Nain Mandeep et.al.

UJMDS 2020, 08 (02): Page 12-15

ISSN 2347-5579

Unique Journal of Medical and Dental Sciences

Available online: www.ujconline.net
Case Report

RESTORATION OF OCCLUSAL PLANE AND ESTHETICS IN

SEVERELY WORN DENTITION
Arora Aman1, Upadhayaya Viram2, Nain Mandeep3*, Phor Deepak4
1
Professor and HOD , Department of Prosthodontics crowns and bridges, J.N. Kapoor D.A.V © Dental College, Yamunanagar, Haryana, India
2
Reader, Department of Prosthodontics crowns and bridges, J.N. Kapoor D.A.V © Dental College, Yamunanagar, Haryana, India
3
PG Student, Department of Prosthodontics crowns and bridges, J.N. Kapoor D.A.V © Dental College, Yamunanagar, Haryana, India
4
Private Practicioner, Yamunanagar, Haryana, India
Received 30-03-2020; Revised 28-04-2020; Accepted 26-05-2020
DOI: 10.46791/UJMDS.2020.080203
*Corresponding Author: Dr. Mandeep Nain
PG Student, Room number-5, Department of Prosthodontics crowns and bridges, J.N. Kapoor D.A.V © Dental College, Yamunanagar, Haryana, India
Email: mandeepnain126@gmail.com, Mobile: 8708449878

ABSTRACT
Most of the cases with severe attrition of teeth need full mouth occlusal rehabilitation. There are many philosophies to follow for an
occlusal rehabilitation. This article describes a case of full mouth occlusal rehabilitation of a 57 years old female patient who reported
with unsatisfactory esthetics and oral examination revealed severe attrition on upper and lower anterior teeth. The treatment followed
full mouth preparations and reconstruction and the occlusal plane analysis done using Broadrick flag.
Keywords: Full mouth rehabilitation, Broadrick plane analyzer, Vertical dimensions, Worn dentition.

INTRODUCTION Category-1: Excessive wear with loss of vertical dimension

The gradual wear of the occlusal surfaces of teeth is a normal
process during the lifetime of a patient. However, excessive
occlusal wear can result in pulpal pathology, occlusal
disharmony, impaired function, and esthetic disfigurement1.
Achieving harmony in full mouth rehabilitation patient is a
challenging procedure. Meticulous treatment planning with a
multidisciplinary approach is needed to achieve the successful
outcomes2.
The objective of full mouth rehabilitation is not only the
reconstruction and restoration of the worn out dentition, but
also maintenance of the health of the entire stomatognathic
system. Full mouth rehabilitation should re-establish a state of
functional as well as biological efficiency where teeth and
their periodontal structures, the muscles of mastication, and
the temporomandibular joint (TMJ) mechanisms all function
together in synchronous harmony.
Proper evaluation followed by definitive diagnosis is
mandatory as the aetiology of severe occlusal tooth wear is
multifactorial and variable. Careful assessment of the patient’s
diet, eating habits and/or gastric disorders, along with the
present state of occlusion is essential for appropriate treatment
planning3.
The most widely used classification for full mouth
rehabilitation is the one given by Turner and Missirlian.
They classify the patients into three categories:
Unique Journal of Medical and Dental Sciences 08 (02), April-June 2020
of occlusion (VDO) but space available to restore the vertical
height.
Category-2: Excessive wear without loss of VDO but with
space available.
Category-3: Excessive wear without loss of VDO but with
limited space.
There is a great apprehension involved in reconstructing worn-
out dentition due to widely divergent opinions regarding the
choice of an appropriate occlusal concepts[4]. All of these
concepts have some advantages as well as disadvantages. The
two most popular concept are Pankey Mann Schuyler
philosophy and the Hobo twin stage technique[2].
This clinical case report describes a case of full mouth
rehabilitation of a severely worn out dentition manage by the
simultaneous preparations and constructions procedure to
produce appropriate esthetics and occlusal schemes for the
patient.
CASE REPORT
A 57 years old female reported to the Department of
Prosthodontics, with a chief complaint of worn out and
missing teeth in both the jaws. Patient was unable to eat and
also not satisfied with the esthetics. No relevant medical
history was found, patient was apparently healthy. Dental
history revealed that patients lost all her posterior teeth due to
caries and periodontal problems.
12
 Nain Mandeep et.al. UJMDS 2020, 08 (02): Page 12-15

Clinical Findings • Tooth preparation of teeth of both the arches were done
Extraoral Examination simultaneously and retraction was done using retraction
The patient had bilaterally symmetrical face with no gross cords (Fig.5). A final full arch impression for maxillary
facial asymmetry . Muscle of mastications and TMJ did not and mandibular teeth was made using polyvinly siloxane
reveal any sign of pathology on examination. Mandibular impression material with double mix two stage putty wash
movements were within the range of normal motion. impression technique (Fig.6) and casts were poured in die
Intraoral Examination stone.
Clinical examination revealed severe attrition and abrasion • Temporization was done using putty index of the wax-up
involving all the teeth that were present. Loss of posterior (Fig.7). the provisional restorations were cemented using
stops at early stage might be the cause of such severe attrition noneugenol zinc oxide cement and the necessary occlusal
of the ateriors. Teeth present were 11,12,13,21,22,23,31, adjustments were carried out to achieve the desired
32,33,34,35,41,42,43,44. occlusion.
Soft tissue examination showed no inflammation or pathology. • Final maxillary cast was mounted on HANAU articulator
Occlusal examination of the existing condition revealed with facebow transfer and mandibular cast using centric
moderate generalized attrition with loss of intercuspation occlusal records at previously determined restored vertical
(Fig.1). OPG of the patient further confirmed these findings. dimensions .
• Metal trial was done with vertex attachment on the 35 and
44 for the lower distal extension RPD (Fig.8).
• Upper and lower bisque trial wrt
11,12,13,14,15,16,21,22,23,31,32,33,34,,35,41,42,43,44
along with wax try in of 17,24,25,26,27.36,37,45,46,47
was done.
Anterior teeth were fabricated in such a way that (1)
simultaneously bilateral contacts of opposing posterior teeth in
the centric occlusion (2) canine guidance by natural teeth for
right working side contacts (3) unilateral balanced occlusion
by the denture teeth on the left working side contacts (4)
Figure 1: Loss of intercuspation
posteriors are protected by anterior natural teeth in protrusive
Objective of Rehabilitation
movements.
• To rehabilitate the entire mutilated dentition in harmony
Final glazed prosthesis was cemented using luting cement and
with somatognathic system.
upper and lower removable prosthesis were fabricated and
• To establish harmony between esthetic and function. inserted at the same day (Fig.9 a and b).
• Canine guided disocclusion on lateral excursions and
mutually protected occlusion on anteroposteriorly.
Treatment procedure
• Diagnostic maxillary and mandibular impression were
made using irreversible hydrocolloid impression material
and casts were retrieved.
• For Diagnostic mounting, maxillary cast was articulated
on HANAU H2 articulator using an earpiece facebow
(Fig.2) and the mandibular cast was mounted was
articulated in centric relation using anterior jig and
posteriorly with temporary record base with rims (Fig.3)
and with this mounting lateral condylar angle was
calculated.
Figure 2: Facebow transfer
• The free way space was 7mm, so a mandibular arch splint
of 4mm was already given to the patient 1 month ago.
Patient was comfortable at this VDO and did not show
any discomfort.
• Root canal treatment was carried out for all the teeth as
they were prone to pulp exposure. Composite build up
was also done in some teeth.
• Impression of upper and lower arch were made again and
casts were mounted at raised VDO using anterior jig and
interocclusal material.
• Occlusal plane analysis was done using broadrick plane
analyzer (Fig.4) and wax-up were performed according to
the plane analysis. Figure 3: Diagnostic mounting done.

Unique Journal of Medical and Dental Sciences 08 (02), April-June 2020 13

 Nain Mandeep et.al. UJMDS 2020, 08 (02): Page 12-15
Figure 4: Occlusal plane analysis using braodrick plane analyzer
Figure 5: Tooth preparations
Figure 6: Final upper and lower impression
Figure 7: Temporization.
Unique Journal of Medical and Dental Sciences 08 (02), April-June 2020
Figure 8: Metal try-in.
Figure 9 a,b: Upper and Lower final prosthesis.
DISCUSSION
Mouth rehabilitation seeks to convert all unfavourable forces
on the teeth which inevitably induce pathologic conditions,
into favourable forces which permit normal function and
therefore induce healthy conditions[5].
Once a complete understanding of the etiology of the
dentition’s present state is appreciated, a treatment plan can be
formulated, taking into account the number of teeth to be
treated, condylar position, space availability, the vertical
dimension of occlusion (VDO), and the choice of restorative
material6.
No rehabilitation of occlusion should be accomplished,
without correction of the occlusal plane. Here Broadrick
occlusal plane analyzer were used for getting the occlusal
plane. The analyzer served three purposes, namely the
determination of the acceptable occlusal plane, determination
of amount of tooth reduction and/or need for intentional
endodontic treatment and finally the determination of the
height of each cusp tip in final restorations7.
14
 Nain Mandeep et.al. UJMDS 2020, 08 (02): Page 12-15
In this case report, canine guided occlusion on the right side,
unilateral balanced occlusion on the left side and mutually
protected occlusion during protrusion was given because it
was difficult to find a proper occlusal scheme as the
restoration was done with distal extension cast partial denture
for lower arch and flexible denture wrt upper left region of the
jaw. Kim et al (2010)8 did a similar full mouth rehabilitation
case and used fixed and removable cast partial prosthesis. He
planned canine guided occlusion on one side and balanced on
the other. Similar case was done by Agrawat et al (2018)9 who
planned to gave bilateral balanced occlusion and anterior
guided disocclusion on protrusive movements.
Full mouth reconstructions involving full arch preparations,
impressions, provisional restorations and master casts are
regarded as simultaneous reconstructions. A variety of
techniques may be used in simultaneous constructions 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 theme, embrasures, crown contour and esthetics10.
The chairside disadvantages include full arch chairside
treatment restorations, multiple occlusal records and possible
loss of the VDO. Miscellaneous disadvantages are (1) the need
for accurate cross‑arch multiple tooth impressions and/or (2)
the need for transfer techniques to fabricate full arch working
casts8.
CONCLUSION
The rehabilitation of the mutilated dentition is a demanding
procedure and should be carried out only when absolutely
indicated. The treatment should aim at restoring the occlusion
for proper mastication and improve the appearance of the
patient. In this clinical report, raising VDO using a removable
occlusal splint followed by fixed and removable prosthesis
based on accurate diagnosis ensured successful full mouth
rehabilitation for a severely worn dentition.
Source of support: Nil, Conflict of interest: None Declared
Unique Journal of Medical and Dental Sciences 08 (02), April-June 2020
REFERENCES
1. Singh A, Bhede R, Chandak M, Saxena A. Full
mouth rehabilitation a multidisciplinary approach:
Case Report. IOSR-JDMS 2013; 9:2, 65-69.
2. Choukse V, Parmar A, Sharma N, Srivastava R. Full
mouth rehabilitation using HOBO twin stage
technique. Int J Prev Clin Dent Res 2017; 4(4):319-
323.
3. Tiwari B, Ladha K, Lalit A, Naik BD. Occlusal
Concepts in Full Mouth Rehabilitation: An
Overview. J Indian Prosthodont Soc (Oct-Dec 2014)
14(4):344–351.
4. Parmar A, Choukse V, Palekar U, Srivastava R. An
Appraisal on Occlusal Philosophies in Full-mouth
Rehabilitation: A Literature Review. Int J
Prosthodont Restor Dent 2016; 6(4): 89-92.
5. Devassy JP, Sivadas A, Muhammed S. Full mouth
occlusal rehabilitation; by Pankey Mann Schuyler
philosophy. Annals of Prosthodontics & Restorative
Dentistry, January-March 2017: 3(1): 29-33.
6. Lerner J. A systematic approach to Full-mouth
reconstruction of the Severely worn dentition. Pract
Proced Aesthet Dent 2008; 20(2): 81-87.
7. Darraj A, Mattoo KA. Full Mouth Rehabilitation
Involving Occlusal Plane Correction-Case Report.
JMSCR 2017; 05(09), 28204-28208.
8. Lee SE, Lee WS, Lee CW, Lee SY. Full mouth
rehabilitation of severly worn dentition with implants
and removable partial dentures. (J Korean
Acad.Prosthodont 2018; 56: 70-6).
9. Agrawat P, Ali R, Mistry G, Shetty O. A systematic
approach to full mouth rehabilitation using
combination of fixed-removable prosthesis with
attachments. Int. J. Life Sci. Scienti. Res; 2015; 4(3);
1822-1826.
10. Jain AR, Nallaswamy D, Ariga P, Philip JM. Full
mouth rehabilitation of a patient with reduced vertical
dimension using multiple metal ceramic restorations.
Contemp Clin Dent 2013; 4: 531-5.
15