PRE-OPERATIVE ASSESSMENT FOR IMPLANT PURPOSES – CLINICAL EXAMINATION
Introduction: The main focus of implantology has shifted from achieving osseointegration to producing aesthetic implant-supported restorations that mimic the teeth to be replaced. A host of treatment options have been devised to improve this goal. The clinician must therefore be able to discern those techniques that offer maximum benefit with minimal risk of failure. Patient examination is therefore essential and must precisely define the problem, which then makes the treatment obvious.
1-Psychological profile of the patient:
The analysis of the patient’s psychological profile is a decisive step in the therapeutic assessment. It is important to evaluate:
-the patient’s wishes (purely functional or with an aesthetic component).
-the aesthetic request (achievable by the practitioner or unrealistic).
-patient motivation (keeping appointments, hygiene skills).
Psychological disorders are sometimes difficult to diagnose. Some pathologies can be considered as potential contraindications to the use of dental implants, these are:
-psychotic syndromes (schizophrenia, paranoia).
– dysmorphophobia (body image disorder bordering on neurosis and psychosis);
-cerebral or senile degeneration syndrome (especially linked to hygiene problems);
-pharmaco-dependencies (drugs, alcohol).
2-General health : the general examination must be rigorous. A detailed medical questionnaire must be completed.
The American Society of Anesthesiologists (ASA) classifies patients according to the risks induced by their general condition:
ASA1 : healthy, without general illness
ASA2 : mild general illness responding to treatment
ASA3 : moderate general illness partially corrected by treatment
ASA4 : severe general illness threatening the patient’s life
ASA5 : moribund patient.
3-Clinical examination : The clinical examination consists of two parts:
-an oral exo examination.
-an endo oral examination.
A-The exo oral examination: It includes the evaluation of:
-from the skeletal model
-of the facial profile
– masticatory muscles
-temporomandibular joints (TMJ) and mouth opening.
-soft parts;
-facial symmetry;
-from the profile of the face
-the harmony of the different levels of the face;
– of the vertical dimension;
-the morphology of the lips;
-smile.
a-skeletal model : the skeletal model should be observed and recorded by Angle’s classification (class I (normal intermaxillary relationship), II (a prominent maxilla) or III (prominent mandible))
b-facial profile : the patient’s profile is observed with and without the prostheses. Thus the importance of the atrophy is appreciated. The naso-labial angle, the volume of the lips and the prominence of the mandible are indications of the loss of support of the musculocutaneous and mucosal perioral tissues.
c-the masticatory muscles : palpation of the masticatory muscles allows to evaluate their size and activity and gives an indication of the chewing forces and the possible presence of parafunction such as clenching, grinding of teeth and poor posture.
a-ATM and mouth opening:
The placement of dental implants, especially in the posterior areas, requires a normal opening.
Palpation of the TMJ is done by placing the index and middle fingers at the tragus of the ear or by placing the index finger in the external auditory canal and the thumb at the tragus. The path of the condyles as well as the opening and closing movements of the mouth are analyzed.
This examination may reveal:
– a discomfort;
– pain;
– a lockjaw;
– a deviation of the path of opening and closing the mouth.
– cracking or popping sounds in the temporomandibular joint.
Treatment of these conditions should be integrated into the overall treatment plan. The reversibility of the pathology must be determined. Some TMJ pathologies limiting mouth opening may contraindicate the placement of implants.
b-Soft parts:
Visual examination of the face and neck can reveal deformations or abnormal coloration of the skin (erythema, ecchymosis, depigmentation, etc.). The color of the face can also suggest certain conditions (pallor; anemia; cyanosis: circulatory problem).
Bimanual palpation allows the presence and consistency of any nodules to be assessed. The entire cervicofacial lymph node chain must be palpated (supramandibular, submandibular, jugo-auricular, retro-auricular, occipital and facial lymph nodes), looking for adenopathies or indurations.
The salivary glands require palpation, the practitioner must look for the ostia in order to visualize the existence of purulent discharge. The parotid gland is palpated by exerting pressure. The examination of the submandibular gland is carried out bimanually, by positioning the index and middle fingers of one hand intraorally at the floor of the mouth and maintaining the same fingers of the other hand in exo buccal.
The masticatory muscles should also be examined. Significant muscle contracture may suggest occlusal or articular disorders. The attachments of the temporalis muscle to the coronoid process and temporal bone are palpated intraorally. The masseter is examined by placing the index finger of one hand intraorally and holding the index and middle fingers of the other hand exorbitally.
c- Facial symmetry :
Facial symmetry is assessed in relation to the vertical and horizontal planes. The midline divides the face into two halves, right and left. It passes through the middle of the glabella, the tip of the nose and the middle of the chin. When these reference points are not aligned, the middle of the upper lip serves as a reference point.
The interpupillary line, when parallel to the horizontal plane, constitutes the ideal horizontal reference point for performing facial analysis. As a general rule, it is parallel to the line joining the eyebrows as well as to the commissural line.
d- Facial profile :
Profile analysis is performed by evaluating the angle formed by the lines joining the glabella, the subnasal point and the pogonion (the lowest and most anterior point of the chin).
When the angle is about 170°, the profile is considered normal. A retroposition of the pogonion leads to a lower angle, the profile is convex. An anteroposition marks a concave profile (angle > 180°).
The observation of the facial profile of edentulous patients or those with many missing teeth is done with and without prostheses. Thus the extent of atrophy is appreciated. The naso-labial angle, the volume of the lips and the prominence of the mandible are indications of the loss of support of the musculocutaneous and mucosal perioral tissues.
e- Harmony of the different levels of the face:
The face is normally divided into three floors, of equal heights:
-the upper level, delimited by the hairline and the eyebrow line.
-the middle floor, delimited by the eyebrow line and the inter-auricular line of the nose.
-the lower level, separated into two parts by the commissural line in a ratio of 1/3 – 2/3, and delimited by the inter-ailar line of the nose and the tangent to the tip of the chin. It is mainly occupied by the teeth and lips, and is of major importance in the overall approach to aesthetics.
f-Vertical dimension:
The lower level of the face defines the vertical dimension of occlusion (VDO). Any sagging of the VDO must be restored in order to reharmonize the relationships of the different levels of the face, the muscle tone and the general shape of the face.
g- Morphology of the lips:
The lips can be thick, medium or thin. The lower lip is often double the upper lip. The practitioner will look for possible labial lesions on the cutaneous and mucous membranes (angular cheilitis, ulcerations, traumatic lesions, angular cheilitis, etc.).
h- Smile:
The smile line is low, high or normal. The smile is said to be gummy when it exposes a height of gum greater than 3 mm. A smile line is said to be ideal when the smile completely uncovers the teeth, in addition to 1 mm of visible gum. The shorter the upper lip, the more the maxillary incisors are visible.
The length and width of the teeth should be recorded. As well as the presence of diastema and the space available for any teeth requiring replacement.
NB: In the presence of an anterior endentation, the analysis of the patient’s smile type is essential. A satisfactory aesthetic result can be difficult to obtain with a gummy smile. Certain prosthetic achievements may then be contraindicated.
PRE-OPERATIVE ASSESSMENT FOR IMPLANT PURPOSES – CLINICAL EXAMINATION
B-Endo-oral examination : The endo-oral examination includes:
-a periodontal assessment,
– an occlusal analysis,
-a prosthetic study,
-an aesthetic assessment;
a-Periodontal assessment : It allows to evaluate:
– the condition of the supporting tissues of the residual teeth;
-gingival inflammation;
– attachment losses;
-the importance of alveolysis;
The dental prognosis will depend on the extent and progression of the periodontal disease.
The diagnostic means are:
-dental plaque index;
-gingival inflammation index;
-the bleeding index;
-pocket depth measurements;
– measurements of gingival recessions;
-dental mobility;
-a long cone radiographic assessment.
The assessment allows bone loss to be assessed and a periodontal diagnosis and prognosis to be established for each tooth.
b-Occlusal analysis :
The relationships between the maxillary and mandibular teeth should be assessed statically and during different functional movements.
-angle classification determines the relationship between the arches in the anteroposterior direction;
– The occlusal plane, seen from the front, is parallel to the horizontal landmarks (interpupillary and commissural lines). In profile, it is parallel to the Camper plane passing through the upper edge of the tragus of the ear and the lower edge of the wing of the nose. An inclination of the occlusal plane relative to these reference lines should be taken into consideration because it alters facial harmony.
Laterality movements allow to evaluate the contacts on the working and non-working side and to determine the presence of a group function or a canine function.
Occlusion in maximum intercuspation and centric relation allows to highlight premature dento-dental contacts. In the anterior sector, the coverage and overjet are measured and the disocclusion must be evaluated.
Occlusion analysis also includes the study of wear facets. These indicate parafunction (bruxism). Mounting the patient’s impression models on an articulator allows for a detailed study of occlusion.
c-Prosthetic examination : This examination allows us to assess:
-fixed prostheses and removable prostheses worn by the patient;
-the residual prosthetic space;
-the residual prosthetic choice to fit out the available space;
-phonation.
d-Aesthetic evaluation :
Tooth loss is assessed as follows:
-the smile line;
-the shape of the arch (vestibular);
-the quality and quantity of soft tissues;
-the line of the necks of adjacent teeth;
-the relationship with opposing teeth;
-lip support.
E-Teeth : examination of the teeth must specify:
-missing teeth
-the presence of cavities
-the condition of dental tissues: the size of the restorations and the presence of root posts
F-Tooth wear: Tooth wear components are used to indicate the degree of parafunction and the occlusal loads the patient has exerted.
G-Soft tissues : examination of the frenulum, lymph nodes and soft tissues is necessary to detect pathological lesions.
Edentulous H-Crete : The height and thickness of the ridges are examined, and a preliminary impression is taken to identify their relative positions in relation to the plane of the prosthetic teeth by observation of the prostheses, adjacent teeth and measurements of the inter-arch distance.
Resorption can be anticipated by observing the thickness and periradicular alveolar bone of the present teeth.
PRE-OPERATIVE ASSESSMENT FOR IMPLANT PURPOSES – CLINICAL EXAMINATION
Conclusion: The patient must be informed very precisely about the success rates, complications, specific risks, cost, commitment of maintenance, if the treatment is undertaken, as well as the alternatives and consequences if he chooses not to undertake the treatment. It is essential that the patient understands the therapeutic proposal made to him and officially accepts it.
PRE-OPERATIVE ASSESSMENT FOR IMPLANT PURPOSES – CLINICAL EXAMINATION
Bibliography:
-Ashok Sethi, Thomas Kaus Clinical Implantology Diagnostics, Surgery and Restorative Techniques for Aesthetic and Functional Harmony Quintessence International
-Mr. DAVARPANAH, S.SZMUKLER-MONCLER, PMKHOURY, B. JAKUBOWICZ-KOHEN, H. MARTINEZ.
Manual of clinical implantology
Concept, protocols and recent innovation 2nd edition
-Alfred Seban Patrick Bonnaud the preoperative assessment for implant purposes Masson dental technique collection
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