Full Mouth Rehabilitation: Presented by DR - Namitha AP 3rd MDS

FULL MOUTH
REHABILITATION
Presented by
Dr.Namitha AP
3rd MDS
1
CONTENTS
• OCCLUSAL EQUILIBERATION/PRINCIPLES OF
• INTRODUCTION OCCLUSAL CORRECETION
• DEFFINITIONS • ROLE OF OCCLUSAL SPLINT IN FMR
• EVOLUTION OF OCCLUSION • EXAMINATION, DIAGNOSIS AND TREATMENT
PLANNING IN FMR
• GOALS OF FMR
• PREPARING THE MOUTH FOR FMR
• INDICATIONS OF FMR
• TREATMENT PROCEDURES AND TECHNIQUES IN
• REASONS FOR FMR FMR
• LIMITATIONS OF FMR • FINAL RESTORATIONS FOR FMR
• MASTICATORY SYSTEM DISORDER • COMMON PROBLEMS AND DIFFICULTIES IN FMR

• POST OP CARE
• INSTRUMENTS USED FOR OCLLUSAL
ANALYSIS AND TREATMENT • TECH FUTURE IN FMR
• DIAGNOSTIC WAX UP • CONCLUSION
• REFERENCES
2
Introduction
• The term ‘full mouth rehabilitation’ is used to indicate extensive and

intensive restorative procedures in which the occlusal plane is modified in
many aspects in order to accomplish “equilibration”.
Both function and health can be
restored in badly detiorated, diseased Ultimate goal -
Multidisciplinary Optimum oral
mouths by utilizing modern
Approach health
techniques of oral rehabilitation
3
The word rehabilitate implies ‘ To restore to good condition or to restore to former privilege’.
Definition (GPT9)
• 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
All the procedures necessary to produce healthy, esthetic, well

functioning, and self-maintaining masticatory mechanism.
4
Reynolds JM. Modern gnathological concepts—Updated: By Victor O. Lucia, DDS, FACD Chicago, 1983, Quintessence
Publishing Co., Inc. 439 pages, illustrated, indexed.
Objectives of FMR
• A static centric occlusion in harmony with centric
relation.
• Even distribution of stresses in centric occlusion and on
eccentric functional inclines.
• Equalization of forces directed against supporting
structures
• Restoration of normal healthy function of the
masticating apparatus
5
Irving Goldman: The goal of full mouth rehabilitation, J PROSTHET DENT 1951, vol 2, 246-251
Reasons for full mouth rehabilitation
• Obtain and maintain the health of periodontal tissues.
• Temperomandibular joint disturbance
• Need for extensive dentistry as in case of missing teeth, worn
down teeth and old fillings that need replacement.
• Esthetics as in case of multiple anterior worn down teeth and
missing teeth.
INDICATIONS CONTRAINDICATIONS
• Restore impaired occlusal

• Malfunctioning mouths that do not need
function extensive dentistry and have no joint
symptoms should be best left alone.
• Preserve longevity of remaining
teeth • Prescribing a full mouth rehabilitation
• Maintain healthy periodontium should not be taken as a preventive
measure unless there is a definite evidence
• Improve objectionable esthetics of tissue breakdown.
• pain and discomfort of teeth • No pathology- No treatment.
and surrounding structures
7
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
Turner KA, Missirlian DM. Restoration of the extremely worn dentition. Journal of Prosthetic Dentistry. 1984 Oct 1;52(4):467-74.
Restoring vertical dimension at occlusion
Category 1
• loss of occlusal vertical dimension • A removable occlusal overlay splint or
due to unstable posterior occlusion or a treatment partial denture that
congenital disease and exhibit restores the occlusal vertical dimension
excessive wear of anterior teeth. is given for 6-8 weeks and the patient
is evaluated for comfort and function.
• method to confirm loss of vertical
dimension is with trial restorations • teeth are prepared and provisional
fixed restoration are given 2-3 months.
• Then the final restorations can be
given
J PROSTHET DENT 1984, vol 52, 467-474

Category 2
• A long history of gradual tooth wear caused by bruxism or moderate oral habits
• Anterior slide is present from centric relation to centric occlusion.
• Equilibration or stability of posterior teeth for stability in centric relation, in
combination with enameloplasty of opposing teeth can provide sufficient space
for restorative materials.
• gingivoplasty and gingivectomy , 2-3mm of supporting bone can usually be
removed without jeopardizing periodontal support, dynamic recordings of
mandibular movement ,are recommended for this type of rehabilitation.
10
•
Category 3
• exhibit minimum posterior wear but excessive gradual wear of anterior teeth
over many years.
• Centric relation and centric occlusion are coincidental.
• Restoring this patient is most difficult because vertical space must be obtained
for restorative materials
• Increasing the occlusal vertical dimension to achieve space for restorative
materials where there has apparently been no loss of occlusal vertical
dimension is seldom advisable; but if deemed necessary , the increase should be
minimal and for restorative needs only.
• Trial restorations are crucial and must be evaluated for longer period of time
to ensure patient accommodation to the altered occlusal vertical dimension
11
Classification by Brecker
• 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.
12
Brecker SC. Clinical procedures in occlusal rehabilitation. WB Saunders; 1966.

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 or 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.
13
Clinical procedures in occlusal rehabilitation .W.B Saunders,Philidelphia 1958

Etiology of extremely worn dentition
Congenital abnormalities Amelogenesis imperfecta
Dentinogenesis imperfecta
Parafunctional occlusal habit Chronic bruxism and other habits
Abrasion
Erosion
Loss of posterior support
14
Bernard smith :Tooth wear : Etiology and diagnosis Gerodontology Text Book 1994, 88-102 46/400
Attrition Abrasion Erosion Splayed teeth Advanced occlusal Anterior
disease guidance
attrition
Sensitive teeth Sore teeth Hypermobility Spilt teeth and Painful

fractured cusps musculature
15
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 21-26
EXAMINATION DIAGNOSIS AND TREATMENT PLANNING IN FMR
Diagnosis
Ist appointment IInd appointment
• Listen to patient’s opinion and • Individual tooth is meticulously
expectations
examined
• Make diagnostic casts • Extracted or restored
• Radiographs • Serve as abutments for RPDs or
• Bite records and facebow transfer fixed prosthesis
Tentative treatment plan done

16
Diagnostic aids
• Medical history
• Dental history
• Behaviour evaluation
• Radiographs – Complete mouth periapical radiographs and orthopentamograph
• Photographs – to remind previous state of mouth prior to restorative therapy
• Clinical examination
• Diagnostic wax-up
• Computer imaging
• CBCT
17
Bowley JF, Stockstill JW, Attanasio R. A preliminary diagnostic and treatment protocol. Dental Clinics of North America. 1992 Jul;36(3):551-68.
DIAGNOSTIC WAX UP
• The process of converting the programmed
treatment plan into a three dimensional
visualisation
• Before diagnostic wax-up, the occlusal
discrepancies in centric and eccentric occlusion
should be eliminated
• Thus planning of subgingival margins or surgical
crown lengthening required can be done
can be used to prepare an elastomeric
• Then wax is used to appropriately shape all putty mould and used for temporization
or sectioned through long axis of tooth to
crowns and final prosthesis is planned act as reduction guide intra-orally.
18
Steps in the diagnostic wax up
• Step 1: Mount upper and lower casts with
centric relation bite record and facebow.
Duplicate the casts to preserve the original
conditions.
• Step 2: Verify the accuracy of the mounting.

• Step 3: Examine the occlusal relationship on
the casts.
19
• Step 4: Lock the centric latch when
observing the casts.
• Step 5: Determine the correct vertical

dimension.
• Step 6: Return the condyles to centric

relation and lock the centric lock.
Occlusal interferences should be eliminated by selective grinding on the casts until the incisal pin contacts the
guide plate. At that point, the original vertical dimension will have been re-established in centric relation. If a
change in VDO is needed to fulfil requirements for stability, it can be determined now.
20
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 368
• Step 7: Observe the teeth that were reshaped.
• Step 8: Remove unsavable teeth from the
casts. From the clinical exam, all teeth that
cannot be saved are marked with an X.
• Step 9: Mark decisions that have been made

to use certain types of restorations.
• For example, in the figure the two upper

molars have been predetermined to need
crowns (C). 21
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 368,369
• Step 10 : Equilibration is the first treatment
option to explore.
The jaw-to-jaw relationship at the first point of tooth

contact in centric relation.
Equilibration of the casts clearly shows that reshaping

the teeth is a good choice of treatment because contact
with the canines is achievable by selective grinding away of
the deflective interferences.
22
• Step 11: Examine the plane of occlusion.
• If the casts were mounted with a facebow
that was parallel with the eyes, the incisal
plane and the occlusal plane will relate to
the bench top.
• If the occlusal plane is slanted in the mouth

(yellow line), it will be slanted on the
articulator (red line)
23
• The occlusal plane established by the
simplified occlusal plane analyzer.
• Model is trimmed back to the

established new occlusal plane.
24
Note how the buccal surfaces have been The completed wax-up. These corrected casts are now used
contoured to move the cusp to form a putty matrix for fabrication of provisional
tip more in line with the upper teeth. The restorations. They are also the perfect visual aid when
wax-up has been started. presenting the treatment plan to the patient. 25
Unmounted casts do not provide the
information needed to fulfill
this objective
• Step 12: Establish stable holding contacts on

the anterior teeth.
• Step 13: Correct lower incisal edges if needed.

This refers to both position and contour.
26
simplifies the whole wax-up.
The range of change in
position of lower anterior
teeth is minimal compared
with the upper anterior
teeth.
Anteroposterior position
of lower anterior teeth has
very little flexibility, and
their position in the
narrow alveolar ridge is
• Step 14: Start with the lower anterior teeth. quite limited.
• Step 15: Re-evaluate the total occlusion with The height of lower
incisors is also within a
the upper cast to see it can be adapted to limited range that is
consistent with the height
and contour of the
occlude with the lower arch. occlusal plane
27
Step 16: Establish holding contacts on the upper anterior teeth
Casts of a This
patient with diagnostic
a tight wax-up
neutral zone positioned
that the incisal
positioned edges
the upper forward
anterior and
teeth with a also made
lingual the teeth
inclination. longer.
28
A digital photograph of this patient shows
This photograph shows how the provisional
the incisal edges in line with the inner
restorations made from the wax-up had to be
vermillion border of the lower lip. It also
recontoured back to achieve a comfortable lip
shows a lingual inclination of the upper
closure path and phonetics.
anterior teeth.
29
Fill-in of area with pink wax
will be used to communicate
desired result to the surgeon. A
bone augmentation was
needed to achieve the planned
contour. All guesswork was
eliminated.
Cast of poorly contoured

anterior restorations. Note Recontouring of the anterior teeth on the
the contour cast will be used to
of the pontics where they form provisional restorations, as well as
meet the ridge. explain the treatment
goal to the patient and the surgeon.
Cast showing defect of lost labial plate of

bone that makes it impossible to establish
gingival contours on pontics that are
30
esthetically pleasing.
Treatment plan 1) Pre-
prosthetic
phase
• Comprehensive treatment plan
must be established prior to start
of the treatment . 2) Prosthetic
phase
• Communication and patient
education are essential in order to
match the dentist’s and patient’s
3) Maintenance
definition of success phase
31
Minor
orthodontic Preprosthetic phase
Scaling and root surface curettage bring back the gingival health.
Surgical crown lengthening - to improve esthetics and provide adequate
caries,
decalcification,
tooth
• To develop
movement- proficiencyretention when clinical
in diagnosing crown
the needis short.
of occlusal rehabilitation,
Free autogeneous gingival graft - increase width of inadequate attached gingiva
erosion,
tooth can be attrition,
periodontist , orthodontist , endodontist , oral surgeon and prosthodontist must abrasion,
uprighted,
rotated, all be integrated in establishing an environment conducive to oral health. exposed root
moved surface or
laterally, fractures -
intruded or Orthodontic Periodontal Endodontic restore where
extruded to considerations considerations considerations required.
improve axial Elective
alignment, endodontic
create treatment may
favorable Oral surgical be necessary for
pontic space considerations supraerupted or
and direct malaligned teeth
occlusal forces post and core
along the long Infected root pieces, hopelessly mobile teeth and impacted or unerupted supernumerary
axis of teeth. teeth are removed. 32
Block resection and movement of both maxillary and mandibular segments

Elective soft tissue surgery ,alteration of muscle attachments and alveoplasty
Prosthetic phase
Prosthetic full mouth rehabilitation is divided into-

• Immediate treatment
• Definitive treatment
33
Postponing
IMPORTANCE OF IMMEDIATE treatment
TREATMENT until
adulthood
impair correct
Amelogenesis relationship between adverse psychological
Imperfecta in a child maxillary and effect
mandibular teeth.
Ni-Cr crowns After all

are placed on permanent
As anterior
first permanent teeth are
teeth and
molars and erupted, these
Vertical premolars
second restorations
dimension is erupt,
deciduous serve as
molars to not altered. polycarbonate
transitional
stabilize resin crowns
treatment
occlusion and are given
until
halt attrition.
adulthood
34
 Vertical Dimension: The distance between
two selected anatomic or marked points, one
on a fixed and the other on a movable
member.
 Vertical Dimension of Rest: The postural
position of the mandible when an individual
is resting comfortably in an upright position
and the associated muscles are in a state of
minimal contractual activity.
 Vertical Dimension of Occlusion: The
distance between two selected anatomic or
marked points when in maximal intercuspal
position.
UNDERSTANDING VERTICAL
DIMENSION
• You cannot determine vertical dimension based on whether the patient is
comfortable.
• Measuring the freeway space is not an accurate way to determine the correct
vertical dimension of occlusion.
• Determining the rest position of the mandible is not a key to determining
vertical dimension.
• Lost vertical dimension is not a cause of temporomandibular disorders.
Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-285. St Louis, MO: CV Mosby, 1989.
The mandible-to-maxilla relationship, The teeth continue
to erupt until they
established by the repetitive contracted meet an opposite
length of the elevator muscles, force of equal
intensity to the
determines the VDO. eruptive force.
The jaw-to-jaw dimension is maintained with such consistent

muscle contraction length that even rapid abrasive wear does not
cause a loss of vertical dimension (A). The alveolar process lengthens in an
Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-285.amount equal
St Louis, to CV
MO: the wear.
Mosby, 1989 page number 115
Abduo J, Lyons K. Clinical considerations for increasing occlusal vertical dimension: a review. Australian dental journal. 2012 Mar;57(1):2-10.
METHODS OF DETERMINING
VERTICAL RELATION
Calliper Method Willis gauge Boley gauge
Geerts GA, Stuhlinger ME, Nel DG. A comparison of the accuracy of two methods used by pre-doctoral students to measure vertical dimension. The Journal of prosthetic dentistry. 2004 Jan 1;91(1):59-66.
Phonetic methods
Silverman’s closest
speaking space
• Patient is encouraged to relax his jaws

so that it goes into physiologic rest
position .
• Swallowing and pronounciation of
‘M’ sounds have been used.
• Then the interocclusal distance should
be measured.
40
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.128
Facial appearance Neuromuscular perception
• Diminished facial contours, • Robert Lytle used centre bearing
thin lips with narrow vermillion device to permit the patient the
borders and drooping of experience different comfort levels
commisure are associated with during use of different vertical
overclosure where as increased
vertical dimension gives a relations for comparison.
stretched out appearance
41
Can vertical dimension be altered?
Sicher(1949) and Silverman42(1952)
• As the teeth wear or become abraded, the teeth and alveolar bone elongate through growth to
maintain the original vertical dimension with the maintenance of the same closest speaking space.
However, occlusal wear may occur more rapidly than continuous eruption depending upon the
etiology of the wear.
Harry Kazis and Albert Kazis

• Treatment of reduced vertical dimension is not designed to increase the vertical dimension beyond
the normal, but is intended to restore the amount of vertical dimension that has been lost. A young
person will tolerate a greater correction of vertical dimension and become adjusted more easily to
a reduction in the interocclusal distance
Silverman(1956)
• Closest speaking space can range from 0 to 10mm in different patients and that there is no average 42
closest speaking space. But it is constant in an individual. Vertical dimension must not be increased
beyond the normal for each patient. . It is better to use a vertical dimension that is too small than
to use one that is too great
Landa(1955)
• stated that increasing the vertical dimension places the muscles of

mastication and temperomandibular joint under strain. The crown to root
ratio is also affected and hence ‘bite raising’ is contraindicated
Dawson(1974)
• even when the teeth have grown down to the gum line the vertical
dimension is not lost because of the eruption of the teeth along with the
alveolar bone.It is not practical to restore severely worn dentition without
restoring the vertical dimension to obtain space for the restorative material,
the dimension can be increased to 1-1.5 mm.The potential problems of
restoring the vertical dimension are clenching, muscle fatigue, soreness of
teeth, muscles and joints, headache,intrusion of teeth, fracture of porcelain ,
occlusal instability due to shifting of restored teeth and continual wear. In
such cases, checking and periodic occlusal adjustment must be done upto a
year before normal stability returns.
43
Carlsson et al(1979)
• increased the vertical dimension in natural dentition by cementing acrylic resin

splints in lower canines, premolars and molars for 7 days. He found that subjects
experienced moderate symptoms of discomfort initially but symptoms decreased
later and no clinically demonstrable symptoms were found. He concluded that
moderate increase in vertical dimension of occlusion does not create problem
provided that occlusal stability is provided
Rivera-Morales(1991)
• Experiments in animals proved that moderate changes in occlusal vertical

dimension does not cause hyperactivity of masticatoty muscles and symptoms of
temperomandibular dysfunction. Occlusal vertical dimension is a variable range
like other quantifiable aspects of a body.
44
When Must The Vertical
Dimension Be Changed? Why Not Increase The VD?
• Any disharmony in the system provokes

• Extremely worn dentition adaptive responses designed to return the
• Crown lengthening vs. increasing system to equilibrium.
the VD • Adaptive process is not always predictable.
• Restoring severe arch mal- • No benefit over time to the patient whatsoever.
relationships • The goal of occlusal therapy is to minimise the
• Extreme occlusal plane problems requirements for adaptation.
• Anterior open bite • Segmental - instability of the entire occlusal
harmony.
45
Methods of
obtaining space
for restoring Equilibrate Reposition Restore Osteotomy Orthognathics
worn teeth
Selective grinding
• Badly worn anterior teeth that have drifted into
anterior wear end to end relationship
• Posterior teeth that interfere, deflect the mandible
forward and cause excessive wear on upper anterior
lingual incline.
• Interferences should be eliminated by selective
grinding so that mandible can close at centric relation
46
Bloom DR, Padayachy JN. Increasing occlusal vertical dimension—Why, when and how. British dental journal. 2006 Mar;200(5):251-6.
Periodontal surgery
• Includes gingivoplasty, osteoectomy

to gain clinical crown length is
sometimes required for retention
and esthetics.
• 2-3mm of supporting bone can
usually be removed without
jeopardizing periodontal support.
47
Splints and provisional restorations
• There are occasionally Teeth preparation
situations where and provisional
restoration of a worn Evaluated for fixed restorations
dentition can be comfort and • Evaluated for 2-3
function months
accomplished only by Removable
occlusal splint
increasing occlusal • Given for 6-8 weeks
vertical dimension, even
though a loss of vertical
dimension is not If deemed absolutely necessary, modification of
diagnosed vertical dimension should be accomplished through
cautious trials with removable occlusal splints
48
Occlusal splints
Permissive occlusal splints Directive occlusal splints

• have a smooth surface on one side • Direct the lower arch into a specific
that allows the muscles to move the occlusal relationship that in turn
directs the condyles to a
mandible without interference from predetermined position.
deflective tooth inclines into centric
• very limited use
relation.
• reserved for specific conditions
involving intracapsular TMDs.
49
When occlusal splints are not
necessary? Occlusal splint is appropriate:
• No history of problems in the TMJs, including no history • If there is doubt about

of clicking, discomfort in the joints, restriction or deviation complete seating of the TMJ
of jaw movement, • Long-standing intracapsular
disorder that has been
• No intracapsular disorder.
resolved.
• No sign of tenderness or tension on load testing • To stabilize hypermobile teeth
• Not necessary to fabricate an occlusal splint prior to and distribute the loading
restorative dentistry orthodontics, or equilibration.
forces over more teeth.
50
Fabrication of occlusal splints
• Three very common errors are:
 The splint does not fit the teeth properly, so it is uncomfortable or loose, or it rocks
in place.
 The occlusal contacts on the splint are not in harmony with centric relation.
 An intracapsular structural disorder was not diagnosed, so centric relation was not
achievable.
51
Remove the
Take a verified centric relation
bite record. Procedure excess from the
base, but do not
remove it from
the cast.
Outline the
coverage area
of the base.
Fabricate a
Biostar vinyl
base on the
cast. (An
acrylic or
light-cured
Place it back on the articulator.
composite
Mount the casts in centric Open the pin enough separate all
base will also
relation with a facebow posterior teeth from any contact
work.)
with the base
52
Remove the base and smooth the
edges. Remove undercuts into
interproximal areas.
Mix resin and position it on

the base just behind the
upper anterior teeth to
contact and be slightly
indented by lower anterior
teeth in centric relation.
The completed splint should fit 53

perfectly and require almost no
adjustment.
The splint in place may contact all of the anterior teeth in centric
relation, but there should be no contact on posterior teeth. Slight
adjustment is often needed on the anterior contact area.
It should be smooth and flat to permit the condyles to seat into

centric relation with no back teeth contact. This is an ideal
permissive anterior deprogramming device to use.
If all tension or tenderness disappears after placement of the

splint and there is verification that no posterior teeth are
contacting the splint, it is a good indication that the TMJs are in
either centric relation or adapted centric posture.
It also indicates that the TMJs are not the source of pain.
54
Principles of full occlusal splint design
The design must incorporate Stability is determined
four main principles: by three verifications:
 The splint should allow uniform, equal-intensity contacts of • Elimination of painful
all teeth against a smooth splint surface when the joints are symptoms
completely seated in centric relation. • Verification of centric
relation by load testing
 The splint should have an anterior guidance ramp angled as
• Stability of the bite on the
shallow as possible for horizontal freedom of mandibular splint over the course of a
movement. few days (or weeks if joint
damage has occurred)
 Occlusal splints for therapy must be worn 24 hours a day
except to eat and brush until the occlusion and the TMJs
become stable. 55
Anterior deprogramming splint is contraindicated
A full-coverage occlusal splint decreases

compressive loading of the joint, reduces loading
of the joint, and reduces compression of the
retrodiskal tissue
increases
compressive
loading and also
activates lateral
pterygoid
activity to more
intense protective
contraction.
If injury or inflammation has occurred within the

capsule of the TMJ, muscle will attempt to protect the
joint from compressing the edematous retrodiskal
tissue 56
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.389
Dahl appliance
• Partial coverage splint, 2-4 mm thick,
designed to depress the opposing teeth
against which it contacts and to allow
the unopposed teeth to overerupt.
• It contacts anterior teeth and allows
posterior teeth to erupt.
• Alveolar remodeling ensures that
anterior teeth are not intruded into the
bone, with a resulting loss of crown
height
57
Poyser, N., Porter, R., Briggs, P. et al. The Dahl Concept: past, present and future. Br Dent J 198, 669–676 (2005). https://doi.org/10.1038/sj.bdj.4812371
• Dahl described the use of
cobalt chromium appliance
but its modifications of acrylic
and bonded composite have
been used satisfactorily.
• Most space is created between

2-4 months of continuous
wear
58
Centric Relation
• It is defined as “ the maxillo-mandibular relationship in which the condyles
articulate with the thinnest avascular portion of their respective discs with the
complex in the anterior-superior position against the slopes of articular
eminences.
• This position is independent of tooth contact.”
59
Methods available to guide the mandible into
centric relation
1.Chinpoint Guidance method
3. Bilateral manipulation method
or one handed technique
• Guichet • Dawson introduced this method in
• It places the condyles in most posterior and which the condyles are in their most
superior position which can result in trauma to
TMJ. superior position in the gleoid fossa.
• not advocated.
• Firmness of upwardly directed
2. Unguided method pressure at or near the angle of the
Brill introduced a muscular position which allows mandible to ensure that the condyles
patient’s natural muscle functions to position the are seated seated againt the eminence
mandible into centric relation position. 60
Brit Dent J.1959, vol 106, pg 391-400

Method for taking centric bite records
Purpose:to capture ,in some stable material ,the relationship of the mandible to the maxilla when the
condyles are in their terminal axis position
1.the ability of the

Factors 2.the ability of the
operator to manipulate 3.tooth mobility
considered patient to co-operate
the mandible
while making
interocclusal
records
6.Occlusal
4.edentulous area 5.condylectomy
interferences
61
4 basic techniques for making centric relation
interocclusal record:
1.Wax bite procedures

2.Anterior stop techniques
3.Use of preadapted bases
4.Central bearing point techniques
62
Wax bite procedure
• Most popular procedure (simple)
• Extra hard baseplate wax is an excellent bite
material
• When it is warm it becomes soft enough not
to cause movement of teeth.
• It should be brittle and not bend to mould
itself to fit the models as it will mask the
errors if not rigid.
• This method is not suitable for patients
having extremely mobile teeth or large
edentulous area.
63
Anterior stop technique
• Extremely accurate
• Allows the condyles to seat up without any possible deviation from
posterior teeth.
• When mandible is closed the lower incisors strike against a stop that
is precisely adapted to fit against the upper incisors
• thin enough so that the first point of posterior contact just barely
misses
• Anterior stop may be made from acrylic or hard compound
Patients with
Posterior
Very loose teeth temporomandibular64
edentulous ridges
joint problems
Mandibular deprogramming
Ask the patient to bite on these with anterior teeth for 5 -10 minutes.
• The memory position of teeth intercuspation is lost
1) Cotton role
2) Anterior Jig
3) Leaf Guage
65
Anterior bite stops/
Jig
Principle
• Anterior jig prevents posterior teeth from occluding and thus disrupts
the proprioceotive memory.
• As the anterior stop is rigid on contact with lower incisor teeth, anterior
resistance is created and a mandibular leverage is created with naturally
braced tripod effect along with two condyles.
• Jig breaks the patient’s habitual closure pattern and acts as the third leg
of the tripod by creating resistance while stopping the closure.
66
Fabrication of anterior jig
• Compound is softened and added to upper incisors so that their lingual surfaces
are completely covered
• The patient closes into the compound until the posterior teeth barely miss the
contact while in supine position the lower central incisors contact the smooth
lingual incline of the jig at only one point.
• The jig incline must stop the mandible before posterior tooth contact and should
be angled 45-60 degrees posteriorly and superiorly from the occlusal plane.
• The jig can also be made of autopolymerizing acrylic resin on mounted casts and
then adjusted intraorally.
• After the jig is made posterior bite record is taken 67
Leaf Gauge – Dr James.H.Long (1973)
Most useful and practical alternative to anterior jig
• Previously they were made of convenient and measure the exact
unexposed X- ray films after vertical opening between the incisors
developing to remove the emulsion • Centric relation interocclusal
coating. records
• Clear film was then cut into 1 cm X 5 • Occlusal equilibration
cm sections.
• Relieve painful spasms of lateral
• Recently, leaf gauges of uniform pterygoid muscle.
0.1mm thickness which are sequentially
numbered are described 68
Procedure
• Arbitary number of leaves are placed at the maxillary anterior midline
parallel to the lingual plane of central incisors. Patient is instructed to
close on back teeth until lower incisors touch on back side of leaf guage.
• Leaves are added or subtracted until patient can barely feel a posterior
tooth touch while closing firmly on leaf guage.
• Often the patient can feel a posterior tooth contact in 15- 52 seconds
after the jaw is closed with a ‘half hard’ closing force.
• This procedure is repeated after adding a leaf guage until the patient can
close for 2-5 minutes without feeling a posterior tooth contact.
69
Power Bite
• Proper use requires precise location of centric relation before closing power from the elevator
muscles is applied.
• starts with a bite record made between the upper and lower anterior teeth.
• a softened compound that hardens after the indentations have been made between the upper
and lower anterior teeth.
• Closure of the jaw must stop short of any posterior tooth contact.
• patient is then instructed to clench tightly to seat the condyles up into centric relation.
• The problem is that if the anterior segment of the bite is made with the mandible displaced
from centric relation, the hardened material locks the jaw into that relationship and prevents
the condyles from moving back and up
70
It is made with triple layer of extra hard
baseplate wax adapted on an accurate model,
usually of the upper arch to avoid
Use of preadapted bases dislodgement by the tongue
• Indicated whenever there is

a danger that teeth will
move or soft tissues be
compressed by the bite
record
• Heated strip of dead soft
wax should be added over it
in edentulous region to
indent the lower teeth in
centric occlusion without
tooth to tooth contact
71
Manipulated centric relation closure can bring the lower anterior
teeth into contact with the wax.
While holding the TMJs firmly on their centric relation axis, ask the patient
to lightly bite into the wax to form shallow indentations.
Then chill the wax to harden it and add the putty silicone to the preformed
wax base.
Manipulate a verified centric relation and close into the indentations.
The soft putty silicone will adapt to the opposing ridge
72
If a central bearing point
Central bearing point technique apparatus is adapted to well-fitted
upper and lower clutches, all
• It enables free movement of the mandible without occlusal contact can be
influence of teeth proprioceptives. disengaged.
• Drawback is that vertical dimension must be increased

considerably to accommodate the clutches and bearing
point apparatus.
• If the terminal axis is not recorded precisely it will
result in mounting error.
The bite record is

made between
the clutches
rather than
directly between 73
opposing teeth.
Long centric / Freedom in centric
• Defined as ‘ freedom to close the mandible either
into centric relation or slightly anterior to it without
varying the vertical dimension of occlusion.
• When interference in centric relation is eliminated by
equilibration ‘long centric will usually be provided
automatically.
• The most important aspect is that the vertical
dimension of occlusion must be the same from back
to front of each long centric contact area. 74
Contact in centric relation Clearance for long centric
75
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.192,193,195
Providing long centric by equilibration
• When Interferences to CR are eliminated by equilibration Long centric is
automatically acquired
• Equilibrated patient is free to move into centric or into his original convenience
position or any where in between
• Freedom to do so the mandible will close directly into centric or a few mm
anterior to it , depends on the anatomy and the musculature .
• Length of the long centric is determined by the anatomy of the condyle disk
relationship.
• Equilibration should not cause extensive flattening of the cusps and reduce the
efficiency of chewing for that careful use of small stones on the interfering
inclines only has to be used 76
Posselt 1952
• studied the positional difference between retruded contact position and

intercuspal positin and found 1.25+1 mm difference between them.
Schuyler 1959
• found the initial contact from rest position to be 1 mm anterior to the border
path produced along the transverse horizontal axis.
Dawson 1974
• advocated freedom in centric relation of occlusion of 0.2 mm which allows

space between condyle and fossa
77
Procedure
• To determine the patient’s long centric two different colours of marking
ribbon are used
• green or blue -centric relation points
• Red ribbon -closure from postural rest position
• knife edge inverted cone carborundum stone is used for accurate grinding
• There are no contraindications for providing the freedom.
78
79
Reading the marks
2.red mark extend forward from
1.Red mark covered by Green green centric mark
• Indicate that terminal hinge • Shows a need for long centric

closure and light closure • Should not grind the green centric marks
from rest are identical equilibration complete when there are no red
• A Long Centric is not marks on the inclines
essential in these cases • In perfected occlusion the red marks will still
extend forward from green but at the same
VD
• VD will slightly open posteriorly but very
minimally
80
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.196,197
3.Red mark extend forward 4.Green centric marks missing
from green from red marks
• The equilibration is incomplete

• Only reason that the dentist has • Teeth with some degree of mobility
not correctly manipulated the CR are being move when patient taps
• To check mobility different color
ribbon should be used for
comparing light contacts from firm
contacts
81
82
Long centric when occlusion is to be restored
• By preparing all posterior teeth all possibilities of interferences are eliminated
then all that is needed is to correct any inclines on the anterior teeth that cause a
deviation from deviation from terminal hinge closure.
• Properly adjusted centric stops on anterior teeth should be stable enough that not
one of the teeth is jarred when the teeth are firmly tapped together in a terminal
hinge closure.
• If the patient requires the freedom of Long Centric red marks will extend from
the green marks.
• Occlusal inclines restricting mandibular movement are potential stress producers
83
Symptoms indicating
requirement of long centric Advantage of long centric
• Patient says they are • Freedom of movement in centric

comfortable when lying down occlusion provides patient
but interfere while sitting up comfort and reduces the tendency
• Patient says teeth fit fine when to bruxism and other
dentist pushes the jaw back traumatogenic influence on the
but hit only on front teeth if supporting structures.
close it themselves
84
CUSTOMIZING THE
ANTERIOR GUIDANCE
85
The centric relation contacts
• The most critical tooth contour in
the entire occlusal scheme is also
the most universally mismanaged.
86
Upper half of labial surface
• second most important determination

is upper incisal edge position.
• will not be precise until the upper half
of the labial contour has been
determined.
• There is no bulge in nature from the
alveolus to upper labial surface ie the
upper half of the labial surface is
continuous with the labial surface of
the alveolar process
87
Lower half of labial surface
• two planes - for incisal position and to allow

the lip closure path to slide along the labial
surface hence the need to roll in the incisal tip.
• very important step in determining horizontal
position of the incisal edges
• lower lip can easily slide by the incisal third to
seal contact with the upper lip - lip-closure
path.
88
Incisal edge
• This should rest along the inner vermillion
border of the lower lip and is best determined
by observing the patient to counting from 50 to
55 ie 'F' sound. This needs to be in harmony
with the neutral zone, lip closure path,
phonetics, envelope of function and aesthetics.
89
Anterior guidance Contour of the lingual surface
from the centric stop to the
gingival margin:
• There should be no interferences

with the 'T', 'D' or 'S' sounds.
This is determined by the protrusive path

but should include a 'long centric' that allows
a little freedom before this path is engaged
and so the lower incisors are not bound in
90
Restoring lower anterior teeth
• Lower incisal edges are the

5 important goals
starting point for anterior 1. Esthetics
guidance and “the view”
when speaking. 2. Phonetics
• The arrangement of the 3. Occlusal plane
entire occlusal scheme starts
with the lower anterior teeth 4. Anterior guidance
5. Stability
91
The height of the incisal plane Lips sealed
In ideal instances, the lower

incisal edges form a continuous
gentle curve that is an extension
of the posterior occlusal
plane (
The lower incisal edge is at the height of the

juncture of the upper and lower lips when the teeth are
together. On a lateral cephalometric radiograph, this usually
positions the incisal edge slightly above the functional occlusal
plane.
92
• Speaking • Smiling • Lips slightly parted
“The view” when speaking is of Only the upper anterior teeth When the jaw is at rest and the lips
the incisal are typically on are slightly parted in a half smile, both
edges of the lower anterior teeth. display during smiling. The upper and lower
A varying amount of labial lower incisors are usually labial surfaces are about equally on
contour may also be on display. hidden during a big smile. display.
The upper teeth are usually
hidden during speech.
93
Lower incisal edge contours
The most important contour on the

lower incisal edges is the
labio-incisal line angle.
The “leading edge”

is important for natural appearance
but also to achieve a stable
holding contact against the upper
lingual stop.
Use of the Esthetic Checklist reminds

the technician to do this on every
lower anterior restoration
94
The entire occlusion can be compromised
by instability if lower incisal edges are not
correct.
It is a critical point for analysis and
treatment of anterior teeth 95
Determining plane of
occlusion
Curvature of anterior teeth
2 basic requirement determined by-
• Permit anterior guidance to Establishing correct
disocclude posterior teeth
when mandible is protruded • smile line
• proper phonetics
• Permit disclusion of all the
teeth on balancing side when • Anterior guidance
mandible is moved laterally
96
CURVATURE OF POSTERIOR TEETH
97
Establishing plane of occlusion
3 practical methods
• Analysis on natural teeth through selective
grinding
• Analysis of models with fully adjustable
instrumentation
• Use of Pankey- Mann –Schuyler methods
of occlusal plane analysis.
98
SOPA-simplified occlusal plane analyzer
99
Broadrick occlusal plane analuser
Bow
compass 142-
1001 with
• The Broadrick flag accomplishes the same occlusal analysis graphite leads
on almost all types of semiadjustable articulators.
Card index 142-101

(1) Card Index 142-101, (1) Bow Compass
142-1001 with
graphite leads, an extra center point and a
needle point, (1)
Scribing Knife 142-3201 and (12) Plastic
Record Cards 142-
3401 100
. Tighten the
Place the Card Index onto the Upper thumbscrew to hold the Card
Member Index in place
with the open end around the incisal pin The accessory
and the slot on Hanau-Mount Split-
the side around the mounting plate Cast Mounting Plate-
thumbscrew. This split cast allows
rapid cast removal
and accurate
replacement during
Maxillary cast mounted by the survey. visual
Facebow transfer guide for adjustment
of the Articulator to
protrusive or lateral
interocclusal relation
records
mandibular cast mounted in
centric relation
Press a Plastic Record Card over the dowels on the

right
Orbitale Indicator be mounted to the articulator, it side of the Card Index.
101
must me removed in order to mount the Card Index The Cards are matte finished on both
sides and readily accept pencil or ink markings.
The relatively small divergence between arcs of 3-3/4",
4" and 5" radii over the functional occlusal surfaces on
the lower posterior teeth
• An average of a 4" radius may be

used in the majority of surveyed
cases.
Variation is necessary only when

pronounced Curve of Spee - 3-3/4"
radius
flat Curve of Spee may require - 5"
radius. 102
With the center point of the Compass positioned on the If the cuspid is worn flat, the A.S.P.
A.S.P., apply a long arc (about 3”) on the Plastic Record may be at the incisal edge
Card.
The occlusal plane survey center (O.P.S.C.) will ultimately

be located on some point on this arc
Position the center point of the Bow Compass on the anterior survey point
(A.S.P.) which is usually the disto-incisal
of the cuspid,
This point must be selected as the most desirable to “Beam” the line and
plane of occlusion posteriorly. 103
Once selected, it is marked on the cuspid and NOT CHANGED

replace the upper cast and place soft
. cast and select a P.S.P. on the modelling
Remove the upper
modeling compound over the lower compound in the same manner as the P.S.P. was selected on the last
ridge molar
Position the center point of the Bow Compass
on the P.S.P.
and apply an arc to intersect the arc from the
A.S.P. as
Close articulator until the Incisal No molars in illustrated.
Pin contacts the Incisal Guide in a the
centric relation mandibular
arch
Chill the compound and carve away

the excess, leaving only compound
contacting into the upper fossae
simulating the lower buccal cusp
Select the posterior survey point (P.S.P.) at the distobuccal cusp of

the last lower molar
104
Alternate to the molar P.S.P. is a position on the
Condylar
Element of the Articulator, at its anterior
intersection with
the Condylar Shaft
Position the center point of the Compass on this

condylar posterior survey point (C.P.S.P.) and apply
an arc to intersect the arc formed from the A.S.P
105
Continue with by substituting the needle point for the graphite lead.
Place the center point of the Bow Compass, still adjusted to the 4”
radius, at the intersection of arcs on the Plastic Record Card (initial
occlusal plane survey center).
Sweep the the needle point over the occlusal surfaces of the
lower posterior teeth to see how the arc conforms to the
existing occlusal plane.
Shift this occlusal plane survey center (O.P.S.C.) on the

long arc on Plastic Record Card, the A.S.P. line, until the
most acceptable line and plane of occlusion is found.
106
By trial and retrial, in ideal survey center forming the most
acceptable line and plane of occlusion will be located
To raise the • move the A Plastic Record Card is then

line and place over the dowels on
center point the left side of the Card Index
plane of
occlusion at anterior to the and marked “L”. Repeat the
survey procedure
the distal end arc intersection
To lower the • move the point The center point of the Bow Compass is now pierced into this
line and posterior of ideal O.P.S.C. on the Plastic Record Card and circled with pencil
plane of the or ink for subsequent relocation.
occlusion intersection. It may be advantageous to mark “R” (right) in the upper corner
of the Plastic Record Card for identification
107
Various survey lines obtained from different radii Measurement of difference between survey lines of
of curvature different radii of curvature
108
Posterior occlusion
• Posterior teeth should have equal
intensity contacts that do not Three key determinants
interfere with either the
temporomandibular joints (TMJs)
1. Plane of occlusion
in the back or the anterior guidance 2. Location of each lower buccal
in the front. cusp tip
• The requirements for perfected 3. Position and contour of each
posterior occlusions start with the lower fossa
lower posterior teeth.
109
Placement of Lower Buccal Cusps
• determined on the basis of providing the optimum effect for buccolingual stability,
mesiodistal stability, and noninterfering excursions.
Buccal cusp placement for buccolingual stability
• Upper central groove position is analyzed.

• On each upper occlusal surface, a line is drawn from mesial tdistal in the central groove.
• The ideal contact point for each lower buccal cusp tip is usually located somewhere on this
line.
• In some tilted teeth, it is advantageous to move the central groove to gain better direction of
forces through the long axis.
• If moving the central groove will enable the stresses to be directed more nearly through the
long axis of any upper tooth, the improved central groove position should be so noted on
the upper cast by drawing a new line.
110
• A mark is made on each lower tooth to
indicate the position of the buccal cusp
that would be optimum for buccolingual
stability and direction of force
• Alignment of the optimum lower buccal
cusp position against optimum upper
central groove position is evaluated.
The basic rule to follow regarding the buccolingual

position of the lower buccal cusp is: The lower buccal
cusp must be positioned so that its contact directs the
stresses through the long axis of both upper and lower
teeth.
111
Mesiodistal placement of lower buccal cusps
• The best mesiodistal stability is attained by

placement of the lower buccal cusps in
upper fossae.
• Placement in the fossae directs the stresses
properly through the long axis, eliminates
any possibility of plunger cusp food
impaction at contact, and is stable.
• There is no tendency for cusp tips to
migrate out of properly contoured fossae
112
Locating the lower buccal cusps
Contouring cusp tips
for noninterfering excursions
• Determining which fossa the lower

buccal cusp should contact depends on
where the cusp travels when it leaves
centric relation.
• The mesiodistal placement of each
lower buccal cusp is determined when
one locates it in the fossa that permits
excursions from centric relation
without interference
113
• Placement of lower lingual cusps
• The position of the tip should have
enough lingual overjet to hold the
tongue out of the way, but it should
• In normal tooth-to-tooth relationships, always be located over the root, within
the tip of the lower lingual cusp never the long axis.
comes in contact with the upper tooth.
• The measurement between buccal cusp
• Even though the buccal incline of the tip and lingual cusp tip should not be
lower lingual cusp can be made to much greater than half of the total
contact in working excursions buccolingual width of the tooth at its
widest part.
• act as a gripper and a grinder by
passing close enough to the upper • lower lingual cusp height should be
about a millimeter shorter than the
lingual cusps to aid in tearing, buccal cusp.
crushing, and shearing the food that is
caught between the opposing surfaces. • Cusp height can be lowered further in
the first premolar
114
Countouring the lower fossae
• As the mandible moves right or left
from centric relation, its front end
should be guided down the lingual
incline of the upper canine.
• When it serves as the lateral
anterior guidance, the lingual
incline of each upper canine
dictates the fossa contour of each
lower incline that faces it
115
If Only Lower Posterior Teeth If Both Upper and Lower
Are to Be Restored Posterior Teeth Are to Be

Restored
• Cusp tip position and fossa contours • If posterior disclusion is the goal, it is
for lower posterior restorations are easily achieved by making fossa walls
aligned and contoured in relation to flatter than the lateral anterior guidance,
the existing upper teeth on the and establishing an acceptable occlusal
opposing cast. plane that permits the anterior guidance to
disclude the posterior teeth in all
• Lower fossa contours will be excursions.
established to conform to the upper • After the anterior guidance has been
lingual cusps. finalized, the simplest method for ensuring
• Fossa walls can be carved to be that fossa walls will be discluded in lateral
excursions is through the use of a
discluded by the anterior guidance fabricated fossa contour guide.
without complication.
116
Determining and Carving
Lower Fossa Contours
Purpose Fossa contour guide
• to ensure a noninterfering • can be used in any stage of wax-up or

accommodation for the upper even porcelain application.
lingual cusps.
• used only if both upper and lower
• It will provide a fossa contour that posterior teeth are to be restored
is compatible with the lateral
anterior guidance regardless of the
• The anterior guidance must be correct
before the guide is fabricated or before
contour of the anterior guidance.
occlusal contours can be determined
• It can be easily modified to provide for lower posterior restorations
extra freedom. 117
Making the fossa contour guide
• The anterior guidance may • Step 1
be corrected in provisional
restorations, and a centrically
mounted cast of the
provisional restorations in
place may be used to
determine the allowable
fossa-wall angulation for the
posterior restorations.
• The guide is usually made
when the casts are mounted,
but it is not used until the
posterior wax-up is done or
the porcelain is being applied The regular incisal guide pin is removed and replaced with
and contoured. the special fossa-contour pin. The blade of the pin is indented into
a mound of wax on a flat plastic guide table
118
When the lateral guidance paths have been cut
The upper bow is moved into left and right
sharply into the wax, the special pin is raised. It is then used to hold
excursions, allowing the contours of the lateral
a handle for the fossa guide. Make the handle by cutting off the tip
anterior guidance to determine
of a plastic protector for a disposable needle. The large end fits
the path that the guide pin cuts into the wax.
snugly onto the raised special pin.
119
A creamy mix of self- Because of the design of the special
curing acrylic resin is
flowed into the Resin is wiped into the hollow end of the handle, and wax-cutter pin, the lateral anterior
the pin is lowered so that the two portions flow guidance angle will be evident as a
indentation in the wax. sharp line running
together. The resin is allowed to set hard. The guide
can then be removed. The wax on the guide table is along the bottom edge of the acrylic
then no longer needed, and so it can be cleaned off guide. The edge is marked with a
after the guide is removed. pencil, and any excess acrylic resin
may be ground off in front of the
line. 120
To ensure posterior disclusion, the The fossa guide can be used to
One may actually hollow-grind the front contour the wax
surface down to fossa walls
must be flatter than the lateral patterns or as a guide for shaping
the line to make a scoop-shaped guide, occlusal surfaces in porcelain.
which is excellent for shaving anterior guidance, so the fossa guide
angle is flattened on the sides and The tip of the guide should be able
out wax from the fossae. to touch the base of the fossa
the tip is rounded to a more
opened-out fossa. without interference from the walls
121
of the fossa.
Carving the marginal ridges Countouring ridges and grooves
• work out the fossae contours first and
• The ridges should be contoured to then functionalize and beautify the
reflect food away from the contact, anatomy by placing the appropriate
which means directing it into the grooves at the working, protrusive, and
fossae. balancing excursion.
• Sluiceways should provide an • There can be no entanglement of cusps in

grooves that have been made into inclines
escape route for the bolus out of that are already out of reach.
the fossae toward the lingual as the
stamp cusps crush the food against • Other grooves may be added as desired to
improve esthetics or to provide more
the fossae walls. ridges for better masticatory function
122
Upper posterior teeth
• 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.
• If the upper contours are determined by the paths of the lower posterior teeth, both
the form and the paths of the lower teeth should be finalized before the upper teeth are
restored
123
LENGTH OF GROUP FUNCTION
CONTACT IN WORKING EXCURSION
• If we elect to provide group function on the working side, we should be aware that
all teeth do not stay in excursive contact for the same length of stroke.
• As the mandible starts its move to the working side, all of the posterior teeth may
contact in harmony with the anterior guidance and the condyle.
• As the mandible moves further to the side, the first teeth to disengage from contact
are the most posterior molars. Balancing inclines must be relieved
• The disengagement is progressive, starting with the back molar, which has on all
thenatural teeth
regardless of the method used to
shortest contact stroke, forward to the canine, which has the longest contact
recordstroke
the border
movements.
124
Types of posterior occlusal contours
There are three basic decisions to make regarding the design of posterior
occlusal contours:
1. Selection of the type of centric relation contacts
2. Determination of the type and distribution of contact in lateral excursions
3. Determination of how to provide stability to the occlusal form
125
Occlusal considerations in full mouth rehabilitation
• There is no one type of occlusion that is optimum for all patients.
• The starting point in designing occlusal contours is to shape and locate the centric
contacts so that the forces are directed parallel to the long axes of the teeth.
• Ideal occlusion can be defined as an occlusion compatible with the stomatognathic
system, providing efficient mastication and good esthetics without creating
physiologic abnormalities ( Hobo)
126
Types of centric holding contacts
• Centric relation contact is usually established on restorations in one of three ways:
127
Types of centric holding contacts
Surface to surface contact/Mashed potato contact
• It is stressful and produces lateral interferences and hence it should be avoided
Tripod contact
• Contact is made on sides of the cusps that are convexly shaped.

• can be given in posterior disclusion cases where anterior teeth are strong enough.
• cannot be used when posterior teeth are in group function (convex cusps immediately disengage upon leaving
centric relation.)
• It is difficult with achieve with no actual indications and no advantage over cust tip to fossa contact.
Cusp tip to fossa contact
• It provides excellent function, stability, resistance to wear and aids easy to equilibrate by shaping the fossa
inclines without disturbing the centric holding contacts.
128
Determinants of occlusal morphology
Posterior controlling factor Anterior controlling factor

• The steeper the articular eminence, • The steeper the lingual surfaces of
the steeper path will the condyles the maxillary anterior teeth, the
follow during protrusion. It is a steeper and more vertical will be
fixed factor. the movement of the mandible.
• It is a variable factor and can be
altered by the dental procedures.
129
Vertical determinants of Horizontal determinants of
occlusal morphology occlusal morphology
• Anterior Guidance • It includes the relationship that influence the
direction of ridges and grooves on the occlusal
• Condylar Guidance surface. Since the cusps pass between the ridges
• Distance of cusps from these controlling over grooves, the horizontal determinants also
influence the placement of cusps
factors
• Ridge and groove direction has the influence of
• Plane of occlusion the following factors
• Curve of Spee • Distance of tooth from axis of rotation
• Bennett movement – Amount, Direction • Distance from mid-sagittal plane
and Timing • Bennett movement
• Intercondylar distance
130
Occlusal scheme
Patient presents with Occlusal scheme
Natural canine protected Canine protected
Natural group function Group function
Canine missing or periodontally weak Group function
Opposing complete denture Balanced or monoplane
Where no posterior tooth remaining Canine protected

131
Variations of posterior
contact in lateral excursions
Group function
contacting inclines
Class 1 occlusion with
must
Class be perfectly
3 occlusion with
all lower anterior teeth
harmonized to border movements
Some end-to-end
• Archoverjet
relationship does not allow theupper
anterior guidance to bites Anterior
do its job of discluding the open bite
extreme of the
nonfunctioning side. condyles
outside of the
anterior teeth
and the anterior guidance.
Convex-to-convex contacts cannot be used to accomplish this.
Partial group function
• allowing some of the posterior teeth to share the load in excursions, whereas others contact only
in centric relation.
Posterior disclusion
• can be achieved by two different types of anterior guidance: anterior group function and canine-
protected occlusion.
132
Anterior group function Canine-protected occlusion
1. It distributes wear over more teeth. • all lateral stresses must be resisted
2. It distributes the stresses to more solely by the canine.
teeth. • capability of the canine to withstand
3. It distributes stress to teeth that are the entire lateral stress load without
any help from other teeth.
progressively farther from the condyle
fulcrum. • Exquisitely sensitive nerve endings
protect the canines against too much
convex lateral guidances make it lateral stress by redirecting the muscles
difficult to accomplish. to more vertical function.
133
Selecting occlusal form for stability
134
Occlusal equilibration in natural dentition
The term ‘occlusal equilibtation’ Objectives

• refers to the correction of stressful • Centric relation occlusion
occlusal contacts through selective • Acceptable disclusion of anterior teeth
grinding. in harmony with condylar movement.
• It is a phase of treatment that • Stability of occlusion
eliminates only that part of tooth • Resolution of temperomandibular
structure that is in the way of joint symptoms.
harmonious jaw function.
135
Equilibration procedures
divided into four parts
Eliminating
Eliminating Eliminating
posterior tooth Harmonization
interference to interference to
interferences of anterior
terminal hinge lateral
with protrusive guidance
axis closure excursions
excursions.
136
Interference to Centric Relation
Centric interference can be differentiated into two types-
Interference to arc of closure Interference to line of closure
137
Interferences to the arc of
closure
Note the
freedom to close
either in centric
relation or
in maximal
intercuspation at
the most closed
vertical
138
Interference to the line of closure
139
A balancing incline interference that would be easily
missed if the condyles are not held firmly up on the centric relation axis
during closure
When the condyles are

seated, the right molar is the
only contact during closure.
Squeezing the teeth together
shifts the jaw to
the right and causes the left
condyle to displace.
140
Grinding Rules
Rule 1: Narrow stamp cusps Rule 2: Don’t shorten a stamp
before reshaping fossae cusp
141
142
Tilted teeth
Tilted teeth or wide cusp tips can be
adjusted to improve stability
as well as to eliminate interferences. If
the mark on the
upper tooth is buccal to the central
fossa, the buccal surface
of the lower tooth is ground to move
the cusp tip lingually if
the shaping can be accomplished
without shortening the
cusp tip out of centric contact.
Grinding on the upper teeth
only may mutilate upper cusps
unnecessarily
143
Rule 4: Eliminate all posterior
Rule 3: Adjust centric incline contacts. Preserve cusp
interferences first tips only.
1. By adjusting centric interferences first,
you have the option of improving cusp- • If all eccentric contacts on
tip position. posterior teeth are to be eliminated,
2. When cusp-tip position is given first any posterior incline that marks in
priority, occlusal grinding is more evenly any excursion can be reduced.
distributed to both arches.
• Centric stops must be preserved,
3. If cusp-tip contours and position are but all other contacts can be shaped
improved first in centric relation,
eccentric interferences can be eliminated so that they are discluded by the
with speed and simplicity. anterior guidance.
144
Lateral excursion interferences
• The path that is followed by the lower
posterior teeth as they leave centric
relation and travel laterally is dictated BALANCING
BULL
by two determinants: SIDE
2 types
1. The border movements of the WORKING
condyles, which act as the posterior LUBL
SIDE
determinant
2. The anterior guidance, which acts as
the anterior determinant determine type of occlusion
Group Function - posterior disclusion

145
Cusp tips are centric holding stops hence adjustings to be done on fossa inclines
PROTRUSIVE
INTERFERENCES
Correction done in case of steep anterior guidance
Grinding rule-DUML
Materials for marking interference
• Ribbons
• Marking paper
• Joffe-marker
• waxes
146
• Works with Denar articulators
• It is preset to 4”
• line drawn on the cast represent an acceptable coclusal plane
• This process is used only if the posterior teeth are to be restored .
• It is never used to determine whether or not teeth must be prepared
147
Schuyler’s principles
1. 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
148
Sequence is advocated by the PMS philosophy:
Examination, Diagnosis,Treatment planning and Prognosis
Harmonization of the anterior guidance for best possible esthetics,

function and comfort
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.
Restoration of the upper posterior occlusion in harmony with the

anterior guidance and condylar guidance
149
The functionally generated path technique is so closely allied with this part of the reconstruction.
Advantages of the Pankey Mann Schuyler
technique:
1. It is possible to diagnose and plan the treatment for entire rehabilitation
before preparing a single tooth.
2. It is a well- organized logical procedure
3. never a need for preparing or building more than 8 teeth at a time
4. It is neither necessary nor desirable to do the entire case at one time.
5. The operator always has an idea where he is at all times.
150
6. The functionally generated path and centric relation are taken on the occlusal
surface of the teeth to be rebuilt at the exact vertical dimension to which the case
will be reconstructed.
7. All posterior occlusal contours are programmed by and are in harmony with both
condylar border movements and a perfected anterior guidance.
8. no need for time consuming techniques and complicated equipment.
9. Laboratory procedures are simple
10. The PMS philosophy of occlusal rehabilitation can fulfill the most exacting and
sophisticated demands if the operator understands the goals of optimum occlusion.
151
Purpose of PM Instrument
1.to engineer the entire oral rehabilitation before a single tooth is prepared
2.Determine the occlusal plane on the lower cast
3.Study and plan the preparations of the lower and upper teeth
4.Orient both the relationship of both arches in centric position with maximum
esthetics and conservation of tooth structure
5.To establish and carve the occclusal plane and curvature in wax patterns
6. to check finished restoratons
152
P-M instrument ( Mann and Pankey)
5.Upper cast mounting
assembly
3.Horizontal rod
4.Facebow frame
2.upright rod
holding two 6.Platform base
assemblies.
Auxiliary parts of the P-M instrument.
8 A and 8 B Diagnostic dividers and cutting dividers

9.Bite fork joined to a crossbar and two face-bow rods attached to the crossbar.
1. Main base from which 10. screwdriver wrench
extends an upright rod 11. Allen wrench
153
Mann AW, Pankey LD. Oral rehabilitation: Part I. Use of the PM instrument in treatment planning and in restoring the
lower posterior teeth. Journal of Prosthetic Dentistry. 1960 Jan 1;10(1):135-50.
P-M face-bow (9) is seated in position
on the lower plaster cast (7) with the
ends of the face-bow rods (9)
approximating the pins in the ends of
the horizontal tube of the face-bow
frame (4).
jackscrews support the cast on the

platform base (6), enabling each
corner of the cast to be raised or
lowered to facilitate adjustment.
Moldine in the center of the
platform base to facilitate the
preliminary cast adjustment.
154
cast (7) is in the same position
Note that the booked end of
the
dividers (8A) is placed in
position in the divider seat on
the horizontal rod (3) and the
straight
end describes an arc of a
sphere, establishing the occlusal
plane (curvature).
155
156
Diagram
showing the
amount of
study cast and
tooth
substance to
be removed.
The occlusal plane (OP.) is the plane passing through

the tips of all major cusps of the lower posterior
teeth.
In the mouth, the preparation plane (PP) guides are
used to facilitate tooth removal down to this plane.
After this, additional tooth substance is removed to
complete the occlusal preparations (F.P.)
157
Casts before and after complete lower posterior
rehabilitation
optimal functional
occlusal curvature has
Before treatment there was been established, and the
a “swayback” functional deformity has been
occlusal curvature caused by eliminated. Note the
a premature loss of the improved cusp-to-fossae
lower first molar and a patterns providing
master cast is mounted in the same manner perpetuation of the optimal functional
as the study casts were mounted, except the deformity in the original efilciency.
diagnostic dividers (8A), set at their original fixed partial denture (The right third molar was
settings, now sweep l/l6 inch above disregarded because it was
tips of the cusps of the prepared teeth. not in occlusion.)
158
Meyer FS. The generated path technique in reconstruction dentistry: Part II. Fixed partial dentures. Journal of Prosthetic Dentistry. 1959 May 1;9(3):432-40.
Meyer FS. The generated path technique in reconstruction dentistry: Part I: Complete dentures. The Journal of Prosthetic Dentistry. 1959 May 1;9(3):354-66.
Functionally generated path

It is a method of rehabilitating the upper posterior teeth using ‘
functionally generated path ’ record based on a modification of
the principles outlined by Meyer and Brenner in 1933
Functionally generated path relies on recording in a simple,
yet precise manner the pathways traveled by the cusps in the
border movements of the mandible.
159
Pankey LD, Mann AW. Oral rehabilitation: Part II. Reconstruction of the upper teeth using a functionally generated path technique. Journal of
Prosthetic Dentistry. 1960 Jan 1;10(1):151-62.
Tracing is begun Paths of the cusps
by having the in working
patient close in excursion are
the retruded recorded. The area
position and direction of
these excursive
Tooth is ready for the movements are
functional tracing when the demonstrated by
occlusal reduction is fine lines in the inset
completed
A square of tacky wax is positioned

over tooth being prepared
160
Paths of the cusps in
working excursion are Path of cusps in non working
recorded. excursions are recorded next Protrusive paths are
recorded last
161
The tray is held in position
while the stone sets
Unneeded portion of the

functional index tray is The bite registration frame
broken off is held while the bite
registration paste sets
Excess mounting
stone is trimmed from Cast with prepared tooth
the functional core is mounted on the lower
member of the twin
stage occlude. Anatomic
cast is seen on upper left
member and functional
The functional core is Cast is placed in wet core on the upper right
begun by brushing stone in Dilok tray member
162
mounting stone on the
functional tracing
Now the occlusal portion of Occlusal
the wax pattern cab be contacts on
completed by waxing against the wax
the functional core. pattern for
mutually
protected
occlusion A,
Axial contours and proximal and
contacts are checked before unilaterally
preceding to the The functional core is painted balanced
occlusal surface. with white liquid shoe polish occlusion B.
The wax added technique

To mark the wax pattern, the Restoration is adjusted to fit
is used to form the
freshly painted functional core against the functional core
163
occlusal morphology.
is closed against it
Hobo’s Philosophy
• They believed in posterior disclusion
in eccentric movements
• Posterior disclusion is dependent on
the angle of hinge rotation created by
the angular difference between
anterior guidance and condylar path,
and on inclination and shape of
posterior cusps, which helps in
controlling harmful lateral forces.
164
• In this case, during the protrusive
movement the mandible does not rotate
around the intercondylar axis but only
translates.
• Translation as defined means "parallel
displacement of a body" (the mandible).
• Since maxillary and mandibular molars
slide in contact during eccentric
movement, disocclusion does not occur
165
Anterior guide component
• In this case, the mandible translates and
rotates around the intercondylar axis; the
maxillary and mandibular molars
dlsocclude.
• McHorris (1979) Incisal path should be 5
degrees steeper than the condytar path.
• However, when setting the sagittal lncisal
path inclination 5 degrees steeper than the
condylar path, the amount of disocclusion
during protrusive movement is only 0.2
mm, about one-fifth the standard value
(1.0 mm).
• If the incisal path is steeper than 5
degrees, the patient will complain of
discomfort.
166
• In this case, the mandible does not
rotate around the intercondylar
axis, it only translates.
• However, since the cusp angle is
shallower than the condylar path,
the maxillary and mandibular
molars disocclude.
• Thus, the component influencing
the amount of disocclusion when
the cusp angle is shallower than the
condylar path is referred to as the
cusp shape component as a
mechanism of disocclusion.
167
• This shows the case when the
sagittal inclination of the condylar
path is 40 degrees, the incisal path
is steeper than the condylar path
and the cusp angle is shallower than
the condylar path.
• In this case, the mandible translates
and rotates simultaneously around
the intercondylar axis.
ANTERIOR
CUSP SHAPE WIDE
GUIDE
COMPONENT DISOCCLUSION
COMPONENT
168
Influence of the amount of disclusion
NON WORKING
WORKING ISDE
SIDE
Cusp Incisal Condylar

angle path path
169
Dependent factors
Twin-tables technique -Hobo (1991)
Limitations
• Posterior teeth are restored using • The cusp angle was fabricated parallel
to the measured condylar path, and the
two customized incisal tables: cusp angle became too steep
without disclusion; and with • To obtain a standard amount of
disclusion disclusion with steep cusp angle, the
incisal path has to be set at an angle
• They did not include freedom in that is extremely steep
centric. • The customized guide tables were
fabricated by means of resin molding.
• Was technique sensitive
170
Standard values of effective cusp angles on molars
Cusp angle Cusp angle on molars a standard value for cusp angle
(deg) was determined such that it may
Protrusive effective cusp angle 25 compensate for wear of natural
dentition due to caries, abrasion
Working side effective cusp angle 15 and restorative works.
By using the standard cusp angle,
Non working side effective cusp angle 20 it was possible to establish the
standard amount of disclusion
• The cusp angle was then considered more reliable ( value of cusp angle at the time
of eruption was used as a reference for occlusion)
• The value of cusp angle was then found by trigonometry.
• The standard cusp values were summarized as standard values of effective cusp
angles on molars-
171
Twin – Stage Procedure
Hobo and Takayama 1989
Advanced version of the Twin-Table INDICATIONS

technique • single crowns
A kinematic formula to calculate anterior • fixed prosthodontics
guidance from condylar path • Implants
Incorporated easily with commonly used • complete-mouth reconstructions,
clinical techniques such as facebow • complete dentures
transfer, various centric recording Contraindicated for malocclusion cases
methods, and cusp-fossa waxing
172
Hobo S (1991) Twin-tables technique for occlusal rehabilitation.Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303
• In order to provide disocclusion, the cusp angle should be shallower than the condylar
path.
• Since anterior teeth help produce disocclusion, when waxing of the occlusal
morphology is done, to produce shallow cusp angle, the anterior portion of the
working cast becomes an obstacle - cast with a removable anterior segment is fabricated.
173
Different adjustment values of an articulator were determined for each occlusal scheme to reproduce the standard amount of disclusion
The application of the two conditions described to fabricate the cusp angle and anterior guidance are termed as ‘
twin stage procedure
Condition 1 Condition 2
• The occlusal morphology of • Secondly, the anterior

the posterior teeth without morphology of the anterior
anterior segment is produced segment is produced to
so that the cusp angle is provide anterior guidance
coincident with the standard with standard amount of
value of effective cusp angle. disocclusion. This is referred
This is referred to as to as ‘ condition 2’
‘condition 1’ 174
Factors that determine
disclusion Cusp shape factor
• Angle of hinge rotation

• Cusp shape factor • Posterior teeth disclude only when the
• Anterior guidance is steeper than condylar cusp inclination of the molar is parallel to
guidance. the condylar path and anterior guidance is
• The mandible rotates around the steeper than condylar path.
intercondylar axis .
• The fact that compensates for the
difference in steepness is the angle of
hinge rotation
175
During protrusive movements, During protrusive movement,
condyle rotates condyle translates
along horizontal axis if anterior without rotation when anterior
guidance (/?) is steeper than guidance (~3) and condylar
condylar path ((Y). Angle of hinge path (fi) are parallel.
rotation compensates for
this angular difference.
176
When cusp inclination of molars Posterior disclusion is evident when
is parallel to anterior guidance, cusp inclination of molars is parallel
there is no posterior disclusion to condylar path and anterior
despite guidance (8) is steeper than condylar
steeper anterior guidance (fi) path ((Y).
than condylar path ((Y).
177
Contraindications
• In the above contraindicated cases, the

vertical axis of the posterior teeth may have • Abnormal curve of Spee
inclined abnormally.
• As a result, the effective cusp angle may vary
• Abnormal curve of Wilson
to some extent even though the cusp angle • Abnormally rotated tooth
of a n atural tooth varies minimally.
• In such condition The standard effective • Abnormally inclined tooth
cusp angle presented in the twin-stage
procedure may not be applicable - occlusion
of a restoration may be inaccurate
178
Evaluation of twin stage procedures
The articulator test The intra oral test

• In the intraoral test, when the results of
test 1 were completed and satisfactory, the
• In the articulator test, after completion of restoration made on the articulator was
the posterior occlusal wax-up on casts cemented in the patient's mouth.
mounted on an articulator (under
Condition 1 ), and adjusting the articulator • Then it was tested to determine if the
(under Condition 2), the specific amount amount of disocclusion was reproduced as
of disocclusion occurring during various occurred in test 1 .
eccentric movements was determined.
• This is an in vivo test.
• This is an in vitro test.
179
180
181
182
Solving deep overbite
problems
• Care must be taken to maintain neutral zone relationship of upper anterior teeth.
• Deep overbites are almost always related to strong lip pressures and a tight neutral
zone.
• Phonetic relationship of incisal edges is critical for deep overbite patients.
• Supraeruption of lower incisors often requires correction.
• If lower incisors are shortened, stops must be provided.
• If stops cannot be provided, a removable substitution may be needed to prevent
supraeruption, or splinting may be considered.
183
Applying the principles
• A poorly made anterior fixed bridge with no holding contacts.
• The lower incisors erupted up to impinge on gingival tissues.
• The lower lip position is behind the upper incisors because the tight neutral zone
prevented the lip from fitting in front for a normal lip seal.
• The result was very unaesthetic as well as unstable.

184
The first goal of treatment is to achieve stable holding contacts on all anterior teeth.
The first treatment option: The second treatment option:

Reshape Reposition
 It is often necessary to • If the upper incisors have

been wedged forward,
reshape the lingual of upper they can be moved back so
restorations to provide a lower incisor contact can
be achieved.
holding contour and • Changes the neutral zone
as the lower lip will be able
shorten the lower incisors if to slide in front of the
they have erupted up too far labial surfaces to hold
them back as the lips seal.
to make contact.
185
• A simple but effective appliance for The complete lack of holding The anterior teeth are brought
moving the anterior teeth back into contacts on the straight lingual lingually, their lingual contours
a predetermined position against contours of the original has to be recontoured to permit
restoration. anterior teeth contact into a stop.
contoured slots in the palatal part of
the appliance. A rubber band directs
the teeth into the slots.
186
The third treatment option: Restore
• After the teeth have been brought • Teeth are prepared and To achieve contact on all lower
into an acceptable alignment by provisional restorations are anterior teeth, it is often necessary
reshaping and repositioning. used refine the anterior to move one or more teeth
guidance and esthetic forward. Any tooth that is
concerns. not in contact will supraerupt.
187
After the teeth have been
repositioned for centric
relation contact, the final
details are worked out in
provisional After approval, the details must be communicated precisely to the technician via
restorations. The patient may casts of the approved provisional mounted in centric relation.
wear the provisionals as long A putty silicone index communicates the exact incisal edge positions.
as necessary to determine that A customized anterior guide table communicates the lingual contours, leaving
they are comfortable, nothing to chance for fabrication of the finished restorations.
functional,
and esthetically acceptable. 188
Deep overbite with tissue contact
• Lower incisors erupt up into soft tissue • The lower incisor tissue contact is
lingual to the upper anterior teeth. It is not simultaneous with contact against the lingual
surface of the cingulums of the upper
a problem if: incisors.
 The upper lingual tissue has been • The incisal edges of the lower incisors are
smooth with no sharp edges.
unaffected by the contact. • The incisal plane of the lower anterior teeth
is acceptable esthetically and must be in
 The contacted tissue is dense, firm, flat, conformity with the rest of the occlusal
and shows no sign of inflammation. plane.
189
190
191
192
Deep overbite problems associated with an
anterior slide
• Such a problem calls for a three-step solution:
1. We must equilibrate to permit the mandible to close without deflection from posterior
teeth.
2. We must shorten the lower incisors to position the incisal edges in an optimum
relationship to previsualized centric stops on the upper incisors.
3. We must restore the upper lingual contours to establish stable centric stops
193
Solving deep overbite problems
by splinting
• Teeth that have supraerupted into the Includes
palatal tissue can be shortened to • Full coverage
relieve the pressure against the soft
• Resin bonded lingual restorations
tissues.
• Modifications in partial denture e.g.
• Splinting is often the most practical continuous clasp splinting and
method of stabilizing such lower Swing-lock design.
anterior teeth.
194
Bite planes to solve deep overbite problems
• Discomfort from tissue impingement and if future problems are imminent.
• Least complicated way of preventing supraeruption of the lower anterior teeth.
• Fabrication is carried out on centrically mounted models.
• The appliance is most esthetically acceptable when it is made of clear acrylic resin. It must provide
stable centric contacts for all lower teeth, and it should be equilibrated so that there is no interference
to any excursive movement.
195
Partial dentures to solve deep
overbite problems
• When an upper partial denture is required, it can sometimes fulfill a double purpose by
serving as a contact for the lower anterior teeth.
• Palatal bar is designed to cover the tissues behind the upper anterior teeth, the lower anterior
teeth may be permitted to contact the palatal bar to prevent supraeruption.
• The contour of the palatal coverage may be designed to permit protrusive excursions of the
lower anterior teeth to slide smoothly from the palatal coverage onto the lingual inclines of
the upper anterior teeth.
196
Solving anterior overjet problems
• Overjet patients present the greatest difficulty for providing centric stops on all the
teeth.
• Careful observation is important to make sure the overjet relationship is not stable
before attempting to correct it.
• The tongue is a common substitute for holding contacts.
• Evaluate to see if it effectively stabilizes the lower incisors
• Evaluate the horizontal component of jaw function before arbitrarily moving
anterior teeth.
• Problems with posterior teeth stability are common with anterior overjet because of
the difficulty of providing anterior guidance with posterior disclusion .
197
• It is essential to determine whether the overjet
is caused by maxillary protrusion, or by
mandibular insufficiency before a treatment
plan is selected.
• Overjet problems are common in children with

airway problems because the tongue must
posture forward to permit mouth breathing.
Correction of the airway problem is critical to
correction of the overjet problem. Note the A point is forward of the nasion
perpendicular while Po is in correct alignment
with the cranial base. The maxilla is
Use the nasion perpendicular analysis the problem.
198
Extreme anterior overjet treatment choices
Reshape
• Some overjet problems can be corrected by closing the vertical dimension of occlusion (VDO) to permit the arc of closure
to move the lower anterior teeth forward into contact with the upper anterior teeth
Orthodontics
• This is very often the best solution, sometimes in combination with restorative dentistry.
Restorative dentistry
• to restore holding contacts or to splint incisors to teeth that have contact in centric relation.
Removable appliances
• to provide palatal bar stops for lower incisors
Surgery
• to move the maxilla back or the mandible forward or to reposition the maxillary anteriors back with an osteotomy
199
The problems of anterior overjet
Problem 1 Problem 2 Problem 3

associated with excessive anterior
• Lower teeth with no stabilizing • Excessive overjet overjet is esthetics.
contact with the upper teeth relationships make
it difficult or The classic bucktooth appearance
either in centric relation or impossible for the has long been used by cartoonists
near centric relation have anterior guidance to depict stupidity.
tendency to supraerupt, drift to do its job of
posterior It is not a pleasant appearance,
out of alignment, and
disclusion. and it is often the real reason why
frequently impinge on the patients seek treatment.
palatal tissues.
200
The resolution of anterior overjet problems
involves four considerations:
 Stabilization of the lower anterior teeth
 Providing the best possible anterior guidance for posterior disclusion in protrusion
 Providing the best possible relationship for disclusion of the balancing inclines
 Improving the position, alignment, or shape of the upper anterior teeth for better
esthetics
201
Option
1 Reshape
Analysis on mounted casts

showed the need to narrow the incisors to
make room for
moving the incisor segment lingually.
The lower lip locks behind the

upper anterior teeth, affecting Option
Overjet with lower incisor contact on speech and causing exposure to 2 Reposition
palatal tissue with esthetic concerns. unesthetic drying of the
incisors" labial surfaces. After narrowing the incisors to a predetermined
width, an appliance is made with 202 a lingual plate
contoured to receive the teeth into their
predetermined
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health position
Sciences; 2006 asPAGE
Jul 31. they are moved lingually.
NO.469
A rubber band attaches to the appliance to move the teeth
into the contoured slots in the lingual plate. Use of such
appliances
is a simple way to achieve dramatic results, but alternative
methods using bands or brackets must always be
considered if final positioning requires horizontal bodily
movement of roots.
Results of repositioning show an improved incisal plane as

incisal edges move down as they are pulled back into a position
that permits contact with the lower incisors. Note: The
appliance increases the VDO to allow room to move the upper
teeth back. The lingual contours are then reshaped to
ideal contact with lower incisors.
203
Restore The mounted cast of approved provisionals
provides exact details to the technician
Option 3
Teeth are prepared, and a

provisional restoration is
made as a copy of the
diagnostic
wax-up. The provisional
restorations are refined in the
mouth The putty silicone index communicates incisal
edge position and contour. The custom
The restorations are tested for anterior guide table communicates the exact
a smooth functioning anterior lingual contours.
guidance, making sure that
immediate disclusion of the
posterior teeth is achieved.
This may require some

reshaping of Final restorations copy all of the
posterior surfaces. details. Nothing is left to chance.
204
Post-op stabilization. Because teeth were repositioned, a period
of post-op stabilization is indicated. This can be easily
accomplished with a simple Biostar appliance made of flexible
Finished restorations (far right) showing vinyl. It requires no clasps because it snaps over the
improved relationship to smile line. teeth and engages the undercuts for retention. 205
Solving anterior open bite problems
• The most important determination is what • Skeletal malrelationships can usually be

caused the open bite. successfully treated.
• Always evaluate the condition of the • There are many degrees of open bite
temporomandibular joints (TMJs). Loss of depending on tongue or lip habits that
condylar height usually causes progressive intrude teeth or prevent their eruption.
anterior separation.
• Many anterior open bites are stable.
• If a habit pattern caused the open bite, • A major problem of anterior open bite is
correction will be unsuccessful unless the
habit is eliminated. trauma to posterior teeth.
• A second major problem is lack of an
anterior guidance for posterior disclusion
206
Treatment objectives
1. Maximize the number of equal- 5. Achieve posterior disclusion in
intensity occlusal contacts on both sides protrusive by determining the anterior
of the arch. guidance as far forward as possible.
2. Correct a "reverse smile line" on upper 6. If anterior guidance cannot be
anteriors for esthetic improvement. achieved for disclusion of the balancing
side, use group function of the working
3. If only one arch is malaligned, close side posterior teeth.
the anterior relationship by correcting the
arch that is wrong. 7. If condylar breakdown is progressive,
correction of the occlusion must keep up
4. If a habit pattern cannot be broken, with it.
the occlusion must conform to the habit.
207
Anterior open bite in a patient with
occluso-muscle pain.
Deflective interferences on molars
created a slide to maximal
intercuspation. At maximal
intercuspation, no contact
was possible for the anterior teeth.
208
Tongue posture at maximal intercuspation
Maximal intercuspation after occlusal correction by
equilibration.
Anterior teeth still could not contact opposing teeth.
Position of teeth after 10 months.
No orthodontic treatment or any other attempt was made

to close the anterior open bite.
The teeth erupted to contact because the tongue no

longer maintained a posture to cushion the bite for
protection of the deflective premature contact.
209
Severe anterior open bites
• Solving the problem of achieving a stable anterior relationship may require a three-
pronged attack:
1. Orthodontic correction of anterior tooth relationships
2. Occlusal equilibration to eliminate the need for protective tongue or lip habits
3. Use of a retainer at night
210
• Anterior open bite. First treatment option: Reshape. Contour of
Contact in centric relation space indicates that the tongue will not be a
problem if the space is closed.
is only on second molars.
The question to ask: How much closure can we
Esthetics is a major get by reduction of the posterior teeth? This can
concern of the patient. be determined on the mounted casts.
it is practical to shorten the molars to gain anterior contact.

This overlay can then be shaped in the
Adjustment on the casts shows that contact in the canines could
mouth to show the patient in advance what
be achieved by judicious reshaping of the molars to close the bite
a change in the incisal plane would
do for the smile. 211
Surgical option
Important rule: Don’t
change what is right to
• Inclination of opening toward the front fit what is
suggests that a successful result can be wrong. Analysis shows
achieved by closing the vertical space that the height of the
between the anterior teeth. lower incisal
• The first treatment option of reshaping plane is correct.
could only achieve this much closure
without mutilating the molar teeth.
• This leads to evaluation of repositioning
the teeth but it would have to involve the
dento-alveolar process to achieve an
acceptable esthetic result.
212
The upper dento-
alveolar segment
should be
repositioned down
to close the space
and gain contact
with the lower
teeth.
Final result achieves a pleasant esthetic

result as well as a functional anterior
guidance.
The steep guidance was acceptable
because the envelope of function was
very vertical (as it is on most anterior
open bites).
213
Treating end to end occlusions
Anterior end-to-end relationships
Important considerations: • The principal problem is failure to disclude
the posterior teeth in excursions, so care
• Anterior end-to-end relationships may must be taken to make sure the occlusal
be very stable if they are in harmony plane and fossae contours are correctly
with centric relation. Lateral anterior related for disclusion by the condylar path
guidance is achieved by sliding on the balancing side.
sideways against ,the flat incisal edges. • This typically requires flatter occlusal
• Condylar guidance can usually contours for disclusion on the working side
combine with flat anterior guidance to because working side disclusion is achieved
disclude all posterior teeth. solely by the lateral anterior guidance.
214
• Changing an anterior end-to-end occlusion to an overlap relationship steepens the anterior
guidance and will probably cause a bruxing wear problem on the anterior teeth.
• A nighttime bruxing appliance is in order whenever the envelope of function is restricted.

• Even though restriction of the anterior guidance causes wear, etc., it is not usually
uncomfortable for the patient as long as there are no interferences to centric relation
closure.
• The ideal solution is to maintain the anterior guidance as flat as possible if esthetic goals can
be met without an anterior overbite relationship
215
Restoring end- to-end anterior teeth
• Minimal changes in incisal edge position can • Restorative recontouring of teeth in an end-to-
effect gross improvements in anterior function. end bite an cause special problems if the
stresses are moved off the direction of the long
• Moving the upper incisal edges forward and the axis.
lower incisal edges inward can extend the • The stresses are so confined to the long axis
protrusive contact by a couple millimeters or that the periodontal fibers and the bone
more. trabeculae are not aligned to resist lateral stress.
• Even a horizontal zero-degree guidance can • Suddenly changing a tooth's contour to subject
it to lateral forces may produce unwanted
fulfill all the disclusive needs of the posterior
effects of tenderness or hypermobility until the
teeth if occlusal contours are also kept flat fibers realign and the bone becomes more
enough and the occlusal plane is correct. resistant to the lateral forces. 216
• The choice that must be made is between increasing the vertical dimension
of occlusion (VDO) or endodontically treating the teeth and maintaining
the VDO.
• The VDO should be increased no more than is necessary to provide room

for the restorative materials on the incisal edges. 1.5 mm increase should
usually provide the needed space.
217
Special considerations
The decision to alter the occlusal relationship should be
based on a careful evaluation of the following factors:
Stability Skeletofacial profile

• Whether an end-to-end occlusion is stable • Requires cephalometric analysis as well
as mounted diagnostic casts.
depends principally on two factors:
• The purpose of the cephalometric
evaluation is to determine whether the
1. Harmony with the neutral zone end-to-end relationship is caused by an
underdeveloped maxilla or an
2. Noninterference with the envelope of overdeveloped mandible, or some
function combination of both.
218
Function Esthetics
It is rare for a patient with a stable • The irony of an anterior end-to-
end occlusion is that although
end-to-end relationship to many dentists believe it should be
complain of inadequate function. "corrected," most patients believe it
is the ideal relationship.
219
Neutral zone
• If an end-to-end relationship occurs

posterior to the facial plane, it results in a
"pushed-in" appearance as a manifestation
of bimaxillary deficiency
• This type of occlusal relationship should

be treated with caution because it is usually
accompanied by a very strong buccinator-
orbicularis oris limitation on arch size.
220
Posterior end-to-end relationships
1. Are all teeth stable or unstable? (Look
for wear or hypermobility.) • reshaping
2. Can the anterior guidance disclude • repositioning
the posteriors? If so, an end-to-end • restoring (with centralized cusps)
occlusion is not a problem.
• surgery
3. If anterior guidance cannot disclude
the posterior teeth in lateral excursions,
correct the posterior relationship by the
best choice of:
221
• Evaluate each method and select the most practical way to fulfill the requirements for
stability.
• The goal is posterior disclusion of the balancing side either by the anterior guidance or by
the posterior teeth on the working side.
• 4. Anterior guidance can sometimes be steepened if it is not steeper than the lateral path
originally found during excursions dictated by posterior teeth
222
Restoring end-to-end
posterior teeth
The goal is to provide as much stability as possible in centric relation and as much relief as possible in
excursions.
• Lower Cusp Tip to Upper Flat Surface

• Overjet can be provided to hold the cheek
away from the contacts.
 Provide almost normal lower posterior
• Adequate as long as the teeth are
occlusal form, with slight modifications to positioned in harmony with the cheeks
flatten and broaden upper cusp tips to and tongue.
serve as stops for the more rounded lower

cusps.
223
Centralization of the Lower Cusps
 By converging the lower buccal and lingual cusps into
single centralized cusps, it is practical to place them in
the central fossae of the upper teeth.
 Stress direction is ideal for both upper and lower teeth,

and function is excellent.
 With centralized lower cusps, the upper working inclines

can be used to disclude the balancing inclines on the
opposite side, and it can be accomplished within the
limits of the normal neutral zone.
224
Treating splayed or separated teeth
• Some splayed anterior teeth with spaces are healthy and have stable holding
contacts.
• If the teeth are stable and the supporting structures are healthy, the decision
is based on the patient's esthetic desires.
• Splayed anterior teeth are usually in a definite neutral zone corridor.
• They can be moved or reshaped within that corridor, but movement toward
either the tongue or the lips usually results in interference with the
musculature and eventual instability.
225
• The patient presented with the
primary concern of improving
the esthetics of his smile.
• The teeth were splayed,

separated, and inclined forward.
• All teeth were firm with no sign

of wear or fremitus.
226
Maximal intercuspation Centric relation
• There is a long slide from the first • The true arc of closure to anterior contact in
contact at the most closed position. centric relation can then be determined on
mounted casts.
EQULIBRATION
OF CASTS
ANTERIOR 227
GUIDANCE
THE DIAGNOSTIC
• DIAGNOSTIC WAX UP NEUTRAL ZONE
WAX-UP COMPLETED
CONSIDERATIONS
Splayed anterior teeth are usually in

Prepared teeth. Note
the most balanced relationship
centric relation contact on
between tongue and lip pressures.
centrals
and canines.
228
Patient can test the provisionals to be The putty silicone index precisely
Matrix used as reduction guide and for direct sure that appearance, communicates the incisal
fabrication of provisional restorations phonetics, and function are all acceptable. edge position and contour that can
then be copied in the
wax-up on the master die model.
A customized anterior guide

Functional esthetics. Mounted cast of the
Provisional restorations in place table dictates
229 the exact
approved provisional restorations eliminates
configuration
all guesswork for the
Elsevier Health Sciences; 2006 Jul 31. of
Dawson PE. Functional occlusion-e-book: from TMJ to smile design.technician. the NO.501,502
PAGE lingual contours.
Precise doctor/technician communication yields precise Lingual contours on the restorations match what
results. The finished restorations follow the exact guidelines was worked out in the mouth and communicated
that were worked out in the mouth and tested in function. via the customized anterior guide table.
The putty matrix simplifies communication in a way that is
verifiable by both the technician and the dentist 230
Treating the cross bite patient
• first analyze the tooth-to-tooth relationships at the selected vertical dimension in

centric relation.
• Is the anterior crossbite the result of mandibular prognathism or maxillary
deficiency?
• What is the anterior relationship in centric relation?
• If it is end to end in centric relation, how much vertical displacement of the
condyles is there in maximal intercuspation?
• Do the anterior teeth need to be restored because of wear or appearance?
• Is the crossbite an esthetic problem? Can the anterior teeth be restored end to end?231
Problems with anterior crossbites
Esthetics No centric contact on anterior teeth
• Elimination of the • In more severe malrelationships, there is no

"bulldog look" of anterior contact.
prognathism • The usual problem associated with lack of
• surgery seems to be the centric contact is supraeruption of the teeth.
only practical method if • This is rarely a problem with anterior crossbites
the prognathism is severe. because the upper lip substitutes for the contact
and holds the lower anterior teeth in place.
232
No Anterior Guidance
Most prognathic patients limit their function to vertical "chop chop"

movements
Provide balancing incline disclusion.

The necessary lift can usually be provided by the working-side inclines.
Group function of the working inclines is usually the occlusion of choice.
233
Why increasing the VDO works?
• If the increased VDO at the anterior • Even if increasing the VDO cannot be
teeth is offset by upward movement of offset completely by upward condylar
repositioning, the increased VDO can
the condyles from maximal
be well tolerated as the muscles return
intercuspation to centric relation, the it to their original contracted length.
interference with elevator muscle
• If all teeth are in contact in centric
contracted length may be minimal or relation, the corrected occlusion will
none. be maintained with minimal
adjustments required
234
235
• Anterior crossbite at maximal closure. At this
most closed position, the condyles are displaced
down and forward
• The end-to-end relationship occurs in centric

relation when the condyles have moved up their
eminentiae.
236
• An existing removable partial denture was used to
increase the VDO at the anterior end-to-end
relationship.
• Based on the analysis on the mounted casts, the

anterior teeth were narrowed a predetermined
amount to facilitate moving them into a better
alignment that was pre-established on the
diagnostic wax-up.
237
• A continuous clasp was cast to fit the
repositioned teeth on the diagnostic wax-
up.
• The clasp is bonded to the canines on each

side. The canines and central incisors are in
the neutral zone and will not be moved.
238
Small rubber bands are
used to pull the lateral The conservative approaches for resolving
incisors into the slots anterior cross bite problems can be summarized
designed to receive as follows:
them 1. Selective shaping and occlusal equilibration
2. Orthodontic repositioning of the teeth within
the
Alignment of present bone framework
the teeth 3. Restorative reshaping
progresses 4. A combination of the above procedures
After the lateral incisors are aligned, direct composite buildup is used to
develop contacts and contours.
It is copied in provisional restorations that serve as a retainer until final
preparation and completion.
239
Surgical Correction of Anterior Crossbite
There are three methods for correcting an anterior crossbite surgically:
1. Resection through the ramus so that the body of the mandible can be moved
distally into alignment with the maxilla.
2. Horizontal resection of the maxilla so that it can be moved forward into

alignment with the mandible.
3. Sectional osteotomies so that an anterior segment can be repositioned. This is

not ideal if there is a severe skeletal discrepancy.
240
• Determining the best treatment choice for posterior crossbite. In most
instances, it is "leave it alone" unless there are interferences to centric relation
or excursions.
• Analyzing cusp/fossae relationships in crossbite cases. The lower lingual cusp

and the upper buccal cusp become the stamp cusps.
Treatment objective
• Cross bite occlusions follow the same rules as normal occlusions with regard to
the requirements for stability. They just use different cusps for holding
contacts. 241
Restoring Posterior Crossbite
• The most common treatment mistake in crossbites: Upper inclines that face the cheek or lower inclines
that face the tongue should never contact in lateral excursions.
• This rule should be followed regardless of the arch relationship.

• All inclines should disclude when the lower teeth move toward the tongue.
• When posterior crossbites are being restored, the lower lingual cusps become the functioning cusps.
• They fit into the same upper fossae and function against the same inclines as the lower buccal cusps do
in a normal relationship.
242
• If posterior group function is desired, the lower lingual cusps contact the
lingual inclines of the upper buccal cusps in working excursions (laterotrusion).
This working incline contact can be used very effectively to disclude the
opposite-side balancing inclines.
• The lower buccal cusp is a nonfunctioning cusp in crossbite relationship, and its
lingual inclines should never contact; so it should be shortened slightly from the
normal contours so that it does not interfere in balancing excursions
(mediotrusion).
243
Treating crowded, irregular, or interlocking
anterior teeth
Five possible ways of solving the space problem:
• 1. We can narrow the teeth so that they will fit into the available space.
• 2. We can widen the space by reshaping the adjacent teeth.
• 3. We can reduce the number of teeth that must fit into a given space.
• 4. We can increase the space by changing the shape 0f the arch.
• 5. We can change the axial inclination of the anterior teeth.
244
Several techniques that can be used
for moving teeth into their Narrowing
predetermined correct position in
the arch: crowded teeth
 Finger pressure • Invisible retainers
Flexible ethylene vinyl acetate (EVA) polymer
 Ligatures and rubber bands joined to a semi rigid polycarbonate material.
 Removable appliances
• Invisalign
 Bands It utilizes a series of computer-generated
sequences for tooth movement to achieve an
 Cemented brackets ideal alignment of teeth in both arches.
 Vinyl repositioners
245
• The upper-left central incisor was
locked behind the lower incisors.
• Because the incisal third of the
tooth was fractured, it was just
shortened further so it could be
moved forward without having to
open the bite temporarily to move
it past the lower incisal edges.
246
A simple removable appliance was used
with a finger spring
to push the tooth forward until it was
positioned in alignment
with the other upper anterior teeth.
After the tooth was in position, it

was prepared for provisional
restorations.
Preparations were then completed.

The anterior guidance was refined so a A provisional restoration was copied from
cast could be made the diagnostic
and mounted in centric relation to wax-up. This will serve as a 247
retainer until
fabricate a custom anterior the bone stabilizes.
guide table. After approval, permanent restorations will
Producing acceptable occlusal relationship
using Invisalign®
• Patient with upper-left

lateral and canine locked
behind lower teeth.
• The upper-right lateral
and canine are lingually
inclined to create a poor
esthetic alignment.
248
A centric relation bite is made using bilateral manipulation with
load testing to verify centric relation.
Casts are mounted in centric relation with an earbow for The index is used in the computer-generated jaw
location of centric relation condylar axis. relationship to
A silicone index is made to relate the casts to centric which the teeth will be aligned. This corrects for
249
relation at first point of tooth contact. discrepancies inherent
in unmounted casts related to maximum intercuspation.
Series of Invisalign® overlays to be used in sequence.
Computer-generated image of
starting point.
Image of projected treatment

goal. The treatment goal for this
patient includes the use of
laminates for the initial
determination of
where the teeth needed to be
positioned to facilitate an
esthetic and functional result.
Finished result of very conservative
Teeth after movement to the treatment. Central incisors were
predetermined treatment goal. bleached to lighten color, avoiding any
Planning included use of need for restorations on them.
laminates for final esthetic Note the uniform occlusal contact in
position and contour on right centric relation, made possible
and left laterals and canines. by aligning the teeth to a correct maxillo-
mandibular relationship.
250
Teeth prepared for laminates.
Crowded anterior teeth with severe posterior
interferences
251
252
253
SUMMARY
Procedural steps in full mouth rehabilitation
Evaluate vertical Diagnostic
Facebow
Case history Diagnostic dimension and mounting on a
record, Inter
and clinical impressions Occlusal semi
interference for occlusal
examination adjustable
slide in centric record articulator
Evaluate for crown

height, retention Diagnostic wax- Occlusal splint Occlusal
Selection of
form,surgical up at estimated to confirm loss equilibration for
occlusal
crown lengthening, vertical relation of vertical removal of gross
intentional root of occlusion scheme
canal treatment dimension interference
Approach to Determine Shade

Multidisciplinar
FMR Segmental material for
y approach
Quadrant wise restorations selection 254
Shade selection Metal tryin
Prepare lower anterior teeth

Bisque tryin
Provisionalization
Prepare upper anterior teeth Temporary cementation of final

Provisionalization anterior restorations
Evaluate anterior plane for Final impression of upper and

occlusion, phonetics, esthetics and lower posteriors
function
Evaluation of anterior guidance,
plane of occlusion, and occlusal Interocclusal record to mount on
scheme on provisional articulator
restorations
Recording and transferring Metal tryin

anterior guidance record of
provisional 255
Final impression of upper and Bisque tryin

lower anteriors
Temporaty cementation of upper
and lower final posterior
restorations
Evaluate for function, esthetics

and comfort
Remounting
Final cementation of restorations
Maintenance phase
•
Follow up
256
CASE REPORTS – Bruxism
• 45-year-old male patient with a habit of bruxism
• Attrition :
• Marginally less in the posteriors as compared to the anterior teeth
• Total collapse of the vertical dimension
• Lower anterior teeth were totally razed to the gingival level
• Upper lateral incisors & canines were also very badly destroyed
257
CASE REPORTS
• Second molars : Intercuspating occlusion
• First molars : > 40% attrition on the occlusal surfaces with no intercuspation
• Upper right lateral incisor & canine : attrided to the gingival level
• Lower Anterior : Right f
• irst premolar - left canine were totally razed to gingival level
• Remaining teeth : > 40% of loss of crown structure
258
CASE REPORTS
• Phase I
• Endontic
• Reestablishment of Vertical dimension
• Occlusal equilibration
• Phase II
• CLP
• Upper and lower incisors
• Endodontics
• Glass fiber posts + Adhesive restorations
• Post & core on upper right canine & lower canine
259
CASE REPORTS
260
Amelogenesis Imperfecta
 Incisal aspects …completely worn away exposing the pulp chambers
 Occlusal aspects of all the posterior teeth were also severely worn
 Cervical & proximal enamel was found to be normal
 Attrition of the molars resulted in a decrease of the vertical dimension of

occlusion
 Interocclusal distance : At physiologic rest position = 7.3 mm

 Centric Occlusion = Maximum intercuspal position
 Gingival status: Good and well maintained
 Oral hygiene : satisfactory
261
CASE REPORTS
Panoramic Radiographic Examination

Enamel of the teeth appeared to have the same radiodensity as dentin
Morphology of the roots were normal
Pulp chambers were normal with no evidence of calcification
Cementum, lamina dura, & bony trabeculations were within normal limits 262
C
 Inadequate crown height for the fabrication
ASE REPORTS
of the prosthesis
 Apically positioned flap
 Crown lengthening
 Increase of crown height by approximately 2 mm was achieved
 Caries excavation was done for all carious teeth
 Endodontic therapy was carried out as required
 Bite registration using Type II modeling wax

 Increased vertical dimension of 5 mm with 3 mm of freeway space
 Splint fabricated with heat-cured Polymethyl methacrylate acrylic resin
 Patient used the splint for three months
263
CASE REPORTS
 Full-mouth, heat-cured provisional restorations were fabricated at the desired vertical dimension (with 3
mm freeway space) using methyl methacrylate acrylic resin & were temporarily cemented
264
Ccores
• Maxillary anterior teeth: cast post ASE REPORTS
• Mandibular anterior teeth : prefabricated posts
• Premolars & right first molar : Composite core build-ups to
increase the crown height
Crown preparation:
Porcelain-fused-to-metal (PFM) : Maxillary & mandibular anteriors,
premolars, and maxillary first molars
All-metal restorations: remaining teeth
265
CASE REPORTS
266
Failure and success in full mouth rehabilitation
• dependent on technical and • Health of periodontium is influenced by

biophysical factors. the oral hygiene practice of the patient,
crown position and margin, contour and
• Technical failures may be loss of occlusion of the restoration.
restorations and retainers or
• Hygiene instructions combined with
fracture of metal or porcelain repeated prophylaxis every six months
components. prove successful in maintaining oral
• Caries, fracture of abutments, health. Adequate plaque control
periodontal disease and extractions program to prevent secondary caries is
are classified as biological failures. essential
267
Conclusion
• The patient needing extensive restorations is often neglected and overlooked by a
general practitioner due to lack of specialized training. Its important to know that
achieving success in full mouth rehabilitation requires a multidisciplinary approach.
The ultimate goal of any dental treatment is to provide optimum oral health1.
• to attain this ooral health it is important to have properly scheduled recall visits and
oral hygiene maintenance . Restorations must be meticulously fabricated considering
mechanical and biological factors,which will ultimately lead to long term success of
full mouth rehabilitation
268
References
• Evaluation.Diagnosis, and treatment of occlusal problems Peter E Dawson 2nd edition
• The freeway space and its influence in the rehabilitation of masticatory apparatus vol 2 no 6 J pros dent
1952
• A Three-Stage Approach to Full-Mouth Rehabilitation Compendium—Volume 29 (Special Issue 1)
• A Three-Stage Approach to Full-Mouth Rehabilitation Pract Proced Aesthet Dent 2008;20(2):81-87
• An analysis of current practices in mouth rehabilitation J pros dent 1955
• Full Mouth Rehabilitation with Group Function Occlusal scheme in a patient with severe Dental Fluorosis
INDIAN JOURNAL OF DENTAL ADVANCEMENTS vol 3 issue 3
• Custom Made Occlusal Plane Analyzer: Fabrication and Technique International Journal of Advanced
Dental Science and Technology 2013, Volume 1, Issue 1, pp. 17-24
269
• PHILOSOPHIES IN FULL MOUTH REHABILITATION – A
SYSTEMATIC REVIEW Int J Dent Case Reports 2013; 3(3): 30-39
• The Dahl principle revisited Irish Dentist July 2011
• ORAL REHABILITATION Part I. Use of the P-M Instrument in Treatment
Planning and in Restoring the Lower Posterior Teeth J. Pros. Den. Jan.-Feb., 1960
• Increasing occlusal vertical dimension — Why, when and how D R Bloom
& J N Padayachy British Dental Journal 200, 251 - 256 (2006)
• Broadrick occlusal plane analyzer 2008 whipmix corporation
• Twin – tables technique for occlusal rehabilitation : part 1 – Mechanism
of anterior guidance J PROSTHET DENT 1991, vol 66 pg 299-303
• Functionally generated paths for Ceramometal restorations J PROSTHET
DENT 1999, vol 81 pg 33-36
270

Full Mouth Rehabilitation: Presented by DR - Namitha AP 3rd MDS

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Mouth Rehabilitation: Presented by DR - Namitha AP 3rd MDS

Uploaded by

Copyright:

Available Formats

FULL MOUTH

• MASTICATORY SYSTEM DISORDER • COMMON PROBLEMS AND DIFFICULTIES IN FMR

• The term ‘full mouth rehabilitation’ is used to indicate extensive and

All the procedures necessary to produce healthy, esthetic, well

• Restore impaired occlusal

J PROSTHET DENT 1984, vol 52, 467-474

Brecker SC. Clinical procedures in occlusal rehabilitation. WB Saunders; 1966.

Clinical procedures in occlusal rehabilitation .W.B Saunders,Philidelphia 1958

Sensitive teeth Sore teeth Hypermobility Spilt teeth and Painful

Tentative treatment plan done

• Step 2: Verify the accuracy of the mounting.

• Step 5: Determine the correct vertical

• Step 6: Return the condyles to centric

• Step 9: Mark decisions that have been made

• For example, in the figure the two upper

The jaw-to-jaw relationship at the first point of tooth

Equilibration of the casts clearly shows that reshaping

• If the occlusal plane is slanted in the mouth

• Model is trimmed back to the

• Step 12: Establish stable holding contacts on

• Step 13: Correct lower incisal edges if needed.

Cast of poorly contoured

Cast showing defect of lost labial plate of

Block resection and movement of both maxillary and mandibular segments

Prosthetic full mouth rehabilitation is divided into-

Ni-Cr crowns After all

The jaw-to-jaw dimension is maintained with such consistent

• Patient is encouraged to relax his jaws

Harry Kazis and Albert Kazis

• stated that increasing the vertical dimension places the muscles of

• increased the vertical dimension in natural dentition by cementing acrylic resin

• Experiments in animals proved that moderate changes in occlusal vertical

• Any disharmony in the system provokes

• Includes gingivoplasty, osteoectomy

Permissive occlusal splints Directive occlusal splints

• No history of problems in the TMJs, including no history • If there is doubt about

Mix resin and position it on

The completed splint should fit 53

It should be smooth and flat to permit the condyles to seat into

If all tension or tenderness disappears after placement of the

A full-coverage occlusal splint decreases

If injury or inflammation has occurred within the

• Most space is created between

Brit Dent J.1959, vol 106, pg 391-400

1.the ability of the

1.Wax bite procedures

• Indicated whenever there is

• Drawback is that vertical dimension must be increased

The bite record is

• studied the positional difference between retruded contact position and

• advocated freedom in centric relation of occlusion of 0.2 mm which allows

• Indicate that terminal hinge • Shows a need for long centric

• The equilibration is incomplete

• Patient says they are • Freedom of movement in centric

• second most important determination

• two planes - for incisal position and to allow

• There should be no interferences

This is determined by the protrusive path

• Lower incisal edges are the

In ideal instances, the lower

The lower incisal edge is at the height of the

The most important contour on the

The “leading edge”