Clinical examination and treatment plan for joint prosthesis

Before any prosthetic construction, it is imperative that a diagnosis be made, this will be done through a general examination and an oral examination. Making a fixed prosthesis requires following a sequence that includes the following elements:

Clinical examination;
Dental preparation;
Fingerprinting;
Installation of a temporary prosthesis.
Installation of a definitive prosthesis.

Clinical examination is of capital importance in the success of prosthetic treatment.

Clinical Examination

Any prosthetic procedure must be preceded by a clinical examination. It is of the utmost importance to establish a climate of trust with the patient in order to establish as clearly as possible the reasons for their visit. The clinical examination will begin with:

Questioning or Anamnesis
- If there is any doubt about the patient’s general health, a doctor should be consulted.
- The quality of oral hygiene must be assessed.
- It is necessary to look for disorders of the masticatory system.
- You have to be attentive to your aesthetic requirements.

2.2. Exo-oral examination

The inspection begins with the observation of certain signs that are sometimes obvious. It must nevertheless be done methodically.

For the analysis of the face, we will examine the symmetry of the face and the balance of the thirds; upper, middle and lower, in the frontal and sagittal planes.

The parallelism of the bipupillary and bicommissural lines in the frontal plane will be checked.

2.3. Oral and Dental Examination

Dental aesthetics and gingival aesthetics work together to give the smile its harmony and balance; The mucous membranes, other soft tissues, dentition and edentulous areas or segments must be palpated and examined during the intraoral examination. This examination includes

1.3.1. A Periodontal Assessment

The periodontal examination allows us to assess: the condition of the supporting tissues of the teeth, gingival inflammation, attachment losses, the extent of alveolysis and the depth of the sulcus.

The fixed prosthesis can only be made after having ensured treatment of all periodontal disease.

Dental examination [6,10]

It is important to remember that the shape, position, mobility, available enamel thickness, and occlusion are factors to consider. Confirming pulp vitality is part of any clinical examination. A very triangular or very thin tooth will pose problems that must all be understood and resolved; the anatomy of the tooth can be reproduced or improved by the fixed prosthesis.

Choosing the color of the tooth

Shade selection is a very important step for the aesthetic success of prosthetic treatment; it is carried out before dental preparation; to determine the color of a natural tooth, a commercial shade guide or a digital color device is generally used.

For example, the Vita Easyshade Compact shade guide

An Occlusal Analysis

The recording of static and dynamic occlusal parameters and the possibility of reproducing them outside the patient’s mouth are necessary for the production of prosthetic restorations and often essential for a complete occlusal analysis.

Occlusion analysis also includes the study of wear facets. These facets indicate a parafunction (bruxism). Articulators are the preferred means of external simulation of mandibular kinematics for occlusal analysis or prosthetic rehabilitation. For this, models from a preliminary impression are mounted on an articulator (e.g.: QillCK MASTER).

2.4 Additional Examinations

Study of casts:

Models are essential to have an overview of the therapeutic possibilities, they are made from faithful alginate impressions, but the occlusal surfaces must not contain air bubbles.

The X-ray examination:

A panoramic X-ray provides an overview of the anatomical bone and dental structures; a retroalveolar X-ray completes the panoramic X-ray. Depending on the clinical case, additional X-ray examinations may be performed: occlusal images, CT scans, etc.

These tests ensure the detection of:

Impacted teeth, supernumeraries or root fragments.
Of caries, periapical lesions, and cysts.
of bone lysis; of periodontal , traumatic or tumoral origin.
Assess the quality of the endodontic treatment; the bone level is assessed especially around the supporting teeth.
The volume, shape, length and orientation of the roots (a short root is contraindicated as a pillar).
The volume and location of the pulp chamber (if important: risk of pulp injury during trimming).
Appreciation of supporting tissues, widening of the desmodontal space.

Digital photographs of the face:

The photographic status serves both as a reference document and as support for the patient’s motivation; it allows for a facial and dento-labial aesthetic analysis of the patient, for optimal integration of prosthetic rehabilitation.

2.5. Diagnostic Phase

During the diagnostic phase, it is therefore necessary to collect several elements to carry out the prosthetic treatment plan: information on the patient’s aesthetic expectations, taking alginate impressions to create study models which will be mounted in an articulator, taking digital photographs of the patient’s face (identity photo, shot of practically closed lips, shots of the smile and maximum laughter). The computer tool can provide support in establishing a diagnosis and an aesthetic project.

1.6. Therapeutic decision

The practitioner must explain and propose to the patient the possible therapies in the oral cavity: whether removable; removable-immovable or fixed prosthesis; and make the therapeutic decision together (practitioner and patient). In certain cases, an aesthetic project can be carried out.

Treatment plan

It depends on the clinical examination, certain decisions will be reserved pending the result of the pre-prosthetic treatment.

Pre-prosthetic treatment
1. Motivation for hygiene

Inform the patient about oral hygiene methods and rules, and perform scaling.

Surgical treatments

Extraction of residual roots, regularization of edentulous ridges, excision of exostoses if they are painful and thorny.

Endodontic treatments

Treatment of all decayed teeth, resumption of dubious endodontic treatment, root canal treatment of mortified teeth, reconstruction of pulpless and dilapidated teeth.

.4. Orthodontic treatment

Generally, it is a minor treatment to correct a slight dental disharmony or to close a diastema.

2.1.5. Pre-prosthetic occlusal equilibration

Any prosthetic restoration must be integrated into the biofunctional balance of the patient’s masticatory system; occlusal equilibration ensures a harmonious distribution of the occlusal load over the entire masticatory system.

Treatment itself

It must go through the evaluation of the supporting teeth, any prosthetic element must be able to withstand the constant occlusal forces to which it is subjected, especially when it comes to making a bridge because the constraints exerted at the level of the missing teeth are transmitted to the support points via the connections and the anchoring means.

We must:

5 2.2.1.Determine the number of support teeth

The number of supporting teeth depends on their location on the arch; increasing the number of abutments improves the balance and retention of the bridge.

For ROY, there are 5 plans,

An incisal plane. (2 central and 2 lateral)
2 canine plans .
2 premolar-molar planes.

In the case of joint reconstruction, the immobility of the teeth depends on the use of abutments chosen in various ROY planes.

Choice of support teeth

It is done based on the masticatory coefficient, missing teeth and abutment teeth.

Duchange’s Law: “the sum of the masticatory coefficients of the abutment teeth must be greater than or equal to the sum of the masticatory coefficients of the missing teeth”

Pillar value
- The value of the pillar depends on the shape of the root; a root that is wide in the vestibulolingual direction and flattened in the mesiodistal direction is more favorable than a root with a circular section.
- For multi-rooted teeth, a tooth with diverging roots is preferable and provides better anchorage than a tooth with fused roots.
- The value of the pillar also depends on the coronal-radicular ratio, it concerns the extra-osseous coronal length on the one hand and the intra-osseous root length on the other hand
- The most favorable crown-to-root ratio for a tooth to be used as a support for a bridge is 2/3 (the root must be twice as long), the 1/1 ratio is the minimum acceptable.
- – The prosthetic height at the level of the edentulous segment must be sufficient in occlusion for the span of the bridge.
Anchor type

The anchor is chosen according to the supporting tooth which can be pulped (onlays) or depulped.

For pulped teeth, partial coverage anchorage onlays
For decayed teeth: intracoronal anchorage, inlay, crown or Richmond type. The indication or contraindication depends on:
Morphology
The retention required by the bridge
Pulp vitality
On the importance of the toothless sector
From the position of the tooth on the arch at the anterior or posterior level.

7 3. Different times of performing a bridge

Search for the insertion axis.

Size of the abutment teeth according to the chosen insertion axis and according to the choice of anchorage.

Taking impressions of the preparations using elastomer. Followed by the placement of a temporary crown ( polycarbonate cap). To maintain the occlusion level and to avoid thermal and chemical attacks on the stumps.

Casting of the working impression in hard plaster and placing in a semi-adaptable articulator. Sculpting of the crown or bridge in wax.

Cylindering then casting of the metal.

Fitting the framework in the mouth: check the cervical adjustment at the cervical limit, its retention and its occlusion.

Placement of the cosmetic in the laboratory (resin or ceramic) Try-in of the finished bridge in the mouth .

Temporary sealing.

Final sealing if all goes well.

CONCLUSION

From a clinical examination, all the information will be grouped together to develop a systematic therapeutic approach.