full mouth rehab

7/31/2019 Full Mouth Rehab

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REASONS FOR FMR

The most common reason -obtain and maintain thehealth of periodontal tissues.

Temperomandibular joint disturbance.

Need for extensive dentistry-

(a) in case of missing teeth

(b) worn down teeth and(c) old fillings that need replacement.

Esthetics- in case of multiple anterior worn down

teeth and missing teeth.

INDICATIONS

Restoration of multiple teeth which are broken,

worn, missing or decayed.

Faulty dentition

Discolored dentition

Developmental defects

Restore impaired occlusal function

Preserve longevity of remaining teeth

Maintain healthy periodontium


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Improve objectionable esthetics

Eliminate pain and discomfort of teeth and

surrounding structures.

CONTRAINDICATIONS

Malfunctioning mouths that do not need extensive

dentistry and have no joint symptoms should be best

left alone. Prescribing a full mouth rehabilitation

should not be taken as a preventive measure unless

there is a definite evidence of tissue breakdown.

Hence it Should be conluded that NO PATHOLOGY- NO

TREATMENT

GOALS FOR OCCLUSAL REHABILITATION

The ultimate goal for every patient should be maintainable

health for the total masticatory system.

Seven specific goals should be the objective for patientcare:I. Freedom from disease in all masticatory systemstructures2. Maintainably healthy periodontium3. Stable TMJs

4. Stable occlusion

5. Maintainably healthy teeth

6. Comfortable function7. Optimum esthetics


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Defined goals give purpose to treatment planning andmake it possible to be highly objective. When the entire

masticatory system is healthy and there is harmony ofform and function, and the relationships are stable, thetreatment can be said to be complete.

GOALS-

Static coordinated occlusal contact of the maximum

number of teeth when the condyle is in comfortable,

reproducible position.

An anterior guidance -in harmony with function in

lateral eccentric position on the working side.

Disclusion by the anterior guidance of all posterior

teeth in eccentric movements

Axial loading of teeth in CR, IP and Function

OCCLUSAL APPROACH FOR RESTORATIVE DENTISTRY

Confirmative Approach And Reorganized approach

CONFIRMATIVE APPROACH

Construct the restoration to conform to patientsexisting inter cuspal position

2 situations


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Where a large amount of treatment is to be undertaken

and operator has opportunity to optimize patients

occlusion

Conditions where ICP is considered unsatisfactory

Repeated fractures or failures of teeth or restoration

Bruxism

Lack of interocclusal space for restoration

Trauma from occlusion due to excessive or abruptly

directed occlusal forces.

Unacceptable function poor tooth to tooth contacts

with tilting and over-eruption of teeth create problems

with masticatory function.

Unacceptible esthetics- alteration of clinical heightis

necessary to improve esthetics.

TMD

Developmental anamolies e.g. amelogenesis

imperfeta.

Classification of patients requiring occlusal rehabilitation

Classification by Turner and Missirlain (1984)

The patients were classified into three categories

Category 1 - Excessive wear with loss of vertical

dimension.


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Category 2 - Excessive wear without loss of vertical

dimension of occlusion but with space available.

Category 3 - Excessive wear without loss of vertical

dimension of occlusion but with limited spaceavailable

CATEGORY -1

A typical patient in this category has few posterior

teeth and unstable posterior occlusion. There is

excessive wear of anterior teeth. Closest speaking

space of 3mm and interocclusal distance of 6mm.there is some loss of facial contour that results in

drooping of the corners of mouth.

Patients with dentinogenesis imperfecta with

excessive occlusal attrition, around 35 years of age

and appearing prognathic in centric occlusion also

belongs to this category.closest speaking space of

5mm and interocclusal distance of 9mm indicates

there is loss of occlusal vertical dimension with

concomitant occlusal wear.

CATEGORY- 2

Patient has adequate posterior support and histoty of

gradual wear. Closest speaking space of 1mm and

interocclusal distance of 2-3mm.

Continuous eruption has maintained occlusal vertical

dimension leaving insufficient interocclusal space for

restorative material. Manipulation of mandible into


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centric relation will often reveal significant anterior

slide from centric relation to maximum intercuspation.

CATEGORY-3

Posterior teeth exhibit minimal wear but anterior teeth

show excessive gradual wear over a period of 20-25

years. Centric relation and centric occlusion are

coincidental with closest speaking space 1mm and

interocclusal distance 2-3mm. It is most difficult to

treat because vertical space must be obtained for

restorative material.

Classification by Breaker

Group I

Class I Patients with collapse of vertical dimension of

occlusion because of shifting of existing teeth caused

by failure to replace missing teeth.

Class II Patients with collapse of vertical dimension

of occlusion because of loss of all posterior teeth in

one or both jaws with remaining teeth in

unsatisfactory occlusal relationship.

Class III Patients with collapse of vertical dimension

of occlusion because of excessive attritional wear of

occlusal surfaces.Group II

Class I Patients with all or sufficient natural teeth

present, with satisfactory occlusal relationship.


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Class II Patients with limited teeth present but in

satisfactory occlusal relationship requiring aid in the

form of occlusal rims.

Group III Patients requiring maxillofacial surgery oforthodontic treatment as an aid in restoring the lost

vertical dimension.

Group IV Patients in whom sectional treatment is

required over extended periods of time because of

status of health of the patient, age or economic factor.

Etiology of extremely worn dentition

Congenital abnormalities -

Amelogenesis imperfect and Dentinogenesis

imperfecta

Parafunctional occlusal habit

Abrasion

Erosion

Loss of posterior support

Diagnostic aids

The following aids should be used -

Medical history

Dental history

Behaviour evaluation


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Radiographs Complete mouth periapical radiographs

and orthopentamograph

Photographs colour of teeth and gingiva is recorded

and photographs are necessary to recall to patients

mind the state of his mouth prior to restorative

dentistry.

Clinical examination

Diagnostic wax-up

Computer imaging It is helpful to demonstrate thevarious treatment options. Computer aided image

manipulation can be used to create the future

appearance

DIAGNOSTIC WAX UP

Before diagnostic wax-up, the occlusal discrepancies

in centric and eccentric occlusion should beeliminated. Diagnostic preparation of gypsum stone

teeth that will require prospective crowns is carried

out. This will reveal any resistance or retention form

problems caused by short axial walls. Thus planning of

subgingival margins or surgical crown lengthening

required can be done. Then wax is used to

appropriately shape all crowns and final prosthesis is

planned. This diagnostic wax-up can be used to

prepare an elastomeric putty mould and used for

temporization or sectioned through long axis of tooth

to act as reduction guide intra-orally.


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TREATMENT PLAN

Comprehensive treatment plan must be established

prior to start of the treatment . Communication and

patient education are essential in order to match thedentists and patients definition of success.

Treatment plan is divided into-

1) Pre- prosthetic phase

2) Prosthetic phase

3) Maintenance phase

Pre-Prosthetic Phase

To develop proficiency in diagnosing the need of

occlusal rehabilitation, periodontist , orthodontist ,

endodontist , oral surgeon and prosthodontist must

all be integrated in establishing an environment

conducive to oral health.

PHILOSOPHIES OCCLUSAL SCHEMES

GNATHOLOGICAL PHILOSOPHY

CRCP- IP coincident

Canine guided lateral excursions

Posterior disclusion in all excursion

1) movement of condyle in fossae determine occlusal

form


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2)simutaneous contact of all posterior teeth in RCP

with forces directed along long axis

3) in any excusive movement , canine should disclude

the posterior teeth

4) If anterior guidance can not be provided, keep it as

far forward as possible.

5) Lingual concavity of anterior teeth is determined by

condylar guidance.

6) Wax up done on fully adjustble articulator.

7) Cusp fossa- tripod contact provided.

Pankey- Mann Schuler

Area of freedom between CRCP and IP (


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Movement of teeth while making FGP compromised

registration.

Functionally generated path technique

Described by Meyer 1933

It is a method of capturing in a usable way the precise

border pathway that the lower posterior teeth follow.

Border pathways of lower posteriors is dictated by 2

determinants

Shape of occlusal surface of lower teeth has a

profound influence.

Advantages

1)Simple, inexpensive instrument.

2)Minimum chairside time

3)Relatively easy tech. to learn

Hobo twin stage (theory of disclusion)

A methodical approach two stage procedure.

Occlusal morphology of posterior teeth reproduced

without anterior segment- cusp angle coincident with

standard value of effective cusp angle produced

(conditon1).

Secondly anterior morphology reproduced with

anterior guidance provided which produced a

standard amount of disclusion (condition 2)


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defined as freedom to close the mandible either into

centric relation or slightly anterior to it without

varying the vertical dimension of occlusion.

This term is now referred to as Freedom inCentric

Area of freedom between CR, IP (0.5 +/- 0.3).

All interference to terminal closure should be

eliminated. If centric relation interference is present,

path of closure will be dictated by the proprioceptors

instead of the muscles. When interference in centricrelation is eliminated by equilibration long centric will

usually be provided automatically

There is no relationship between the length of a slide

and length of a long centric. Length of a slide is the

result of interference of the teeth whereas long

centric is dependant on anatomy of the condyle disc

relationship and varying patterns of muscle activity in

different individuals

It should be clarified that :

Long centric involves primarily the anterior teeth

(posterior are disoccluded due to condylar guidance

even with zero degree anterior guidance )

Long centric refers to freedom from centric not

freedom in centric

Nyman and Lindhe concept


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Used in advanced periodontal disease.

Clinically hypermobility of teeth, unfavourable

distribution of teeth.

Bridge on such abutment teeth exhibit mobility

But such bridge hypermobility can be tolrated,

provided it does not exhibit increase with time or

interfare with patients comfort or bridge function

Such mobile bridge can further exagerrate the

periodontal weaking but can be prevented bydesigning occlusion in such a way to obtain &

maintain stability.

Even and simultanuous contacts all over the dentition

in ICP and excursion.

If distal abutment teeth are missing in a cross arch

bridge with increased mobility, balance and functionalstability obtained by cantilever units.

However cantilevers increased risk of failure.

If increased mobility is not observed, balancing

contacts on non working side should be removed.

When bridge exhibit increased mobility- fulcrum

identified, occlusion designed so that forces exerted

by masticatory muscles meet the bridgework

simultaneously with balanced load on both side of

fulcrum


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Freedom in creatingesthetic occlusal plane

Arduous, unpredictable, patient visits

Freedom in occlusalscheme

Full arch anaesthesia

Freedom in intra-archtooth spacing and inter-arch crown position

Increased chair time, full arch temporar

Maximum freedom increating and controlling

porcelain esthetics

Multiple occlusal records, highly accuraimpressions

Individual quadrants (Pankey, Mann, Dawson,

Granger)

Advantages DisadvantagesReduced chair time Restriction for achieving ideal occlus

altering occlusal plane

Sequential provisionalrestorations

Less freedom in controlling porcelain

Quadrant anaesthesia

Vertical Dimension iscontrolled

Impression procedures areeasier


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PROSTHETIC PHASE

Prosthetic full mouth rehabilitation is divided into-

1. Immediate treatment

2. Definitive treatment

Immediate treatment

In some cases like amelogenesis imperfecta in a child,

postponing treatment until adulthood may cause

adverse psychological effect and impair correct

relationship between maxillary and mandibular teeth.

Preformed nickel-chromium crowns are placed on firstpermanent molars and second deciduous molars to

stabilize occlusion and halt attrition. Vertical

dimension is not altered. As anterior teeth and

premolars erupt, polycarbonate resin crowns are

given. Second molar is fitted with nickel crown to

preserve vitality. After all permanent teeth are

erupted, these restorations serve as transitionaltreatment until adulthood.

Definitive treatment

Once all teeth have erupted and adulthood is reached,

the size of pulp horns decreases compared to newly


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erupted teeth. A definitive treatment can then be

planned.

Selection of instruments for full mouth rehabilitation

Articulators

Awni Rihani has classified articulators as-

Fully adjustable articulator

Non- adjustable articulator

The two basic types if semi adjustable articulators are- Arcon type

Non-arcon type

Semi-adjustable articulator cannot record the full

range of protrusive and lateral condylar movement

but mechanical equivalent of tooth movement can be

recorded with much accuracy if instrumentsshortcomings are compensated.

The instruments shortcomings are compensated

with

1. Customized anterior guidance

2. Simplified fossae contour technique to relate lower

fossae form to anterior guidance

Functionally generated path procedures to capture the

precise border movements of posterior teeth at correct

vertical dimension


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Facebow selection

There is a definite three dimensional relationship

between the maxillary arch and the condylar motion

to record this spatial relationship to the opening and

closing axis of the articulator, a facebow is used.

A facebow is a caliper-like device that is used to

record the relationship of the jaws to the TMJ and to

orient the same relationship to the opening axis of the

articulator.

Vertical relation consideration for full mouth rehabilitation

When fixed prosthodontic treatment is indicated for all

teeth in one or both arches, the dentist must evaluate

the existing vertical dimension of occlusion.

There has never been a scientific, practical and

accurate method by which vertical dimension of the

patient could be recorded

Classic techniques have been used to determine the

vertical dimension of occlusion like

phonetics,

interocclusal distance,

facial soft tissue contour,

cephalometrics,


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centric relation without forward deviation to the same

vertical dimension

Dahl Appliance - If wear is localized eg. Upper

anterior teeth.

Grind opposing teeth - Possible esthetic and pulpal

problems

Restore the lost vertical dimension _ Indicated

only if majority of posterior teeth need full coverage

restorations

Distalize Mandible - Extensive occlusal adjustment

needed to eliminate slide from RCP- ICP ( retruded

axis position to intercuspal position) Only if large

anterior slide present

Crown Lengthening - May be required to increase

axial wall height to aid in crown retention

Extraction or _ Rarely indicated but may berequired

Surgical Repositioning where gross over-eruption

has occurred

Tests for checking the patient tolerance to the new

OVD :

1. Splints

2. Temporaries

SPLINTS


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Permissive splintHave smooth surface onone side that allows themuscles to move themandible in the centricrelation withoutinterference . Generallyused. E.g. Stabilizationappliance

Directive occlusal splintDirect the lower arch into a specrelationship . They are mainly ustreatment of TMDse.g. anterior repositioning split

Temporary restorations

Provisional restorations generate specific information

regarding functional and esthetic requirement of

definitive restorations.

The functions of provisional restorations are

Protect the pulp of prepared teeth from external

irritants.

Proper contour and adaptation maintain periodontal

health.

Provide positional stability of prepared teeth in

elation to adjacent and opposing teeth.

Evaluate esthetics and phonetics.

Occlusion can be checked on the temporaries.

Re-establish the vertical dimension of occlusion in

extremely worn dentition.


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It is a reversible treatment appliance and can be

adapted to patients own neuromuscular limitation.

Customized incisal guidance can be created with the

help of provisional restorations. Thus horizontal and

vertical overlap can be duplicated in subsequent

prosthesis.

Short term temporary restorations:- intraoral

technique, chairside, coldcure acrylic.

Long term temporary restorations:- indirect technique,

heat cure acrylic resin, composite resin

EQUILIBRATION PROCEDURES

They can be divided into four parts-

Eliminating interference to terminal hinge axis

closure

Eliminating interference to lateral excursions

Eliminating posterior tooth interferences with

protrusive excursions.

Harmonization of anterior guidance.

Determining plane of occlusion

Pankey- Mann Schuyler method accomplishes thefollowing-

1) Determine plane of occlusion

2) Determine the amount of tooth reduction


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3) Simple transfer to mouth

4) Help in laboratory wax-up to determine cusp

height

5) Determine cusp height in restoration

6) Select the type of occlusal scheme

ANTERIOR GUIDANCE

The correct relationship of the upper and lower teeth

is so critical that differences of a millimeter in the

incisal edge position can feel grotesque to the patient.

Along with esthetics and function of mastication,

anterior teeth have a very important job of protecting

the back teeth.

The dynamic relationship of the lower anterior

teeth against the upper anterior teeth through all the

ranges of function is called anterior guidance.

Steps in harmonizing anterior guidance

1. Establish coordinated centric relation stops

2. Centric stops in a postural position must have the

same vertical dimension as those for centric relation

3. Refine protrusive excursions

4. Establish ideal anterior stress distribution in lateral

excursions.


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5. Check lateral protrusive movements

6. Smooth transition to a crossover position.

Concepts of occlusion1. Gnathological concepts of occlusion, point centric

concept of occlusion.(Stuart and Stallard,1960)

2. Long centric occlusion.(Dawson, 1978)

3. Cuspid protected occlusion.(Schuyler)

4. Group function. (Schuyler)

5. Mutually protected occlusion. (Stuart and

Stallard,1957)

6. Organic occlusion. (Stuart)

7. Anterior protected occlusion. (Dawson)

SELECTION OF OCCLUSAL SCHEME

The factors to be considered in restoring occlusal

surfaces are

Number of teeth contributing for occlusal support

Material of occluding surface

Type of occlusal scheme

Parafunctional habits.

Procedural steps in restoring occlusion

Two best rules


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1. Never begin any restorative procedure unless all the

procedures that follow are outlined in advance and

properly related to one another in correct sequence

2. Never begin any restorative procedure unless theresult is visualized and understood.

PRELIMINARY MOUTH PREPARATIONS

Restorative procedures are the last step

1)Mouth hygiene instructions

2)Caries control

3)Periodontal therapy

4)Minor tooth movement

5)Necessary extractions

6)Equilibration TMJ should be comfortable before

finalization of any restorative treatment.CASES-

Restoring all upper posterior teeth only

Steps :

1. Preliminary mouth preparation

2. Selective grinding

3. Prepare all upper posterior

4. Correctness of anterior guidance should be verified

and modify


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5. If canine guided- set condylar path at 20degrees

complete wax up

6. Or complete the restoration on fully adjustable

articulator out of excursion

7. For group function- use FGP

8. Place posterior restorations and do necessary

modifications

CASE-2

Restoring all upper but no lower teeth


2. Selective grinding of lowers

3. Prepare upper posterior

4. Correct anterior guidance

5. Do alternate tooth preparation in anteriors and

make throw-away patterns

6. Centric record, articulate lower cast with first upper

cast

7. Customize guide table

8. Articulate final cast

9. Duplicate anterior restorations by using throw- away

patterns


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10. Replace upper posteriors as described

11. Reevaluate disclusion and guidance and do

necessary corrections in patients mouth

CASE- 3

Restoring all posterior but no anterior


2. Broadrick occlusal plane analysis

3. Prepare lower teeth accordingly

4. Harmonize anterior guidance

5. Complete lower wax patterns and restorations

6. Place lower restorations

7. Prepare upper posteriors

8. Complete upper posterior restorations (FGP)

9. Remove balancing contacts

10. Redefine working contacts

CASE-4

Restoring all lower teeth but no upper teeth

1. Preliminary mouth preparation2. Redefine interferences in the upper arch

a. correct marginal ridges

b. equilibrate occlusion


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c. harmonious anterior guidance

4. Every other lower anterior tooth should be prepared,

through away patterns

5. CR record with ant. teeth in contact

6. Remaining teeth should be prepared

7. Articulate working cast

8. Place through away patterns

9. By using this guide prepare lower ant restorations

10. Prepare and place posterior restorations

11. Remove balancing contacts

12. Redefine working contacts

CASE-5

Preparing all upper teeth and lower posterior teeth

only


2. Restablish anterior guidance

3. Prepare every other maxillary ant tooth

4. Place through away wax pattern

5. Prepare all anterior teeth

6. Establish predetermined anterior guidance


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8. Prepare and restore upper anterior teeth (exactly

duplicate the pattern of provisionals)

9. Place upper anterior restorations

10. Refine the anterior guidance.

11. Prepare lower posterior teeth by taking guidance

of Broadrick occlusal plane analyzer

12. Reestablish the occlusal plane.

13. Complete lower posterior restorations

14. Complete upper posterior restorations

accordingly

15. Refine centric, working and nonworking contacts

REMOUNTING

Remounting is a procedure whereby restorations are

accurately related to each other and to masticatorymechanism for the purpose of minute refinement of

various surfaces. It enables us to observe with

accuracy just how the restorations are working.

SPLINTING

A splint is a rigid or flexible appliance for the fixation

of displaced or movable parts. Splinting is joining of

two or more teeth into a rigid unit by means of fixed

or removable restoration

The purpose of splints are

1) To stabilize the temperomandibular joint


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2) To improve function of masticatory system

3) To reduce abnormal muscle activity

4) Protect teeth from attrition

5) Prevent mobility due to traumatic loading

6) Alter occlusal forces

Splints provide the benefits on the following rationale

Redirection of stresses

Redistribution of stresses

Prevention of migration

Prevention of supraeruption

Stabilization of tilted teeth

Stabilization and strengthening of abutmentsMaintenance phase

After placement and cementation of a prosthesis the

patient treatment continues with carefully structured

sequence of follow-up appointments to monitor the

dental health, stimulate meticulous plaque control

habits, identify incipient disease and introduce any

corrective measures if required. Adequate scaling is

done periodically to maintain gingival health. Margins

of restoration must be evaluated to detect secondary

caries. Oral hygiene aids prescribed are tooth brushes,


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full mouth rehab

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