THE JOTJRNAL OF
PROSTHETIC
FIXED PROSTHODONTICS
SECTION EDITORS
SAMUEL 1:. GUYER WILLIAM LEFKOWITZ
WILLIAM F. MALONE JOHN E. RHOADS
A practical approach to full mouth rehabilitation
T. K. Binkley, D.M.D.,* and C. J. Binkley, D.D.S.+*
University of Louisville, School of Dentistry, Louisville,
A pprehensions involved in reconstructions for debili-
tated dentitions are heightened by widely divergent
views concerning the appropriate procedures for success-
ful treatment.‘.’ Proposed techniques vary greatly and
range from procedures involving an almost mystical aura
of complexity to techniques overly simplified for solu-
tions of complex clinical problems.
Most philosophies and associated techniques for full
mouth rehabilitation share similar characteristics: (1)
they are based on an author’s specific philosophy of
occlusion and (2) they appear highly individualistic and
often precisely dictate one inflexible sequence for suc-
cessful treatment.
Although occlusal philosophies are diverse, most asso-
ciated clinical and laboratory procedures originate from
one of two basic treatment categories, (1) those advocat-
ing simultaneous restoration of both arches,6-‘0and (2)
those advocating complete restorations of individual
quadrants in a programmed sequence before proceeding
to the next.‘1-‘6
Table I presents the desired characteristics most
associated with the two methods of reconstruction. The
desirable characteristics occur as either chairside or
laboratory advantages. It is noticeable that a desirable
attribute for one technique can be a liability in the
comparative method.
A third column in Table I labeled “segmented simul-
taneous” is an alternate reconstruction technique. This
third technique as described illustrates how desired
characteristics of the full mouth simultaneous rehabilita-
tion and the programmed quadrant approach may be
combined into a single reconstructive technique. This
segmented, simultaneous technique simplifies the essen-
tial, basic procedures for reconstructions, while permit-
*Assistant Professor, Department of Prosthodontics.
**Assistant Professor, Department of Community Dentistry,
Director, General Practices Residency Program.
THE JOURNAL OF PROSTHETIC DENTISTRY
DENTISTRY
MARCH 1987 VOLUME 5’ NUMBER 3
l OPERATIVE DENTISTRY
ROBERT C. SPROULL
Ky.
ting the dentist to use a suitable occlusion for a particular
patient.
TECHNIQUE
Treatment planning
A diagnostic evaluation including radiographs, oral
tissue examination, periodontal assessment,and occlusal
analysis with mounted diagnostic casts is essential.‘7“9
Diagnostic wax-ups provide a preliminary view of the
final restorations for the dentist and patient and a guide
to fabrication of the provisional restorations?’
Tooth preparation and chairside temporary
fabrication
The teeth are prepared and temporary restorations
are fabricated chairside segment by segment during
several appointments (Figs. 1 and 2) to minimize patient
discomfort and efficiently use the appointment time. The
patient’s vertical dimension of occlusion is maintained by
using unprepared teeth or provisional restorations as
occlusal vertical stops. Minimal occlusal reduction is
indicated for patients scheduled for rehabilitation at an
altered vertical dimension of occlusion.
Occlusal records
After the teeth are prepared, irreversible hydrocolloid
impressions are made in each arch, and a face-bow
transfer is made. These casts are used for making
heat-processed acrylic resin treatment restorations. Cen-
tric relation records are obtained by removing the
chairside temporary restorations in opposing segments
and placing Duralay resin (Reliance Dental Mfg. Co.,
Chicago, Ill.) between the maxillary and mandibular
preparations (Fig. 2). When the Duralay resin has set in
one segment; it is used as an index to maintain the
vertical relation while additional quadrant relationships
and are recorded in an identical manner. This procedure is
repeated until sufficient records are available to ensure
261
 BINKLEY AND BINKLEY

Table I. Comparison of reconstruction techniques

Segment/
Full mouth quadrant Segmented
simultaneous completed simultaneous
Desired characteristics Yes No Yes No Yes No

1. Maximum freedom in creating desired X X X

occlusal plane
2. Maximum freedom in creating desired X X X
occlusal scheme and intercuspation
3. Maximum freedom in creating intra-arch X X X
tooth spacing and interarch crown position
4. Maximum freedom in creating and X X X
controlling porcelain esthetics
5. Teeth may be prepared one X X X
quadrant/segment at a time
6. Chairside temporary restorations may be X X X
constructed by quadrant or segment
7. Final impressions involve few teeth per X X X
impression
8. Maximum control of desired vertical X X X
dimension of occlusion
9. Anesthesia by quadrant if desired X X X
10. Maximum control of appointment length X X X

accurate relation for the desired mounting of the maxil-
lary and mandibular models. Casts of the prepared teeth,
mounted on an articulator with the face-bow transfer
and centric relation records, are also used to verify
adequate tooth reduction, tooth position, and path of
insertion.
Fabrication of heat-processed treatment
restorations
A complete wax-up of the reconstruction is performed
directly on the mounted casts. The occlusion, pontic
design, crown contours, and embrasures are developed in
the wax to an acceptable level and then heat-processed in
acrylic resin.
When processed acrylic resin treatment restorations
are constructed at an altered vertical dimension of
occlusion, they permit evaluation of the patient’s accom-
modation and time to verify esthetics, occlusion, tooth
morphology, and tissue responses.2’-23
Tooth preparation, including margin location, paral-
lelism, and clearance for porcelain may be refined after
the initial cementation of the treatment restorations.
Additions to the interim restorations are required when
major changes are made in tooth preparations. Occlusal
adjustment and periodontal therapy should also be
accomplished during this trial period (Fig. 3).
Articulation of facsimile casts
Intraoral irreversible hydrocolloid impressions are
made of the occlusally adjusted heat-processed treatment
restorations and a face-bow transfer is obtained. The
mandibular cast may be manually related if centric
relation and centric occlusion are coincident. These casts,
a facsimile of the final reconstruction, are mounted on
the articulator (Fig. 4) and are the opposing casts for
framework waxing during metal framework fabrication.
The incisal guide table is set from the anterior guidance
of the facsimile mountings while condylar settings
remain from the initial mounting.
Final impressions and working casts
Three full arch final impressions are made for each
arch, with tooth preparations recorded in one segment at
a time. The heat-processed treatment restorations
remain except where impressions of preparations are
being made. If attachments are used, at least one tooth
proximal to the attachment is included in the same
impression. Working casts for wax pattern fabrication
are made from these impressions and hand-mounted to
the previously mounted opposing facsimile model of the
heat-cured treatment restorations. If stabilization of the
working cast in the region of the prepared teeth is
required for mounting, a Duralay resin index may be
made intraorally between the prepared teeth and the
opposing heat-cured treatment restorations.
Metal framework fabrication
Laboratory fabrication of the metal framework con-
sists of a total of six working casts or three per arch, with
each cast containing one segment of dies. Waxing each
segment of dies against the opposing facsimile cast aids
in reproducing the characteristics, such as occlusion and

262 MARCH 1987 VOLUME 57 NUMBER 3

PRACTICAL APPROACH TO FULL MOUTH REHABILITATION

Fig. 1. Preparation and temporary fabrication of first segment.

Fig. 2. First step in recording centric relation. Posterior temporary restorations main-
taining vertical dimension of occlusion.
Fig. 3. Processed acrylic resin temporary restorations. Corrective periodontal proce-
dures in progress.
Fig. 4. Casts of processed temporary restorations mounted on articulator.

tooth position, of the time-tested heat-processed treat-
ment restorations. Occlusion for each quadrant is then
refined by attaching the appropriate maxillary and
mandibular cast with patterns to the articular (Fig. 5).
Interproximal contact between segments are estab-
lished between the wax pattern and the model of the
adjacent heat-processed treatment restoration. The wax
patterns are then cut back to appropriate contours to
facilitate porcelain application, invested, cast, and fin-
ished.
The metal frameworks are seated intraorally, margins
verified, and tooth position and occlusion checked. If
soldering is required, the frameworks are indexed with
Duralay resin.
Full arch cast fabrication
These casts are designed to transfer all frameworks to
a single articulator mounting.
Full arch intraoral elastomeric impressions are made
of the seated frameworks. The impression is removed
from the mouth and the frameworks are reinserted into
the impression to ensure accurate positioning. The
internal surfaces of the frameworks are lubricated and
dies are made by flowing Duralay resin into the
frameworks.24 The base of the cast is completed by filling
the remainder of the impression with dental stone.
Removable dies are unnecessary because these work-
ing casts are only for porcelain application and not for
margin adaptation.
When porcelain veneer crowns with metal occlusal
surfaces are used, the maxillary full arch working cast
with the frameworks can be hand-articulated against the
previously mounted mandibular cast of the heat-
processed treatment restorations. The mandibular full
arch working cast with frameworks can be hand-
articulated opposing the maxillary framework (Fig. 6).
Duralay resin interocclusal records are required with
full posterior occlusal porcelain. This centric relation is

THE JOURNAL OF PROSTHETIC DENTISTRY 263

 BINKLEY AND BINKLEY

Fig. 5. Working casts of opposing segments placed on articular to refine wax

patterns.
Fig. 6. All framework segments mounted on articulator.
Fig. 7. Simultaneous porcelain application to all framework segments.
Fig. 8. Try-in of completed maxillary restorations.
Fig. 9. Try-in of completed mandibular restorations.
Fig. 10. Completed rehabilitation after permanent cementation.

recorded by placing Duralayresin between opposing Porcelain application and final try-in
posterior framework sections intraorally, leaving the Porcelain is applied to the framework segments simul-
anterior opposing segment of treatment restorations to taneously (Fig. 7). A final try-in is common for charac-
maintain the vertical dimension of occlusion. terization and final occlusal adjustments. The porcelain

264 MARCH 1987 VOLUME 57 NUMBER 3

PRACTICAL APPROACH TO FULL MOUTH REHABILITATION
is glazed and the restorations are temporarily cemented
(Figs. 8 and 9). The patient is encouraged to function
with the final product temporarily cemented. Final
adjustments are then performed and the restorations are
permanently cemented (Fig. 10).
DISCUSSION
Full mouth reconstructions involving full arch prepa-
rations, impressions, provisional restorations, and
master casts are regarded as simultaneous reconstruc-
tions.
A variety of techniques may be used in simultaneous
reconstructions to obtain complete arch dies and
mounted casts. These techniques assist in concomitant
laboratory construction of the units. When all of the
prepared teeth are on a single articulator, there is
flexibility in developing the occlusal plane, occlusal
scheme, embrasures, crown contour, and esthetics.
The chairside disadvantages include (1) arduous,
unpredictable patient visits, (2) full arch anesthesia, (3)
full arch chairside treatment restorations, (4) multiple
occlusal records, and (5) possible loss of vertical dimen-
sion of occlusion. Miscellaneous disadvantages are (1)
the need for accurate cross-arch multiple tooth impres-
sions, and,/or (2) transfer techniques to fabricate full
arch working casts.
An alternative approach to the full mouth simulta-
neous reconstruction is to complete one quadrant before
beginning another. The advantages of this approach are
primarily chairside and include preparation and final
impressions of select teeth, maintainence of vertical
dimension, quadrant anesthesia, and shorter, predictable
appointments.
The disadvantages of the quadrant reconstruction
include restrictions for achieving ideal occlusion when
altering vertical dimension, occlusal plane, and embra-
sure development. The existing opposing dentition limits
the reconstruction of an isolated quadrant. Esthetic
consistency can be compromised because the porcelain
restorations are made in stages.
The advantages of the simultaneous and quadrant full
mouth reconstruction are combined in the present tech-
nique.
The heat-processed treatment restorations are the key
feature in providing both clinical and laboratory advan-
tages. They closely resemble the final restorations while
maintaining vertical and centric relation, minimizing the
need for multiple and complicated occlusal records.
Treatment restorations also provide a stable and esthetic
interim prosthesis during the fabrication of the final
restoration and allow appraisal of an altered vertical
dimension of occlusion.
The cost and laboratory time involved in fabricating
the processed acrylic resin temporary restorations are a
THE JOURNAL OF PROSTHETIC DENTISTRY
limitation but the complexity of the patient’s treatment
warrants the extra effort.
SUMMARY
The concepts of traditional full mouth reconstruction
have been reviewed. A practical full mouth rehabilita-
tion technique has been described combining the chair-
side advantages of the programmed quadrant reconstruc-
tion with the laboratory advantages associated with the
complete mouth simultaneous rehabilitation.
REFERENCES
1. Schweitzer JM. An evaluation of 50 years of reconstructive
dentistry. Part I: Jaw relations and occlusion. J PROSTHETDENT
1981;45:383-8.
2. Schweitzer JM. An evaluation of 50 years of reconstructive
dentistry. Part II: Effectiveness. J PR~STHETDENT 1981;45:492-
8.
3. Goldman I. The goal of full mouth rehabilitation. J PROSTHFX
DENT 1952;2:246-51.
4. Bronstein BR. Rationale and technique of biomechanical occlusal
rehabilitation. J PROSTHETDENT 1954;4:352-67.
5. Schweitzer JM. A conservative approach to oral rehabilitation. J
PROSTHETDENT 1961;11:119-23.
6. Bailey EE. A master model technique for the construction of
inlays, crowns and bridgework. Dent Dig 1936;42:119-23.
I. Grubb HD. Occlusal reconstruction. J Am Dent Assoc 1938;
25:372-83.
8. Linkow LI. An oral rehabilitation technique utilizing copper
band impressions. J PROSTHETDENT 1961;11:716-21.
9. Sendax VI. Master impression technique for fixed and precision
removable bridge restorations. Dent Dig 1962;68:554-6.
10. Kazis HK. Complete mouth rehabilitation through restoration of
lost vertical dimension. J Am Dent Assoc 1948;37:19-39.
11. Mann AW, Pankey LD. Oral rehabilitation. Part I: Use of the
PM-instrument in treatment planning and in restoring the lower
posterior teeth. J PROSTHETDENT 1960;10:135-50.
12. Pankey LD, Mann AW. Oral rehabilitation. Part II: Recon-
struction of the upper teeth using a functionally generated path
technique. J PROSTHETDENT 1960;10:151-62.
13. Jones SSM. The principles of obtaining occlusion in occlusal
rehabilitation. J PROSTHETDENT 1963;13:706-13.
14. Nuttall EB. The principles of obtaining occlusion in occlusal
rehabilitation. J PROSTHETDENT 1963;13:699-705.
15. Granger ER. The principles of obtaining occlusion in occlusal
rehabilitation, J PROSTHETDENT 1963;13:714-18.
16. Brown K. Reconstruction considerations for severe dental attri-
tion J PROSTHETDENT 1980;44:384-8.
17. Gill JR. Treatment planning for mouth rehabilitation. J PROS-
THET DENT 1952;2:230-45.
18. Mann AW. Examination, diagnosis, and treatment planning in
occlusal rehabilitation. J PROSTHETDENT 1967;17:73-8.
19. Kazis H, Kazis JK. Complete mouth rehabilitation through fixed
partial denture prosthodontics. J PROSTHETDENT 1960;10:296-
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20. Braly BV. A preliminary wax-up as a diagnostic aid in occlusal
rehabilitation. J PROSTHETDENT 1966;16:728-30.
21. Preston JD. A systemic approach to the control of esthetic form.
J PROSTHETDENT 1976;35:393-402.
22. Hausman M. Occlusal reconstruction using transitional crowns.
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265

23. Nyman S, Lindhe J. Considerations on the design of occlusion in
prosthetic rehabilitation of patients with advanced periodontal
disease. J Clin Periodontal 1977;4:1-15.
24. Eggleston DW. Advantages and use of the remount for fixed
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Minimizing problems in fitting, seating, and
cementation of fixed prosthodontic retainers
A. Milton Bell, D.D.S.+
New York University, College of Dentistry, New York, N.Y.
M any technically acceptable crowns and fixed par-
tial dentures (FPD) have been jeopardized by incom-
plete seating. After conscientiously treating a patient,
dentists are often apprehensive after cementing cast
restorations. The traditional concerns are: “Was the
shade appropriate for the patient? Was the retainer fully
seated? Was there enough tissue displacement for the
pontic? Was the occlusion suitable?” It is essential that
these fundamental questions be answered before the
final cementation.
If the cast restoration has been judged biologically
acceptable, it should be retrievable after functioning for a
trial period to ensure patient acceptance. If the prosthe-
sis cannot be recovered for correction before cementation,
the dentist is compelled to institute remedies that com-
promise the treatment with deterioration of patient and
dentist relationships.
INTERIM PLACEMENT OF FINAL CAST
RESTORATIONS
Many problems have been associated with temporary
cements that set hard or have a rubbery consistency. The
hard-setting cements made it difficult to retrieve multi-
unit ceramic veneered crowns because of fracture during
removal. The rubbery temporary materials were unac-
ceptable because they set quickly and prevented complete
seating. Nonsetting compounds were introduced that
acted as a lubricant between the restoration and the
prepared tooth. This permitted settling of the prosthesis
without locking the retainer and the tooth in a rigid
*Clinical Associate Professor, Department of Fixed Prosthodontics
and Occlusal Studies.
266
BINKLEY AND BINKLEY
Reprint requests to:
DR. THOMAS K. BINKLEY
UNIVERSITY OF LOUISVILLE
SCHOOL OF DENTISTRY
LOUISVILLE, KY 40292
relationship. Various compounds were investigated with
similar intentions but dentists still relied on petroleum
jelly and nonsetting materials. Fry et al.’ suggested
topical corticosteriods for the relief of pain sensitivity.
Mosteller2s3 advocated prednisolone for the reduction of
postoperative thermal sensitivity and demonstrated a
year later that pulpal inflammation was eliminated after
the application of prednisolone solution. Swerdlow et a1.4
verified these results with experiments on minimizing
pulpal reactions with prednisolone therapy. Berk and
Krakow5 stated, “If pain is the result of inflammation
caused by injudicious operative procedures, chemical
irritants, a loose restoration, or trauma, and if there is no
evidence of an infectious process, the use of corticoster-
iods to reduce the inflammatory process is indicated.”
These independent investigators reported similar
results-“ corticosteroids properly employed reduced
pulpal inflammation.”
DEVELOPMENT OF A TECHNIQUE
The development of a sedative, nonsetting lubricant
that desensitized the prepared tooth resulted in the
uneventful seating of long-span FPDs. The try-in of
cast crowns on sensitive teeth can be discomforting for
the patients and troublesome for the dentist. Pulpal
hyperemia is routine in the prepared tooth as a result of
instrumentation and is expressed in hypersensitivity to
touch, thermal changes, and sweet or sour foods.*
Application of a lubricant (Figs. 1 and 2) is beneficial for
seating retainers to overcome tension and frictional
resistance during placement. The provisional placement
*Piliero S: Personal communication.
MARCH 1987 VOLUME 57 NUMBER 3