FULL MOUTH REHABILITATION

PART-I

P R E S ENTED B Y
D R . P R I YADAR SHINI
PG IIIYR
Introduction
STOMATOGNATHIC SYSTEM

TMJ

MUSCLES

TEETH AND
SUPPORTING
STRUCTURES
 BIOLOGIC ADAPTATION

Stomatognathic
system
• Stress/strain

Adaptation to the
environment • If the strain exceeds
adaptive capacity

Damage or • It has to be
disturbance to the restore to normal
system level
 WHAT IS FULL MOUTH REHABILITATION
• Full mouth rehabilitation entails the performance of all the procedures
necessary to produce healthy, esthetic, well functioning and self
maintaining masticatory mechanism

- GPT 8

• Occlusal rehabilitation is defined as the restoration of functional integrity

of dental arch by the use of inlays, crowns, bridges and partial dentures

- GPT 8
WHEN FMR
severly attrited , eroded teeth and in conditions
which will cause pain and discomfort of teeth and
surrounding structures.
Restoration of multiple teeth which are broken,
missing or decayed.
To restore impaired occlusal function
Developmental anomalies , discoloured teeth
WHEN NOT TO.....
• Friends and relatives of one's rehabilitation
• patients will request similar treatment.

• Do not prescribe a full mouth rehabilitation unless

• there is definite evidence of tissue breakdown

• NO PATHOLOGY- NO TREATMENT
GOALS OF ANY DENTAL TREATMENT

ANATOMIC
HARMONY

OPTIMAL FUNCTIONAL
ESTHETICS
ORAL HEALTH HARMONY

OCCLUSAL
STABILITY
OBJECTIVES OF FULL MOUTH
REHABILITATION
Occlusal stability

Anterior guidance

Disclusion of
posterior teeth

Axial loading of
teeth
 HOW TO DETERMINE IF THE TMJS ARE HEALTHY
Range and path of movement tests
Doppler analysis

Load test

Anterior bite plane for muscle deprogramming

Radiography/imaging
Masticatory Musculature
Muscle Response to Occlusal
Interference
DIAGNOSING OCCLUSO-MUSCLE PAIN
WITH NO TMD
• Step 1: Determine whether
any masticatory muscle is
involved in the pain. Is the
medial pterygoid muscle
tender to palpation?
• Step 2: Rule out
intracapsular problems
• Step 3: Relate the specific
muscle pain to the
direction of condyle
displacement
• Step 4: Verify the general
acceptability of condyle
position and condition with
TMJ radiographs if
warranted
• Step 5: Rule out pathologic
factors as a source of pain
• Step 6: Correct the cause
of the problem
 MASTICATORY MUSCLE RESPONSES
Internal pterygoid muscle
Superficial masseter muscle

Deep masseter muscle

Temporalis muscle
Inferior lateral pterygoid muscle. Superior lateral pterygoid muscle.

Hyoid area
• Sternocleidomastoid (SCM) muscle
• Occipital area
• Trapezius muscle
Eruptive Force Vs Tooth Wear
• Throughout life, eruptive force causes teeth to move
vertically with their alveolar bone
• Stopping force:
• Teeth of opp arch
• Tongue..Thumb …Lips
• Objects…. Pipes/ appliances

• Dentoalveloar Compensation: [Berry & Poole 1976]

• TSL compensated by alveolar growth which maintains occlusal vertical
height eg.: Bruxism
• Rate of wear > comp alveolar growth = Loss of VDO
 Tooth Wear
Physiological
At a lower rate
Molar: 29 µ m/ year
Premolar: 15 µ m / year
oLoss of convexity on the cusps
oFlattening of cusp tips on posterior tooth
oLoss of mammelons on anterior tooth
oWear facets with minimal length & depth
oNon Diagnostic
Pathological/ Excessive
At a Higher rate
Parafunction: 3 times of normal
oUnacceptable damage to occluding
surfaces
oDestroy anterior tooth structure
oLoss of anterior guidance
Diagnostic:
Dependably related to tooth surfaces that are
in direct interference with functional / para
functional movements of mandible
TOOTH WEAR
• Attrition
• Normal Process
• Excessive occlusal wear  Intracapsular disorder
• Pulpal pathology  Decreased ramus ht. puts the
• Impaired function molars into interference
• Occlusal disharmony  Posterior tooth Wear:
• Esthetic disfigurement  Interference with completely
seated TMJ / anterior guidance
 Worn surfaces can be contacted
during centric relation closure /
during excursions to and from CR
• Abrasion of teeth
• Diet & chewing of abrasives (tobacco)
• Environmental Factors
• Dust & grit
• Unglazed porcelain restorations

 Erosion
 Chemical action
Citrus juices…Cold drinks… Vinegar…Pickled foods
 Constant Regurgitation/ Projectile vomiting (GERD)
 Loss of Posterior Support
 Attrition of Ant. teeth ….
 Loss of posterior teeth
 Malposition of teeth
 Occlusal interference…. Drives mandible forward
Tooth Wear
• Congenital Anomalies
• Amelogenesis Imperfecta
• Hypoplastic … . 1/8 – ¼ enamel
thickness
• Hypomaturation … . .softer enamel
• Hypocalcified … . friable enamel
• Dentinogenesis Imperfecta
• Weak enamel attachment
• Rapid Attrition
 Tooth Wear

• Bruxism /Parafunctional habits

• Occlusal interferences
• Occlusal splints  Chewing Tobacco
• Occlusal adjustments  Pipe smoking
 Pencil/ Pen biting
 Holding objects b/w teeth
 Emotional stress
 Patient counseling & periodic
self-monitoring
 TURNER AND MISSIRLIAN’S
CLASSIFICATION OF TOOTH WEAR
Category-1: Excessive wear with loss of vertical occlusal
dimension(VDO).

Category-2: Excessive wear without loss of VDO but with

space available.

Category-3: Excessive wear without loss of VDO but with

limited space.
PINDBORG’S CLASSIFICATION OF TOOTH
SURFACE LOSS

• COMPENSATED TOOTH SURFACE LOSS – WITHOUT LOSS OF

VDO

• NON COMPENSATED TOOTH SURFACE LOSS – WITH LOSS OF

VDO
 OCCLUSAL APPROACHES FOR
REHABILITATION
• Constructing the restoration to
CONFIRMATORY conform to patient’s existing
APPROACH intercuspal position

• Entire occlusal scheme is

REORGANIZATION modified and restoration
OF OCCLUSION provided in harmony with
new jaw relationship.
 OCCLUSAL CONSIDERATIONS IN FULL
MOUTH REHABILITATION
Balanced occlusion

Group function

Canine guided occlusion

 Requirements for Occlusal Stability
• 1. Stable stops on all teeth when the condyles are in
centric relation
• 2. Anterior guidance in harmony with the border
movement of the envelope of function
• 3. Disocclusion of all posterior teeth in protrusive
movements
• 4. Disocclusion of all posterior teeth on the nonworking
(balancing) side
• 5. Non interference of all posterior teeth on the working
side, with either the lateral anterior guidance, or the
border movements of the condyle.
HOW TO RECOGNIZE A STABLE OCCLUSION
REGARDLESS OF WHAT IT LOOKS LIKE
• 1. Temporomandibular joints (TMJs) are healthy and stable

• 2. All teeth are firm

• 3. No excessive wear is present

• 4. All teeth have stayed in their present position

• 5. Supporting structures are maintainably healthy

HOW TO RECOGNIZE AN UNSTABLE OCCLUSION
REGARDLESS OF WHAT IT LOOKS LIKE

• THREE SIGNS OF INSTABILITY:

• 1. Hypermobility of one or more teeth
• 2. Excessive wear
• 3. Migration of one or more teeth
a. Horizontal shifting
b. Intrusion
c. Supraeruption
• OCCLUSAL EQUILIBRATION: The modification of the
occlusal form of the teeth with the intent of equalizing
occlusal stress, producing simultaneous occlusal contacts
or harmonizing cuspal relations. ( GPT 9)

• • SELECTIVE GRINDING is defined as any change in the

occlusion intended to alter the occlusal surfaces of the
teeth or restorations to change their form. ( GPT- 9)
OBJECTIVES

• Centric relation occlusion

• Coupling of anterior teeth
• Acceptable disclusion of anterior teeth in harmony with
condylar movement.
• Stability of occlusion
• Resolution of temperomandibular joint symptoms.
INDICATIONS
Nonphysiological occlusion.
-Occlusal trauma
-Occlusal instability.
-After Orthodontic treatment.
-Before/after prosthetic or restorative procedures.
-Marked discrepancy between ICP& RCP.
-Unacceptable interferences.
EQUILIBRATION PROCEDURES
• • 1. Reduction of all contacting tooth surfaces that
interfere with the completely seated condylar position
(centric relation)

• • 2. Selective reduction of tooth structure that interferes

with lateral excursions.

• • 3. Elimination of all posterior tooth structure that

interferes with protrusive excursions.

• • 4. Harmonization of the anterior guidance

INTERFERENCE TO CENTRIC RELATION

• Centric interference can be differentiated into two types-

• 1) Interference to arc of closure
• 2) Interference to line of closure
Interference to arc of closure

• Primary interferences that

deviate the condyle
forward produce what is
commonly called an
anterior slide.

• The basic grinding rule to

correct an anterior slide is
always MUDL: Grind the
Mesial inclines of Upper
teeth or the Distal inclines
of Lower teeth
• When mandible deviates from the line of closure
towards the cheek, grind the buccal incline of
upper or lingual incline of lower.

When the mandible deviates off the line

of closure towards the tongue , grind the
lingual inclines of upper or buccal incline
of lower.
 GRINDING RULES

• Rule 1: Narrow stamp

cusps before reshaping
fossae

• Rule 2: Don’t shorten a

stamp cusp

• Rule 3: Adjust centric interferences first

• Rule 4: Eliminate all posterior incline

contacts. Preserve cusp tips only.
Interference to line of closure

• When mandible deviates

from the line of closure
towards the cheek, grind
the buccal incline of
upper or lingual incline of
lower.

• When the mandible

deviates off the line of
closure towards the
tongue , grind the lingual
inclines of upper or buccal
incline of lower.
INTERFERENCE IN LATERAL EXCURSION

• Lateral interference should be located by gentle

manipulation of the mandible into terminal axis and then
firmly manipulating all the way out to its outer limit..
• Lateral interferences can be divided into –
• Interferences on balancing side
• Interferences on working side
Balancing side interferences
• The goal here is to eliminate all contact on inclines as soon
as the lower teeth move out of centric relation and start
toward the tongue.
• Grinding rule – BULL
• Grind buccal inclines of upper or lingual inclines of lower
 Working side interferences

• Determine the type of occlusion

• Group function
• Posterior disclusion
• Grinding rule – LUBL
 Protrusive interference
• Posterior disclusion in protrusive -by both the anterior
guidance and downward movement of the condyles.
Steep anterior guidance- is usually minimal.
• Flat anterior guidance - extensive corrections.
• During protrusion only anterior teeth should touch and all
posterior contact should be eliminated.
• Grinding rule –DUML
DETERMINING THE PLANE OF OCCLUSION
• refers to an imaginary surface that touches the incisal
edges of the incisors and tip of occluding surface of the
posterior teeth.
• The two basic requirements of plane of occlusion are-
• It must permit the anterior guidance to do its job of
discluding the posterior teeth when the mandible is
protruded.
• It must permit the disclusion of all teeth on the balancing
side when the mandible is moved laterally.
Curve of Spee:

 The relationship of the curve of occlusion to the condylar axis

relates to the condylar path in protrusion.
 It is designed to permit protrusive disclusion of the posterior teeth
by the combination of anterior guidance and condylar guidance.
CURVE OF WILSON
• There are two ways of effectively changing the curve of
Wilson-
• Change the lateral anterior guidance angle
• Change the length of upper lingual cusps
ANTERIOR GUIDANCE

• The dynamic relationship of the lower anterior teeth

against the upper anterior teeth through all the ranges of
function is called ‘anterior guidance’.
STEPS IN HARMONIZING ANTERIOR GUIDANCE

• Establish coordinated centric relation stops

• Centric stops in a postural position must have the same
vertical dimension as those for centric relation
• Refine protrusive excursions
• Establish ideal anterior stress distribution in lateral
excursions.
• Check lateral – protrusive movements
• Smooth transition to a crossover position.
DETERMINANTS OF OCCLUSAL
MORPHOLOGY
• Structures that control the mandibular movement are
divided into two types :
• those that influence the movement of posterior portion of
mandible and
• those that influence the movement of anterior portion of
mandible.
• Posterior controlling factor(TMJ’S)
• The steeper the articular eminence, the steeper path
will the condyles follow during protrusion. It is a fixed factor.
• Anterior controlling factor
• The steeper the lingual surfaces of the maxillary
anterior teeth, the steeper and more vertical will be the
movement of the mandible. It is a variable factor and can
be altered by the dental procedures.
Determinants of occlusion
 OCCLUSAL SCHEMES

• GNATHOLOGICAL CONCEPT/CANINE GUIDED OCCLUSION

• PMS
• FREEDOM OF CENTRIC
• BALANCED OCCLUSION
• HOBO’S TECHNIQUE
• NYMAN & LINDHE CONCEPT
• YOUDELI’S CONCEPT
 OCCLUSAL SCHEME-GNATHOLOGICAL
• Indicated when CR & IP coincident
CONTRAINDICATIONS:
• Tooth loss
• Malocclusion
• Periodontally compromised
OCCLUSAL SCHEME Pankey –Mann-
Schulyer
Area of freedom between CR & IP

Group function in lateral excursions

Long centric is incorporated on lingual surfaces of maxillary

incisors

Potential for error with this technique

 OCCLUSAL SCHEME-Youdelis

• CR & IP coincident

• Canine guided-changes to group function when canine is

periodontally weak.
 OCCLUSAL SCHEME-AREA OF FREEDOM
IN CENTRIC

Canine guidance/ group function

Useful when large horizontal slide exist

between CR & IP
OCCLUSAL SCHEME-BALANCED OCCLUSION

• Area of freedom between CR & IP

• Balanced working and non-working contacts in lateral

occlusion

• Balanced anterior and posterior contacts in protrusive

movements

• Indicated for CD and extensive RPD cases

OCCLUSAL SCHEME-Nyman and Lindhe

• Contacts provided in intercuspal position [IP]

• Bilateral balanced excursive contacts

• Used for cross arch bridges with extreme advanced

periodontitis
SUCCESS OR FAILURE FOLLOWING FULL
MOUTH REHABILITATION
• may be dependent on technical and biophysical factors.
• Technical failures may be loss of restorations and retainers
or fracture of metal or porcelain components
• Caries, fracture of abutments, periodontal disease and
extractions - biological failures.
• Health of periodontium is influenced by the oral hygiene
practice of the patient, crown position and margin,
contour and occlusion of the restoration.
• Hygiene instructions combined with repeated prophylaxis
every six months prove successful in maintaining oral
health.
 References :
Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent
1985;52:467-74.

Krishna MG, Rao KS, Goyal K, Prosthodontic management of severely worn dentition:
including review of literature related to physiology and pathology of increased vertical
dimension of occlusion. J Prosthet Dent 2005 ; 5(2): 89-93

Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems, ed 2. St Louis:

Mosby, 1989.

Okeson JP, Management of Temporomandibular Disorders and Occlusion, ed 4. St Louis: Mosby,

1998:160.