full mouth rehabilitation

FULL MOUTH REHABILITATION

Under The Guidance Of Dr Akshey K SharmaDr Pardeep BansalDr Poonam BaliDr Rajnish BansalDr Gagandeep K ChahalDr Rajnanda Khuller

Presented by Asmita sodhi

Pg student

CONTENTS•Introduction•Goals •Indications•Classification of patients•Objectives of Occlusal schemes•Philosophies for full mouth rehabilitation•Treatment Philosophies

The goal of dentisty is increasing the

sapan of functioning just as the goal of medicine is to increase the life span of the functioning individual.

Planning and executing the restorative rehabilitation of a decimated occlusion is probably one of the most intellectually and technically demanding tasks facing a restorative dentist.

DEFINITIONACCORDING TO GPT-9

Full mouth rehabilitation is defined as the restoration of the form and function of the masticatory apparatus to as nearly a normal condition as possible


COMPLETE DENTISTRY HAS FIVE

COMPREHENSIVE GOALS

OPTIMAL ORAL

HEALTH

ANATOMIC HARMONY

FUNCTIONAL HARMONY

OCCLUSAL STABILITY

BEST ESTHETICS

INDICATIONS


•RESTORATION OF MULTIPLE TEETH –MISSING,WORN ,BROKEN DOWN,DECAYED.

BEFORE AFTER


•TO REPLACE IMPROPERLY DESIGNED AND EXECUTED CROWN AND BRIDGE WORK.

BEFORE

AFTER


DEVELOPMENTAL DEFECTS

BEFORE AFTER


DISCOLOR DENTITION

Full mouth rehabilitation with whiter teeth.

BEFORE

AFTER


http://www.jerseysmiles.com/image-1ab.html

http://www.jerseysmiles.com/image-1ab.html

OCCLUSAL REHABILITATION


Contraindications for full mouth rehabilitation 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 breakdownIn short, it can be concluded that :No pathology- No treatment.

Temporomandibular disorder

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.

• 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 space available

Category 1 - Excessive wear with loss of vertical dimension. • 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.

Category 2- Excessive wear without loss of vertical dimension of occlusion but with space available • Patient has adequate posterior support

and history 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.

• History of bruxism• Parafunctional oral habits

Category 3 –- Excessive wear without loss of vertical dimension of occlusion but with limited space available • Posterior teeth exhibit minimal wear but anterior

teeth show excessive gradual wear• 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.

• Vertical space obtained by • Orthodontic movement

Classification by Brecker Clinical Procedures In Occlusal Rehabilitation Charles Brecker In 1966

• 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.• 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 of orthodontic 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.

OBJECTIVES OF OCCLUSAL REHABILITATION•Static centric occlusion in harmony

with the maxillomandibular relation.•An even distribution of stress in centric

occlusion over the maximum number of teeth.

•Lateral and anteroposterior freedom of movement in C O.


OBJECTIVES…•Masticatory efficency which involves

uniform contact and an even distribution of stress on eccentric functional tooth inclines which are coordinated with the incisal guidance and normal fuctional condylar movements.


Objectives….

•Reduction Of The Buccolingual Width Of The Occlusal Surfaces Of The Teeth, And A Reduction Of The Balancing Incline Contacts As A Means For Reducing A Traumatogenic Load On The Structures Supporting The Dentition.

Full Mouth Rehabilitation

Constants•Patients present in our practices with functional determinants that are unchangeable by the restorative dentist as part of their present condition. •THESE CONSTANTS INCLUDE 1.INTERCONDYLAR DISTANCE,2. HINGE AXIS POSITION3.THE RELATIONSHIP OF THE MAXILLA TO THE MANDIBLE IN CENTRIC RELATION4. THE PATH OF THE CONDYLE-DISK ASSEMBLY IN THE GLENOID FOSSAE.• These constants must be evaluated, recorded, andtransferred to a patient simulation device accurately enough to permit diagnostic planning prior to treatment and the fabrication of dental restorations duringtreatment.

OCCLUSAL SCHEMES(AN OCCLUSAL SCHEME IS A PATTERN OF

OCCLUSAL CONTACT USED FOR RECONSTRUCTION)


Gnathological Philosophy (Stuart Ce1964) •Centric Relation Contact Position (CRCP)and

The Intercuspal Position (ICP) (Centric Occlusion).Are Coincident

•Canine Guided Lateral Excursions•Posterior Disclusion In All Excursions.•Lingual Concavity Of Anterior Teeth Is

Determined By Condylar Guidance•Wax Up Done In Fully Adjustable Articulator.•Good For Restoring Cases With Large

Horizontal Component Of Cr And Ip.


Pankey-Mann-Schuyler Concept

In 1929 C.H. Schuyler stated that maximum intercuspation must occur in the retruded mandibular position (centric relation) under all circumstancesSchuyler’s principles were1. A static co-ordinated occlusal contact of the maximum number of teeth when the mandible is in centric relation.2. An anterior guidance that is in harmony with function in lateral eccentric position on the working side.3. Disclusion by the anterior guidance of all posterior teeth in protrusion.4. Disclusion of all non-working inclines in lateral excursions.5. Group function of the working side inclines in lateral excursions.

In order to accomplish these goals, the following sequence is advocated by the P.M.S. philosophy:PART 1. Examination, diagnosis, treatment planning, prognosis PART 2. Harmonization of the anterior guidance for best possible esthetics, function, and comfortPART 3. Selection of an acceptable occlusal plane and restoration of the lower posterior occlusion in harmony with the anterior guidance in a manner that will not interfere with condylar guidance.PART 4. Restoration of the upper posterior occlusion in harmony with the anterior guidance and condylar guidance. The functionally generated path technique is so closely allied with this part of the reconstruction that it may almost be considered part of the concept.

The advantages of the technique are many. Some of the major ones are as follows:

• It is possible to diagnose and plan treatment for the entire rehabilitation before preparing a single tooth.

• It is a well-organized, logical procedure that progresses smoothly with less wear and (car on the patient, operator, and technician.

• There is never a need for preparing or rebuilding more than eight teeth at a time.

• It divides the rehabilitation into separate series of appointments. It is neither necessary nor desirable to do the entire case at one time.

• There is no danger of "getting at sea" and losing the patient's present vertical dimension. The operator knows exactly where he is at all times.

• The functionally generated path and centric relation are taken on the occlusal surface of the teeth io be rebuilt at the exact vertical dimension to which the case will be constructed.

• All posterior occlusal contours are programmed by and are in harmony with both condylar border movements and a perfected anterior guidance.

• There is no need for time-consuming techniques and complicated equipment.

• Laboratory procedures are simple and controlled to an extremely fine- degree by the dentist.

YOUDELIS SCHLUGER S et al

•FOR ADVANCED PERIODONTAL CASES.

•CR AND IP ARE COINCIDENT.•ANTERIOR DISCLUSION FOR

PROTRUSIVE AND CANINE DISCLUSION FOR LATERAL EXCURSIONS.


Youdelis…• Lateral Contacts Are Arranged Such That

If Canine Disclusion Is Lost Through Wear /Tooth Movement-posterior Teeth Drop Into Group Function.

• Both Fully /Semi Adjustable Articulators Can Be Used.

Useful –Parafunction Cannot Be Controlled/Canine Compromised Periodontally


Freedom In Centric (Ramfjord Sp)•Area Of Freedom B/W Cr And Ip-

0.5mm.•Either Canine Guidance/Group

Function,but Ant. Guidance Will Be Delayed During Posterior Contact In Area Of Freedom.

•Cusp To Fossa Occlusion.•Useful For Cases With Large Horizontal

Component Of Slide.


Nyman and Lindhe concept 1983• 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 by designing 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 functional stability 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

Occlusal scheme RCP–ICP relationship Excursive contacts CommentsGnathological (1964) Coincident, with tripod

contactsCanine-guided lateral excursions, posterior disclusion in all excursions. Anterior and posterior contacts are mutually protected1

Good for restoring cases without a large horizontal component of RCP–ICP slide. Real purists would insist on the use of a fully adjustable articulator and all that goes with it.

Youdelis (1977) Coincident, with tripod contacts

As for gnathological, but designed to drop into group function if canines wear or move

Useful option where excursive parafunction cannot be controlled or where the canine is compromised

Pankey–Mann–Schuyler (1963)

Area of freedom2 between ICP and RCP (<0.5 mm) and morphology functionally generated

Anterior guidance determined functionally on temporaries. Either canine guided or group function

The potential for error with the functionally generated path technique, which is used to determine the occlusal morphology of posterior teeth is considerable

Area of freedom in centric (1982)

Area of freedom between ICP and RCP (0.5 mm ± 0.3 mm); cusp to fossa occlusion

Either canine guided or group function, but anterior guidance will be delayed during posterior contact in area of freedom

Useful where there has been a large horizontal component in the RCP–ICP slide before treatment. Area of freedom needs careful adjustment

Balanced occlusion (1960) Area of freedom between ICP and RCP

Balanced working and non-working contacts in lateral excursions. Balanced anterior and posterior contacts in occlusion

Keeps complete dentures stable during excursions, but difficult to manage in the natural dentition and risk of non-working-side overloading

Nyman and Lindhe (1983) RCP and ICP must have even contact

Bilaterally balanced excursive contacts determined in provisional (long-term temporary) restorations and then copied into definitive restorations

This is used in cross arch bridges where there is advanced, but controlled, periodontal disease. Balanced contacts give stability to an otherwise mobile bridge

HOBO TWIN STAGE CONCEPT (Hobo St) (Theory Of Disclusion)•Two Stage Procedure:•Occlusal Morphology Of Posterior Teeth

Reproduced Without Ant. Segment.•Ant. Morphology Reproduced With

Ant.Segment And Ant. GUIDANCE-PRODUCE Std AMT OF DISCLUSION.


HOBO’S TWIN TABLE PHILOSOPHYAnother philosophy was given by Dr. Sumiya Hobowhich is followed in rehabilitation of dentatepatients. He proposed Twin table concept whichdeveloped anterior guidance to create a predetermined, harmonious disclusion with the condylar path.

•The technique utilizes 2 different customizedincisal guide tables. The first incisal table is termedINCISAL TABLE WITHOUT DISCLUSION. It is fabricated by preparing die systems with removable anterior and posterior segments

• It is fabricated by preparing die systems with removable anterior and posterior segments. This table helps us achieve uniform contacts in the posterior restorations during eccentric movements• used to fabricate restorations for posterior teeth

Incisal table without disclusion

The other incisal table is made when the articulator can simulate border movementsby placing 3 mm plastic separators behind thecondylar elements. This is termed THE INCISALGUIDANCE WITH DISCLUSION.•used to achieve incisal guidance with

disclusion.

Incisal table with disocclusion

Examination , Diagnosis , And Treatment Planning In Occlusal Rehabilitation


•Preclinical examination.•Accurate diagnostic casts•Colored pictures •Radiographic evaluation•Detailed oral examination•Case presentation •Pt acceptance for the extensive

treatment plan and cost factor•Treatment planning


Treatment plan is divided into-•1) Pre- prosthetic phase•2) Prosthetic phase•3) Maintenance phase

PRELIMINARY MOUTH PREPARATION

•MOUTH HYGIENE INSTRUCTIONS•CARIES CONTROL•NECESSARY EXTRACTIONS•ORAL PROPHYLAXIS•MINOR TOOTH MOVEMENT•EQUILIBRATION


Treatment philosophies

Restoring all upper posterior teeth only1. Preliminary

mouth preparation

2. Selective grinding

3. Prepare all upper posterior

4. Correctness of anterior guidance should be verified and modify

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

Restoring all upper but no lower teeth1. Preliminary mouth

preparation2. Selective grinding

of lowers3. Prepare upper

posterior4. Correct anterior

guidance5. Do “alternate

tooth preparation” in anteriors

6. Centric record, articulate lower cast with first upper cast

7. Customize guide

table8. Articulate final

cast9. Duplicate anterior

restorations by using throw- away patterns

10.Replace upper posteriors as described

11.Reevaluate disclusion and guidance and do necessary corrections in patients mouth

Restoring all posterior but no anterior

Preliminary mouth preparationBroadrick occlusal plane analysisPrepare lower teeth accordinglyHarmonize anterior guidanceComplete lower wax patterns and restorationsPlace lower restorationsPrepare upper posteriorsComplete upper posterior restorationsRemove balancing contactsRedefine working contacts

Restoring all lower teeth but no upper teeth

1. Preliminary mouth preparation

2. Redefine interferences in the upper arch

a. correct marginal ridges b. equilibrate occlusion c. harmonious anterior

guidance4. 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 cast8. Place through away

patterns9. By using this guide prepare

lower ant restorations10. Prepare and place posterior

restorations11. Remove balancing contacts12. Redefine working contacts

Preparing all upper teeth and lower posterior teeth only

1. Priliminary mouth preparation

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

7. Prepare mandibular posteriors

8. By using brodrick occlusal plane analyser establish occlusal plane

9. complete lower restorations

10.Prepare maxillary posteriors

11.Establish desired occlusion

12.Place all restorations13.Redefine balancing

and working side contacts

PREPARING ALL UPPER AND LOWER TEETH

1. Preliminary mouth preparation2. Prepare lower anterior teeth3. If the anterior relation is acceptable,

prepare the lower wax patterns against unprepared maxillary ant

4. If unacceptable relation, reestablish the anterior guidance

5. Place provisional restorations in the redefined anterior guidance

6. Complete the lower restorations by exactly duplicating the incisal edge position of provisional restorations

7. Place lower restorations against upper provisionals to verify the ant guidance

8. Prepare and restore upper anterior teeth (exactly duplicate the pattern of provisionals)

9. Place upper anterior restorations10.Refine the anterior guidance.11.Prepare lower posterior teeth by taking

guidance of Broadrick occlusal plane analyzer12.Reestablish the occlusal plane.13.Complete lower posterior restorations14.Complete upper posterior restorations

accordingly15.Refine centric, working and nonworking

contacts

Treatment techniques Simultaneous restoration of both

arches (Bailey, Grubb, Linkow)Advantages Disadvantages

Freedom in creating esthetic occlusal plane

Arduous, unpredictable, patient visits

Freedom in occlusal scheme

Full arch anaesthesia

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

Increased chair time, full arch temporaries required

Maximum freedom in creating and controlling porcelain esthetics

Multiple occlusal records, highly accurate cross arch impressions

Individual quadrants (Pankey, Mann, Dawson, Granger)

Advantages DisadvantagesReduced chair time Restriction for

achieving ideal occlusion when altering occlusal plane

Sequential provisional restorations

Less freedom in controlling porcelain aesthetics

Quadrant anaesthesiaVertical Dimension is controlledImpression procedures are easier

Segmented simultaneous arch technique (Binkly & Binkly)•Combines desired features of bothe the

techniques•Simplifies essential basic procedures for

reconstruction

DESIRED CHARACTERISTIC FULL MOUTH SIMULTANEOUS

SEGMENT / QUADRANT COMPLETED

SEGMENTED SIMULTANEOUS

Freedom to produce occlusal scheme

. .

Freedom in tooth spacing and intra arch crown position

. .

Freedom for porcelain work

. .

Teeth preparation quadrant wise

. .

Chair side temporaries . .Easier final impression . .Control of VDO . .Anesthesia by quadrant . .Control of appointment length

. .

ReferencesOkeson J P:Management of temperomandibular joint Sumiya Hobo : Twin – tables technique for occlusal rehabilitation : part 1 – Mechanism of anterior guidance j prosthet dent 1991, vol 66 pg 299-303. Sumiya Hobo : Twin – tables technique for occlusal rehabilitation : part 11 –Clinical procedures

j prosthet dent 1991, vol 66 pg 471-477Philosophies in full mouth rehabilitation – a systematic review Int J Dent Case Reports 2013; 3(3): 30-39

Occlusion for fixed prosthodontics:A historical perspective of thegnathological influence J Prosthet Dent 2008;99:299-313

full mouth rehabilitation

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