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APPRAISAL OF FULL COVERAGE AND MOUTH REHABILITATION

WILLIAM CHASE, D.D.S.


Washington, D.C.

be it the construction of fixed or removable dentures


.A or the restoration
NY DENTAL PROCEDURE,
of carious teeth with amalgam, may be referred to as a
process of mouth rehabilitation. These procedures have been part of everyday den-
tal practice from the beginning of dentistry as a profession. Yet, the phrase mouth
rehabilitation has become a widely used term only in recent years and does not
encompass all of these operations. Rather, rehabilitation is applied to a specific
type of restorative dentistry.
In this article, the term mouth rehabilitation is used, in its recently as-
signed sense, to connote the large scale restoration, splinting, and replacement of
the various units in the dental arch utilizing full coverage acrylic resin veneer
crowns for abutments and acrylic resin veneer pontics for replacement of the
missing teeth. This process involves the joining of many units into a single rigid
mass to an extent not usually carried out in conventional fixed prostheses.

ADVANTAGES OF REHABILITATION

Some of the suggested advantages of rehabilitation by full coverage restora-


tions are : ( 1) elimination of the display of gold or defective enamel, (2) more
effective retention of restorations, (3) reduction of the incidence of failure due
to the greater vulnerability of inlay margins to leakage, (4) immobilization of
the teeth into rigid units is an adjunct to periodontal therapy, and (5) simplicity
of execution.
Even casual observation of this type of work after it has been in use for rela-
tively short periods of time (less than 5 years) leads one to the conclusion that
these beliefs are fallacious. Such restorations are neither more durable nor do they
offer improved esthetics over more conservative procedures. Furthermore, there
is no convincing clinical or scientific evidence of an improvement in periodontal
health.

REASONS FOR MOUTH REHABILITATION

Mouth rehabilitation came into being shortly after the acrylic resins became
available for dental uses. Its popularity was accelerated by the invention of the
high-speed dental engine, the rubber-base type of impression materials, and the
development of new laboratory techniques. The high-speed drills make the prep-
aration of multiple abutment units in one session possible and practicable. The
new impression materials enahle the dentist to make impressions of many pre-
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J. Pras. Den.
88 CHASE
Jan:Feb., 1964

pared teeth and edentulous spaces at one time. Laboratory techniques permit the
completion of the entire restoration upon the master cast made from that impression.
This technique is simple to execute and is less time-consuming than other
procedures. However, other advantages are nonexistent. They are rationalizations
to justify the delegation of the major portion of work and responsibility to dental
laboratory technicians.

RATIONALE FOR FULL COVERAGE

Full coverage is an integral part of the mouth rehabilitation concept. Full


coverage makes good sense when used on second and third molars in caries-
susceptible mouths because it offers maximal retention, minimal danger of recur-
rence of decay, and because veneers are not necessary for esthetics.
The use of a full coverage acrylic resin veneer crown on the other teeth, and
especially on sound unblemished anterior teeth, has created a philosophy and
attitude toward tooth structure which is both destructive and dangerous. Enamel
and dentin are treated as though these tissues were indiscriminately expendable.
Acrylic resin veneers are not satisfactory alternatives for conventional fixed
restorations because : (1) the preparation of the abutment teeth usually is ex-
cessive, (2) the durability and esthetics of the restorations are limited by the
inherent weakness of the acrylic resins, and (3) the restorations tend to increase
periodontal disorders.

PREPARATIOh- OF ABUTMENT TEETH

The preparation of the abutment teeth for the reception of acrylic resin
veneer crowns is frequently excessive and inconsistent with the continued health
and vitality of the pulp. This is perhaps the principal reason for the temporary
cementation of these restorations as advocated by some dentists who recognize
that a threat to the vitality of the pulp is inherent in these preparations. The
natural crowns are reduced to mere pegs to permit the alignment of multi-unit
fixed partial dentures over teeth with divergent long axes, and in a futile attempt
to avoid bulk in the finished restoration. If the preparation is conservative and
respectful of the pulp, the resulting crown is likely to be bulky. If the acrylic
resin veneer is thinly applied to avoid bulk, poor esthetics and structural weak-
ness will result.

ACRYLIC RESIN IN FIXED RESTORATIOXS

The inadequate physical properties of the acrylic resins make these materials
undesirable for fixed restorations. No dental plastic is hard enough to withstand
masticatory forces; it is not resistant to the abrasive action of the toothbrush
and dentifrice, and does not possess lasting esthetic qualities. Within a few years
the dentist is faced with the need either to remake the restoration entirely or to
resort to repairs which are not satisfactory at best. Experience dictates caution
in the widespread use of plastics except as temporary or short-term expedients.
(;old is the foundation material upon which the acrylic resin is superim-
Volume 14
Number 1
MOUTH REHABILITATIOK 89

posed. When properly alloyed, gold has the needed structural strength if the
casting is not too light in design. However, the casting is frequently too light
when the conflicting demands of esthetics and strength are encountered. On the
other hand, when both demands are satisfied, the health of the surrounding tissues
is endangered by the extension of one or both of these materials to a point
which will make maintenance of hygiene impossible or irritation of the gingivae
inevitable.

ESTHETICS IN REHABILITATION

Good esthetics depends upon color, form, size, arrangement, etc. Dental enamel.
even when slightly marred by minor defects, presents a naturalness which no
artificial substitute can fully match, especially under artificial light. The obvious
artificiality of oversized crowns is further emphasized by the monotonous and
gleaming immaculateness of these restorations while they are still relatively new.
After some use, the effects of wear, as well as the often occurring discoloration
at the margins, give rise to defects which are inconsistent with good esthetics.
4 further detraction from a good appearance is the frequently encountered in-
flammation and congestion of the gingiva due to irritation by pressure induced by
the gold and acrylic resin fitted under the free gingival margins.

REHABILITATION AND PERIODONTAL DISEASE

Symptoms of periodontal disease result from restorations which are in-


correctly designed and executed, and which ignore basic essentials for the mainte-
nance of health of the supporting tissues. In addition to fulfilling the requirements
for proper contact, correct anatomy, and freedom from irritation by rough over-
hanging metal or other material at the gingival margins, it is equally important
that the restorations be in good balanced occlusion. The natural teeth, having
been ground down to receive crowns, no longer guide in establishing the occlusaf
relationship.
Frequently, mouth rehabilitation procedures preclude the possibility of proper
mouth hygiene because of the bulkiness of the restorations and because of the
crowding of pontics into narrow spaces which resulted from the shifting of teeth.
This crowding of pontics also causes impingement upon the free gingival margins.
In spite of the extensive preparations of the abutment teeth in mouth re-
habilitation, the insertion of the restorations causes considerable strain. Thus the
additional factor of torque and its deleterious effect on the periodontium is added
to the other insults.

REHABILITATIOK AND IMMOBILIZATION OF TEETH

The concept that immobilization of teeth helps in the control of periodontal


disease is not sound. Actually two methods of splinting are in use. Some dentists
employ a type of splinting which restricts tooth movement through wiring or by
the use of removable restorations. This article deals only with rigid fixation achieved
1,~ soldering many tooth units into a single structure.
J. Pros. Den.
90 CHASE
Jan.-F&., 1964

The theory of rigid splinting is that immobilization of loose teeth causes


them to become tighter. Although many dentists believe this to be true, there
is no scientific evidence to sustain this theory. However, there is much roentgeno-
graphic evidence to indicate that the theory is fallacious and that the tightening is
illusory. Roentgenograms indicate continuing bone degeneration even after splint-
ing has been in effect.
Kronfeld refers to the movement of teeth during mastication. Chayes3 be-
lieved that partial dentures must not only be removable but that they must
be movable as well, so that the supporting teeth may be free to respond to mas-
ticatory stresses. Teeth normally not only move during mastication but they
actually move in different directions. The molars do not move the same way as
do the lateral incisors. The cuspids move in opposite directions. This accounts for
the failures of many of the so-called bulkhead bridges when three-quarter crowns
are used as abutments. The stronger multi-rooted teeth exert stresses which are
abnormal for the weaker single-rooted teeth when they are rigidly connected.
When two adjacent teeth moderately and equally affected by periodontal
disease are used as a support for a restoration, joining them may be justified. How-
ever, splinting a tooth severely affected by disease to a more or less unaffected
tooth is contraindicated. This procedure tends only to shorten the life expectant)
of the stronger tooth without any material benefit to the severely affected tooth.

SCMMARY

Full coverage of natural teeth and mouth rehabilitation as described breeds


a number of abuses. Such procedures are often fraught with threats to the health
and vitality of the abutment teeth and of the supporting tissues. The prognosis for
an adequate period of usefulness of this type of restoration is far below that of
other forms of well-executed dental restorations.
Alternate types of restorations other than rehabilitation require more plan-
ning, the expenditure of more time for both the patient and the dentist, and a cur-
tailment of the functions of the dental laboratory technician. However, better
dentistry will result from the increased participation of the dentist and from a
greater appreciation of the value of preserving tooth structure.

REFERENCES

1. Kronfeld, R.: Histopathology of the Teeth, ed. 4, reviewed by P. E. Boyle, Philadelphia,


1955, Lea & Febiger.
2. Chayes, H. E. S.: System of Movable Removable Bridgework in Conformity With the
Principle That Teeth Move in Function, D. Review 31:87-123, 1917; D. Digest
23:192-193, 1917.
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