Clinical examination in total removable prosthesis
Introduction :
The word “clinic” derives from the Greek “kline”, which means bed.
The clinical examination is therefore that carried out at the patient’s bedside, and by extension in our specialty, in the chair.
The principle is to go into observation, from the general to the particular, and therefore from the exo-oral examination to the intra-oral examination.
This is an examination of the patient leading to a diagnosis and making it possible to detect any pathologies that the patient is unaware of, the consequences of which could be harmful.
The care of a person with total edentulism or wishing to renew or even improve their prosthetic rehabilitation requires an initial consultation.
During this clinical examination, several elements will be addressed, allowing the practitioner to consider different prosthetic solutions and establish a prognosis.
Clinical interview:
Presentation – 1st contact :
– Civil status: name, first name, etc.
-Gender: Currently, in our society, men are as concerned about their aesthetics as women. Depending on gender, personality, predominance and treatment plan, one will be oriented either towards function, aesthetics or both.
-Age: Chronological age: corresponds to civil status.
Biological age: is linked to organic aging.
Mental age: decisive for adaptation.
Young patients will be difficult to fit because they are very demanding. The same goes for very old patients because the adaptation for the latter is longer and more delicate.
-Profession, social status, intellectual level:
-Professional activity as well as social or family contacts bring an additional requirement in the need to appear normally and naturally healthy. The financial situation also plays a preponderant role.
Attitude, behavior, constitutional type, temperament:
HOUSE & ANDERSON classification “1937”:
1/The philosopher: Presents the best state of mind to accept a total removable prosthesis.
2/the suspicious one: Has all the qualities of the previous patient but requires a lot of attention.
3/the aggressive: Unstable, uncooperative, very fearful, aggressive patient.
4/the indifferent: Inert patient, is in no way interested in the treatment.
ANDERSON adds a fifth category:
5/the anxious: Patient who is afraid, dreads the different stages of treatment.
Anamnesis:
- – General factors: Predispose to bone resorption or the per and/or post-operative course
-Heredity.
– Congenital deficiencies.
-General illnesses.
*Joint conditions:
Clinical examination in total removable prosthesis
*Eye conditions:
Cataracts, Muscle degeneration, Glaucoma… Difficult hygiene control.
*Neurological conditions:
- -Local factors:
1. The condition of the parents’ teeth :
And his history (natural or artificial teeth), the patient collaborates better, if his family are satisfied with their prosthesis.
2. History of the patient’s teeth : Reasons for extractions, and date of last extractions .
The prosthetic past : A conversation will be established between the patient and the practitioner in order to reveal the subject’s behavior on a general level and vis-à-vis the prosthetic act in particular. Ex: -Has he experienced partial prosthesis? -Has he already had experience with total prosthesis? Since when? Is he satisfied or not?
3. Reasons for consultation
The patient can request a restoration, aesthetic, phonetic, functional or triple.
Exo-oral examination:
Upon inspection:
-Symmetry : Patients with congenital deformities, motor deficits in various forms, paralysis, tumor excision surgery, etc.
-Shape : The clinical examination should begin with the observation of the shape of the face. Determining the facial type is important: square face, round face, triangular face. The facial type can help us choose the morphology of the anterior prosthetic teeth.
– The profile : More or less marked sagging of the upper lip (convex, straight or concave). It is necessary to note a possible anomaly in the relationship of the maxillary and mandibular bone bases: mandibular prognathism, maxillary pretrognathism.
-Height of middle and lower floors : Assessment of the vertical dimension.
-Color of the integuments/presence of scar or particular sign.
On palpation:
Examination of the temporomandibular joint: Bimanual palpation of the auriculotemporal territory by asking the patient to perform several slow opening/closing movements. Screening for joint noises: Cracking, clicking.
Examination of the masticatory muscles: Palpation of the masticatory muscles
Screening for possible muscle pain. An abnormal contraction of one of the muscles of the head or neck will have a direct response on the muscle complex as a whole .
Assessment of the degree and path of mouth opening:
Degree of mouth opening: if the mouth opening is narrow, if the corners of the mouth have cracks, fissures or any other condition, the serial impression trays will be reduced to a minimum and tried before being filled with the impression material. Special precautions should also be taken at the secondary impression and occlusion stage.
Endo-oral examination:
In the maxilla:
The shape of the arch: it can be square, triangular, ovoid, symmetrical or asymmetrical.
The palatal vault: its characteristics determine prosthetic stability. Flat or U-shaped vaults are very favorable, which is not the case for rounded, ogival vaults which offer little stabilization.
Classification of alveolar processes according to ATWOOD
The tuberosities: they are favorable for support and stabilization if they are rounded, well marked, covered by firm and adherent tissue. They are unfavorable if they have vestibular undercuts, very large volumes, or covered by non-adherent depressible tissue or absent.
The appearance of the tissues: ideally the mucosa is pink in color, indicating healthy orthokeratotic mucosa, while a whitish appearance indicates hyperkeratosis. On the other hand, when it is red, eroded, hyperemic, the presence of papules indicates dyskeratosis or even prosthetic stomatitis.
Examination by digital or instrumental palpation concerns the soft tissues:
The resistance to pressure of the tissues covering the palatine vault is estimated using the fingertip or a T-shaped burnisher. It allows the location of the extent of depressible zones, such as Schroeder’s zones, or particularly hard zones such as the tori to be delimited.
The texture of the ridges and tuberosities is then assessed in order to discover any potentially depressible or floating parts. On the vestibular side of the ridges, the attached mucosa generally stops at mid-height, then continues with a free, unattached mucosa, to end at the reflection zone which is more or less wide depending on the degree of resorption.
The examination of muscle play assesses: The reflection zone which is marked by 3 brakes, one anterior and 2 lateral.
The soft palate which is a crucial region for the retention of the maxillary prosthesis because it allows the creation of the posterior seal. Clinically it is preferable to analyze the functional behavior of the soft palate to determine the position of the posterior seal, this is placed between two reference lines, the anterior and posterior vibration lines.
In the mandible:
The shape of the arch: same as the maxillary for the body of the mandible, horseshoe-shaped.
Ridges: the ideal ridge in the anteroposterior direction is parallel to the occlusal plane, but the ridge can be much more resorbed or even negative. Distally, the ridges are extended by the retromolar trigones.
Retromolar trigones: These are triangular structures.
The limits of the support surface: on the vestibular side, in the anterior region, the reflection zone is marked by the insertions of the mental muscles. In the lateral regions, the width of the Ackerman plates which first provide support for the prosthesis is approximately 4 to 6 mm. In the posterior region, the support surface is limited by the low insertions of the masseter on the external part of the trigone, distally by the insertions of the pterygomandibular raphe.
The appearance of the tissues: their color, appearance, presence or absence of lesions or injuries are assessed. Palpation of the summit and the vestibular and lingual slopes of the arch: the summit of the arch: the pulp of the finger determines the characteristics of the mucosa, the ideal being a firm and adherent mucosa. Distally, the retromolar trigones are examined.
The lingual side: Genioglossal spines: determine the height. In case of strong resorption they are located above the top of the crest.
Exostoses or mandibular tori: located between the 1st and 2nd at the level of the floor of the mouth.
Mylohyoid lines: which may be prominent or not, irregular or smooth, can be a negative element because they prevent the insertion of the prosthesis.
The vestibular side: In the anterior region in the event of significant resorption, if they are not visible, the two para-sagittal bony eminences are sought by palpation. Their vestibular slopes correspond to the anterior limits of the prosthetic support surface. Laterally the oblique line limits the external vestibular part of the prosthesis.
Clinical examination in total removable prosthesis
Peripheral organs: (lips: Buccinator, tongue and lingual floor) note the volume and power of the tongue, insertion of the frenulum They have an action on the limit and volume of the edge of the bases and on the stabilizing polished surfaces during function, movements and palpation are the means of appreciating their activity and influence.
Saliva examination:
Quality: palpation of the support surfaces is carried out; the sensation of adhesion between the fingertip and the mucous membrane indicates asialia or a significant decrease in the mucin level; similarly, stretching the saliva between two fingers allows the mucin content of the saliva to be assessed.
Quantity: sugar cube test.
Additional examinations:
Panoramic radiography: it allows to evaluate the bone volumes, the volume of the sinuses, the position of the inferior alveolar nerve and its emergence at the level of the mental foramen, the included teeth, the forgotten apices, the benign or malignant tumors, the most frequently encountered are the remaining roots and the radio opacities of the included teeth.
The symmetry of the ascending branches and the shape of the condylar head are sought, as asymmetry may be due to an old condylar fracture.
Pre-extraction documents and examination of old prostheses:
Study of castings:
Biological examination: Hematological examination and biochemical examination.
Treatment plan:
The assessment allows the treatment plan to be drawn up , which is made up of:
*The pre-prosthetic phase includes the prior correction of certain anomalies or alterations of the bone and mucous membranes of the support surfaces. But it also concerns occlusal and aesthetic problems, the shifting of the bone bases, and the management of psychological problems.
*The prosthetic phase corresponds to the actual development of the prosthesis. It consists of a clinical phase devoted to the choice of techniques, impression materials, the choice of the assembly of the prosthetic teeth and a technical phase: taking the impression, occlusion, etc. All of these choices depend on the patient’s anatomical and physiological data.
*The post-prosthetic phase is devoted to the restoration and concretization of the prosthetic balance, whether psychological, tissue or biomechanical.
Prediction:
The prognosis of prosthetic treatment of total edentulism varies depending on the medical characteristics of the patient (age, organic and psychological pathologies, resorption)
May be: favorable, moderately favorable or reserved in the short term and long term.
Conclusion:
The main thing is to recognize the difficulty of the case to be treated, to better estimate the possible prosthetic compensation in accordance with the patient’s hopes.
Clinical examination in total removable prosthesis
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.