CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

1. INTRODUCTION: The clinical examination in joint prosthesis, including the anamnesis, must be conducted in a complete, meticulous and methodical manner where each is a case. At the end of the first contact the patient must be convinced that the practitioner will do the maximum for his patient so he will be psychologically ready to undergo a complete examination during the following sessions. Thus the indication of a joint or fixed prosthesis can be posed. Whatever the cause of the patient’s visit, the clinical examination should in no case be limited to a restricted territory incriminated by the patient but rather to the entire stomatognathic apparatus.

2. DEFINITIONS: 
   1. clinical examination: also called clinical assessment or clinical observation, it is the act of gathering as much personal information as possible from the patient, general medical, orofacial and oral concerning the patient and his close family in order to make a diagnosis and draw up an appropriate treatment plan.
   2. treatment plan: the sequence of procedures planned for the treatment of a patient after diagnosis (THE GLOSSARY OF PROSTHODONTIC TERMS Ninth Edition)
3. GOALS : 
   1. Establish a relationship of trust with the patient,
   2. Establish a diagnosis,
   3. Establish a treatment plan,
   4. Restore functions while preserving dental and osteo-mucosal structures.
4. CLINICAL EXAMINATION: the most important thing in this step is to let the patient express his desires and his complaints and to listen to him carefully (When, why and how = you have to know how to get the answers from these three questions in relation to his illness).
   1. anamnesis:
      • patient’s first and last name
      • age (civil and apparent)
      • address
      • occupation
      • personality: intellectual, cooperative, demanding
      • background: personal and family
        1. general condition of the patient
        2. causes of tooth loss: is it an accident, functional imbalance, pathological process, etc.?
   2. reasons for consultation: why did he come to consult? pedagogically speaking or medically it revolves around three essential points:

• aesthetic motif 
• functional pattern 
• or painful reason  

More precisely: patients consult by looking for either:  

• Comfort: Discomfort can come from pain, tenderness, 
• Function: Dysfunction may occur during chewing or speaking,
• Social: The unpleasant aspect may be due to the mouth, bad taste or smell,
• bad taste or smell.
• Appearance: Unpleasant appearance may be due to poor restoration or discoloration of the teeth.

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

3. oral exo examination:
   • inspection:
     1. physical appearance of the patient (idea about the state of health)
     2. examination of mouth opening: amplitude, closing path
     3. facial examination:
        1. morphological type
        2. face and profile 
        3. musculature 
        4. facial symmetry/asymmetry 
        5. appearance of the integuments
        6. harmony of floors, DV
        7. scar 
   • palpation:
     1. examination of the temporomandibular joints for
        1. joint noises (cracking, popping, crepitating)
        2. joint jerks
     2. pain when opening mouth 
     3. examination of the orofacial muscles: labial, jugal, etc.
4. endo-oral examination:
   • inspection:
     1. general appearance of the oral condition  : 
        1. existence or not of pathological process
        2. oral hygiene (cavities, tartar)
        3. lingual volume
        4. appearance of the gums
        5. presence or absence of caries
        6. existence or not of prosthetic restorations
        7. intrinsic value of residual teeth:
           1. pulp vitality
           2. presence of caries, dysplasia, abrasions, fillings and prosthetic elements
        8. extrinsic value of residual teeth:
           1. volumes and shapes of teeth
           2. misaligned teeth
           3. presence of diastemas
        9. general appearance of the dental arches on the occlusal plane
        10. occlusion conditions
        11. importance and topographical situation of the edentulous sectors 
     2. palpation:
        1. Assessment of fibro-mucous membranes
        2. tongue tone
        3. Degree of tooth mobility
        4. Periodontal probe
5. additional examinations: 
   • X-ray examination: dental panoramic , retro-alveolar images , cone beam (implantology) to highlight:
     1. Pulp volume
     2. Alveolar bone level  
     3. Bone infrastructure 
     4. Root anatomy: shape, orientation, volume, length 
     5. ATM study
   • Review of plaster study models: 
     1. Static and dynamic occlusion study  : By direct vision on plaster model and on semi-adaptable articulator
     2. The importance and distribution of edentulous segments.
     3. Visualization of the tooth axis.
     4. Plan the general axis of insertion of the future prosthesis (study completed with the parallelizer)
     5. Allows for an internal view of the occlusion.
     6. Allow the practitioner to directly visualize disturbances in their teeth.
     7. Serve as a reference throughout the rehabilitation work and as proof in the event of an appeal. 
6. DIAGNOSIS: this is the final assessment of existing dental problems that must be treated before prosthetic therapy: 
   1. endodontic,
   2. periodontal,
   3. pathological,
   4. orthodontic.
7. THERAPEUTIC DECISIONS (or therapeutic options): Depending on the data collected during the clinical examination, several therapeutic options are possible:
   1. Removable Partial Prosthesis Cast ,​​​
   2. Joint prosthesis,
   3. C omposite prosthesis ,
   4. I mplantoborne prosthesis​

Joint or fixed prosthesis  : The decision to treat with fixed prosthesis depends on many parameters  : 

• the patient’s desire,
• Number of supporting teeth according to their location on the arch (Roy theory), their intrinsic and extrinsic value, occlusion conditions,
• Anchoring on pulped or pulpless teeth,
• Type of anchors depending on: age , corono-radicular condition of the tooth , retention required for the bridge to stay in place , aesthetic requirements,
• The extent of toothlessness.
• The patient’s wishes: it is essential to involve the patient in the choice of treatment that the practitioner will adopt, although the decision is largely managed by the clinical and radiological assessment, the position and opinion of the patient remain decisive for the success of the treatment, of course a good explanation and a good presentation of the different therapeutic options to the patient are necessary. 
• According to the number of supporting teeth  : the number of supporting teeth depends on their location on the arch, increasing the number of pillars improves the balance and retention of a fixed plural prosthesis (bridge):

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

• a tooth rarely replaces a missing tooth,
• Two teeth replace a missing tooth,
• Three teeth can replace three missing teeth under certain conditions.
• Depending on the situation of the supporting teeth  : for ROY , there are 5 planes; In the case of a joint reconstruction, the immobility of the teeth depends on the use of the abutments chosen in various ROY planes.
• Choice of support teeth: According to DUCHANGE ‘s law  : “the sum of the masticatory coefficients of the pillar teeth must be greater than or equal to the sum of the masticatory coefficients of the missing teeth”

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• Depending on the intrinsic and extrinsic value of the tooth:
  • a wide root in the vestibulo-lingual direction is flattened in the mesio-distal direction is more favorable than a circular root 
  • multi-rooted: a tooth with divergent roots is preferable and provides better anchoring.  
  • coronal-radicular ratio: favorable = 2/3 (the root must be twice as long), the ratio 1/1 can be tolerated as a minimum.
  • The prosthetic space at the edentulous segment must be sufficient in occlusion for the bridge span. 
  • type of anchoring: according to the vitality or non-vitality of the pulp:
    • partial coronal anchoring,
    • total coronal anchorage,
    • coronal-radicular. 
  • Anatomy of the abutment tooth:
    • Pulp anatomy: depending on the shape, volume and location of the pulp, wells, grooves or flutes will be used to ensure retention of the preparation.
    • Root anatomy: the convergence or parallelism of the roots of a devitalized tooth with a dilapidated crown will determine the choice of intra-radicular anchoring
  • Power of masticatory muscles: Anchor retention should be maximized in powerful masticators of the brachycephalic type.

7. THERAPEUTIC CHOICE: this is a very crucial step , in which it is necessary to be very careful between the patient’s wishes and the result of the clinical and radiological assessment for the choice of the most appropriate therapeutic option for the clinical case.   
8. TREATMENT PLAN:
   1. pre-prosthetic treatment: the preparation of the toothed sectors to receive prosthetic treatment is multidisciplinary, and the older the edentulism, the more pre-prosthetic treatment is the rule:

Please note:

2. Periodontal therapy  
3. Surgical therapy 
4. Operative dentistry
5. Prosthetic therapy:
   • temporary, transitional prosthesis, occlusal equilibration (regularization of the occlusal plane , removal of disruptive prosthetic elements, selective grinding.
   • Medical therapy
   • Ortho-ontic therapy: repositioning of teeth that have undergone pathological migration, functional rehabilitation
6. prosthetic treatment: This involves implementing the classic protocol chosen and adapted to the case considered, namely:
   • Preliminary impression, if not study models kept as archive
   • Decortication and preparation of teeth used for anchoring
   • Work footprint 
   • Temporary prosthesis
   • Permanent prosthesis
   • Maintenance

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

9. CONCLUSION: Prosthetic treatment in joint prosthesis is not a standard therapy that goes everywhere but it is rather a thoughtful act resulting from a careful clinical examination followed by a treatment plan specific to each clinical situation. And the fixed prosthesis is in no way limited in the aesthetic result but it is a whole chain of successive and inseparable diverse therapies.

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

10. BIBLIOGRAPHY  : 

1. manual of fixed single prosthesis: JOSEPH exbrayat and jean schittly masson edition 1992.
2. fixed prosthesis and periodontium: FRANÇOIS UNGER, PHILIPPE LEMAITRE, ALAIN HOORNAERT. edition 1997.
3. fixed prosthesis principles and practice: R OGOLNIK, MVIGNON;, F. TAIB. edition masson 1993.
4. clinical guide to odontology. RODOLPHE ZUNZARREN. elsevier masson.
5. the glossary of prosthodontic terms ninth edition 2017
6. AHMED A. oral health, diseases, examination, diagnosis, treatment plan & mouth preparation. adv tooth & oral health. 2016.

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

CLINICAL EXAMINATION AND TREATMENT PLAN FOR FIXED PROSTHESIS