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Full mouth rehabilitation : a smooth pathway for complex journey

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 Review Article

Full mouth rehabilitation :

a smooth pathway for complex journey

Mandeep Kaur1, Harpeet Singh1, Jaidev Singh Dhillon1

1 Dept of Conservative Abstract

Dentistry and Endodntics,
Gian Sagar Dental College and
Hospital, Ramnagar (Patiala)
Panjab. India
Full mouth rehabilitation entails the performance of all the procedures necessary to
produce healthy, aesthetics, and well functioning, and self-maintaining masticatory
mechanism. This article is aimed to understand the physiology and mechanics of occlusion
while maintaining the full mouth rehabilitation.
Key words : Diagnostic wax up, full mouth rehabilitation, morphology, occlusion.

Address for Correspondence :
Dr. Mandeep Kaur
Senior lecturer
Dept of Conservative
Dentistry and Endodntics
Gian Sagar Dental College and
Hospital, Ramnagar (Patiala).
Panjab. India
Email:mandeepkaursandhu2@gmail.com
Introduction
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.The term "occlusal
rehabilitation has been defined as the
restoration of the functional integrity of
the dental arches by the use of inlays,
crowns, bridges and partial dentures".
Occlusal rehabilitation therefore involves
restoring the dentate or a partially dentate
mouth. The aim is to provide an orderly
pattern of occlusal contact and articulation
that will optimize oral function, occlusal
stability and esthetics.Occlusal
adjustment by grinding may be required,
as part of the rehabilitation but does not
constitute rehabilitation per se. Occlusal
rehabilitation is discussed in the context of
cases where restorations are supported by
natural teeth and doesn't include the
restoration of the fully edentulous arch or
maxillofacial defects, nor does it include
the use of osseointegrated implants [1-4].
This review article attempts to compile
and understand the philosophy of occulsal
rehabilitation.
Indications for occlusal
rehabilitation
The reasons for undertaking occlusal
rehabilitation may include the restoration
of multiple teeth, which are missing, worn,
broken-down or decayed. Increasingly
occlusal rehabilitation is also required to
replace improperly designed and executed
crown and bridge work. In certain
circumstances treatment of temporo-
mandibular disorders may also be
considered an indication for
rehabilitation, but great caution is
advisable in such cases. Regardless of the
clinical reason, the decision to carryout
any treatment should be based upon
achieving oral health, function, esthetics
and comfort, and treatment should be
planned around these rather than the
technical possibilities. If these goals are to
be achieved certain biological
considerations are necessary when
planning and carring out occlusal
rehabilitation [5-9]. Theyare:
1. The indications for reorganizing the
occlusion
2. The choice of an appropriate occlusal
scheme
3. The occlusal vertical dimension
4. The need (or otherwise) to replace
missing teeth
5. The effects of the material used on
occlusal stability control of
parafunction and TMD

14 ISSN 2248 - 9045 Central India Journal of Dental Sciences Vol. 7 Issue 3 Sep. - Dec. 2016
The goal of full mouth rehabilitation e.g. Certain critical teeth may have unacceptably short
clinical crown
The modern practice of renewing and reorganizing the
teeth by prostheses began with the idea of “raising the Important areas may have inadequate interocclusal
bite" to rectify closure resulting from excessive wear of clearance.
the occlusal surfaces. Later, such closure was associated Key teeth may have inadequate zone of attached tissue
with hearing loss, noted by Costen. To accomplish this,
these teeth were rebuilt to harmonize with the High-frenum or supra-erupted teeth may be present
movements of the joints in order to protect them from Treatment of TMDs is also necessary
further injury.With our present understanding of
traumatic occlusion and its deleterious effect upon the 3. Full mouth series of R/Gs
supporting structures, the procedure known as "bite This may also reveal non-physiologic processes that must
raising" has shifted in emphasis and broadened in scope be considered.
and is now designated by a term that describes it
accurately. Full mouth reconstruction, as of now includes e.g. Vertical bone loss, periapical pathologies, retained
therapy which will, by improving the relationship of the roots, impacted teeth and poor bone factors.
teeth, improve the condition and health of the supporting These may have an influence upon the sequence of
structures. It should be kept in mind that although the treatment and the final restorations placed.
operations of all mouth rehabilitation procedures are
performed on tooth units, they have one basic objective: 4. Diagnostic casts fixed to an articulator
the equalization of the forces directed against the Give 3-dimensional relationship of patient's opposing
supporting structures. Any disharmony at the occlusal or arch. Viewing of occluded arches from lingual aspect
incisal aspects of a tooth will direct forces against these cannot be visualized otherwise
malaligned surfaces and thus subject the supporting
structure to traumatic injuries. Similarly, any impairment Show occlusal clearance problems
of buccal or lingual harmony will be reflected in injury to Occlusal relationships
the gingival tissue and subsequently to the deeper tissues
involved in supporting the tooth. The proximal contact Causes of tooth were by opposing teeth
anatomy is also vital in maintaining the health of the 5. Diagnostic Waxup [21-24]
underlying soft tissue. Poor contact relationships
encourage food impaction with resultant periodonlal A diagnostic waxing procedure should be performed for
tissue loss [10-13]. all prosthodontic treatment plan.
This is done on diagnostic tooth preparation and
Diagnosis and treatment planning establishes the optimum contour and occlusion of the
eventual prosthesis.
Prior to initiating the restoration of a patient's dentition, The procedure is of particular importance if the patient's
a thorough diagnostic planning must be completed. occlusal scheme or anterior guidance requires alteration.
These include the following [14-20]
Type of treatment
1. Patient's medical and dental history
Distinction can be made between those therapeutic
Give the clinician important bits of information that must modalities that modify the occlusal scheme (occlusal
be considered when formulating the treatment plan. treatment) and those which do not modify it (collateral
E.g. Stroke hampers oral hygiene and therefore may treatment) [14,15].
preclude the use of specific restoration.
Occlusal Treatment Collateral Treatment
History of allergy to nickel or acrylic
Temporary occlual treatment, Biofeedback
History of unsuccessfully adopting to a specific type of occlusal splints Other relaxation techniques
removable restoration may a contraindication to that Definitive occlusal treatment: Exercises
type of restoration. Orthodontic treatment, Physiotherapy
2. Clinical dental examination selective grinding, Electrogalvonic stimulation
prosthodontic treatment Drug treatment
May reveal pathologies or other factors that will dictate Occlusal and articular
the type of restorations is indicated or not. Surgical therapy

15 ISSN 2248 - 9045 Central India Journal of Dental Sciences Vol. 7 Issue 3 Sep. - Dec. 2016
Treatment Planning
Treatment plan is developed on the basis of diagnostic
data [25-32].
Careful evaluation on the articulator of discrepancies
between ICP and therapeutic position allows exact
programming of most adequate occlusal splint and
planning of definitive occlusal treatment.
Definitive occlusal treatment may require selective
grinding only, or orthodontic or prosthodontic treatment
of various level of complexity.
In more complex cases, exact planning of definitive
treatment is possible only after the stage of temporary
occlusal treatment and evaluation of results.
Definitive occlusal treatment is initiated when subjective
and objective symptoms have disappeared permanently
or at-least improved significantly.
1st stage Temporary occlusal treatment and collateral
therapy: Duration of treatment, few weeks to 5-6 months
or more.
2nd sage Definitive occlusal treatment and collateral
therapy: Duration depends on the complexity of
therapeutic program. E.g. Ortho treatment + FPD.
Preparation of the mouth for
rehabilitation
Having completed the necessary diagnostic procedures,
having decided that complete oral rehabilitation is
indicated, and having made our treatment plan, we must
now prepare the mouth for the restoration.
Depending upon our findings, we will remove or have
removed any infective processes such as retained roots,
impactions, unimportant devitalized teeth, and the like.
Today, with proper endodontic treatment, the retention
of questionable strategic teeth is possible. However, since
these teeth are potential liabilities from the standpoint of
the complete treatment, often it is wise to include in our
restoration plan the possibility of their loss at a
subsequent time. In other words, we should be prepared
for such contingencies as fractures, undetected decay,
and recurrent infection. Whenever feasible, we should
provide insurance against fracture by the use of a metal
post and/or collar of metal. As with most general rules,
exceptions are sometimes in order; for example, the
retention of an impacted third molar. If its removal would
jeopardize a second molar needed for a bridge abutment
or the removal of a devitalized strategic root in a patient
suspected of having a focus of infection. Occasionally, a
perfectly good tooth may have to be sacrificed because of
its relation to the other teeth. It is not wise to compromise
the result of the entire effort just to save a single tooth".
16 ISSN 2248 - 9045
Selecting instruments for
occlusal rehabilitation
There are four basic types of instruments that can be used
with equal success to achieve fine results in restorative
procedures. The purpose of all good instrumentation is
simply to capture accurately theborder pathways of the
teeth; this may be done by reproducing the border
movements of the condyles and then combining the
reproduced condylar pathways with corrected anterior
guidance paths. Or it may be done by recording the
results of anterior and posterior determinant pathways
at the site of the teeth themselves.In using any
instrument, it must be remembered that anterior
guidance is a product of functional border movements
that fall within the outer limits of the envelope of motion.
Recording only condylar pathways does not furnish
enough information for the instrument to precisely
reproduce tooth movements that are in harmony with the
envelope of function. The anterior guidance is a separate
entity that must be recorded and programmed into any
articulator in addition to condylar pathways if the
instrument is to be used as a device for reproducing jaw
movements.
Anterior guidance is not determined by condylar
guidance, so there is no instrument that is capable of
determining how the front end of the mandible should
move. If anterior guidanceis correctly determined in the
mouth and its pathways are recorded at the "front end" of
the articulator, any one of several instruments can be
used withexcellent results.The simpler the articulating
device, the more compensation must be made for its
shortcomings. But if compensations can be made easily
and accurately, there is practical value in keeping the
instrumentation as simple as possible.
Semiadjustable instruments
Fully adjustable instruments
Pantographic instruments
Stercographic instruments
Mounting models
Without correct mounting procedures, even a perfectly
made centric bite record has limited value. Many dentists
who are genuinely striving for preciseness waste a great
amount of time meticulously carrying out procedures
that are not needed.
A facebow recording is one of the essential steps for
proper mounting of casts. After location of the condylar
axis in the skull, it provides a method of transferring that
axis to the articulator by relating it lo the upper cast. If a
Central India Journal of Dental Sciences Vol. 7 Issue 3 Sep. - Dec. 2016
centric bite record is made at an opened vertical
dimension, the accuracy of the bite record will only be
maintained if the closing axis is the same on the
articulator as it was on the patient.Any change of axis
changes the direction of the closing path. Built-in error
results when models are mounted on instruments that do
not reproduce the axis correctly. Instruments that arc
capable of reproducing the axis will only do so if the
models are mounted with a facebow. It is good practice to
record centric relation as close to the correct vertical
dimension as possible.The most accurate method for
recording the correct horizontal axis include the use of
some type of kinematic device for locating the terminal
hinge axis. A hinge axis can be recorded at any point along
the protrusive pathway. Unless good manipulative
technique is used to position the condyles in their
terminally braced position, the recorded hinge axis will
be incorrect. Furthermore, even the most precisely
recorded hinge axis cannot compensate for a missed
centric bite record [33-38].
Procedural steps in restoring occlusion
Restoring posterior teeth before the anterior guidance is
finalized is an example of a common error of sequence
[39-51].
Two of the best rules to follow for staying out of trouble
with restorative procedures are:
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 the
end result is perfectly visualized and understood.
1. Preliminary mouth preparation:
2. Mouthhygiene instructions should be given
3. Caries control should be achieved
4. Periodomal therapy should be completed.
5. Minor tooth movement should be complete.
Stabilization of the occlusion following any
orthodontic procedures should have occurred.
When teeth have been moved ample lime should be
given for reorganization of the periodontal fibers
and bony support before final impressions are made
for restorations.
6. Necessary extractions should be done and tissues
healed before permanent placement of fixed
prostheses.
Equilibration should be completed prior to preparation
of the teeth. The temporomandibular joints should be
17 ISSN 2248 - 9045
comfortable prior to finalizing any restorative treatment.
One thing that every dentist should know before he
attempts to restore anterior teeth is that besides being
nice to look at and to bite sandwiches with, the anterior
teeth have the very important job of protecting the back
teeth. So important is this job of the anterior guiding
inclines that posterior teeth that are not protected from
lateral or protrusive stresses by the anterior teeth will, in
time, almost certainly be stressed beyond the resistance
of their supporting structures.
Restoring lower anterior teeth
When planning the restorative correction of any occlusal
problem, the first segment to be completed should be the
lower interior teeth. Until the precise location and shapes
of the lower incisal edges are set, there is no practical way
to work out the lingual contours of the upper anterior
teeth.The first consideration in restoring lower anterior
teeth should be to determine the correct location of the
incisal edges. While this would ideally be decided on the
basis of providing the most stable centric contact with the
upper anterior teeth [52-53].
Restoring upper anterior teeth
No technician, including Ihe dentist who prepared the
teeth, can consistently shape anterior restorations
precisely enough unless he is furnished the necessary
information.In order to successfully restore upper
anterior teeth, the correctness of the following
information must be verified in the mouth and it must be
accurately transferred to the laboratory bench [54-56].
The plane of occlusion
The plane of occlusion refers to an imaginary surface that
theoretically touches the incisat edges of the incisors and
the tips of the occluding surfaces of the posterior teeth.
Instead of flat surface, the plane of occlusion actually
represents the average curvature of the occlusal surface.
There are two basic requirements of a proper plane of
occlusion:
1. It must permit the anterior guidance to do its job of
discluding the posterior teethwhen the mandible is
protruded.
2. It must permit the disclusion of all teeth on the
balancing side when the mandible is moved laterally.
It is possible for an occlusal plane to be flat and still fulfill
the basic requirements, but if optimum efficiency in
function is the goal, the occlusal plane will usually have
curvatures to it. Better esthetics is in most cases also
dependent on curvatures of the occlusal plane, the
Central India Journal of Dental Sciences Vol. 7 Issue 3 Sep. - Dec. 2016
perfectly flat plane of occlusion often being the epitome
of artificiality. A flat occlusal plane can even be harmful,
since it can actually create stressful crown-root ratios
when the curvature of the supporting alveolar bone is not
matched to a reasonable degree with the curvature of the
occlusal plane [57-59].
Posterior occlusal morphology
There is no one type of occlusal form that is optimum for
all patients. Techniques oriented concepts may work well
for the majority of patients, but the varied problems of
stress associated with sick mouths can be solved better
by flexibilityof form that enables us to vary the direction
and distribution of forces.
The first objective of occlusal form is proper direction of
forces. Teeth can withstand tremendous force if it is
directed up or down the long axis of each tooth when
force is directed parallel to the long axis, it is uniformly
resisted by all of the supporting periodontal ligaments
except those at the apex. If the force is directed rurally, the
tooth loses the support from about half of the ligaments
that are compressed and puts almost the entire load on
the half under tension. So the starting point in designing
occlusal contours is to shape and located the centric
contacts so that theforces are directed as nearly parallel
as possible to the long axes of both upper and lowerteeth
[60-61].
Restoring lower posterior teeth
The lower cup-fossae inclines are determined by the
anterior guidance and the condylar guidance. If the lower
lingual cusp is 10 have functional contact in working
excursions, its buccal incline must be the same as the
lateral anterior guidance, with some modifications to
maintain simultaneous conformity to condylar paths. If
the lower lingual cusp is to be discludcd in working
excursions, its buccal incline must be Halter than the
lateral anterior guidance.So from a practical standpoint,
lower cusp-fossae angles should be flatter than the lateral
anterior guidance.62-64
Posterior teeth in the lower arch can be accurately
restored with cusp tip-to-fossa contact if the following
determinations can be made:
1. Correct height and placement of buccal cusps
2. Correct height and placement of lingual cusps
3. Correct placement of fossae
4. Correct inclines for fossae walls
5. Fairly accurate ridge and groove direction
18 ISSN 2248 - 9045
Restoring upper posterior teeth
The upper posterior teeth should be the last segment to
be restored. It is the fixed posterior segment, and its
cusps, inclines, grooves, and ridges are placed and
contoured to accommodate the many border movements
of the lower posterior teeth.
While it is possible to fabricate upper and lower posterior
restorations together on a fully adjustable instrument,
upper posterior restorations should never be fabricated
against lower posterior teeth that require correction of
their occlusal plane cusp tip placement, or fossa
contours. If it is absolutely necessary to restore upper
posterior teeth first, the lower teeth should be corrected
as close to optimum as possible with selective grinding or
temporary restorations [65-67].
Summary and conclusion
Several decision must be made concerning the complex
area of occlusion, before starting occlusal rehabilitation.
So many contrary writing and recommendation have
been made that the subject of occlusion is still very
unclear to many clinicians. Various factors, general and
specific recommendation and procedural steps of
occlusal rehabilitation have been discussed. The clinician
must be aware of the requirements that a physiologic
restoration be made that is not only aesthetic and
functional but that also remains in harmony with the
entire gnathostomatic system. We must also remember
that not all patients can be successfully treated with a
single preconceived treatment philosophy. Satisfactorily
restoring a patient to a state of physiologic health is a
challenge that requires that the clinician not only be an
acute diagnostician but also a master of a wide range of
treatment modalities.
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Central India Journal of Dental Sciences Vol. 7 Issue 3 Sep. - Dec. 2016