset) of the maxillary and mandibular inter-incisal points as well as the value of the overjet and the overlap in OIM are measured.
- Marking of contacts in OIM:
Marking (in black or blue) is done on clean, dry dental surfaces. The patient repeatedly clicks his teeth hard on the marking papers. Examination of the occlusal surfaces allows the intensity and distribution of the points supporting the occlusion to be noted.
Contacts should be punctiform, large surfaces constitute exaggerated contacts.
- Centric Relation Occlusion (CRO) Examination:
- Marking of contacts generally located on the mesial slopes of maxillary premolars or molars (and distal on mandibular teeth). For this operation, a 10 µm marker tape is chosen.
- Evaluation of the ORC/OIM differential: In ORC, using a caliper or a metal ruler, it is advisable to measure:
– The overhang of the incisors, subtracting the overhang measured in intercuspidation.
– The gap between the two horizontal lines, which measures the vertical amplitude of the ORC-OIM slip.
c- Guidance examination:
- In propulsion: The patient is asked to make a grinding path in propulsion “as if cutting a wire with his teeth” after having placed a thin colored film at the level of his anterior teeth held by a MILLER clamp.
End-to-end contacts mark the limits of the anterior guide. If only one tooth contacts during protrusion, this tooth constitutes an obstacle that can cause a deviation outside the sagittal plane.
During this protrusion, the disocclusion of the posterior teeth must be immediate and total. If the contact of the anterior teeth is interrupted during the sliding by one or more posterior contacts this represents an interference.
- Laterality: The lateral movement represents the path that the mandible takes when the lower teeth slide laterally on the internal faces of the vestibular cusps of the maxillary teeth, and more particularly on the palatal face of the upper canine. The diduction movement then takes place in inocclusion. The mandible comes to rest and settles into a working position in the vicinity of the canine tip to tip.
Interferences can occur on the working side (pivoting condyle), that is, the side towards which the mandible moves, or on the non-working side (orbiting condyle), opposite the previous one.
Marking of the interference is carried out using the same maneuvers. A colored marker tape of medium thickness.
II-3 – Lingual and jugal parafunctions :
It is necessary to note swallowing disorders (interposition or tongue thrust), tics or harmful habits (biting objects, nail biting) likely to alter or move the teeth (progressive diastemas or dystopias).
Observation of the inner surface of the cheeks and the peripheral edges of the tongue often gives information on pressure ( dental imprints ) or on injuries caused by bites.
Clinical examination and occlusal analysis
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.