full mouth rehabilitation/ academy general dentistry

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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full mouth rehabilitation/ academy general dentistry

  1. 1. www.indiandentalacademy.com
  2. 2. Part III INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Contents Requirements for Occlusal Stability Programmed treatment planning Diagnostic wax up Occlusal Splints Occlusal equilibration Solving Occlusal Wear Problems www.indiandentalacademy.com
  4. 4. How to recognize a stable occlusion All five signs of stability must be evident. 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 www.indiandentalacademy.com
  5. 5. Three Signs of Instability 1) Hypermobility of one or more teeth 2) Excessive wear 3) Migration of one or more teeth i. Horizontal shifting ii. Intrusion iii. Supraeruption www.indiandentalacademy.com
  6. 6. Five requirements for equilibrium of the masticatory system Stable, comfortable TMJs (even when loaded) Anterior guidance in harmony with functional movements of the mandible Non interference of posterior teeth  Equal intensity contacts in centric relation www.indiandentalacademy.com
  7. 7.  Posterior disclusion when the condyle leaves centric relation All teeth in vertical harmony with the repetitive contracted length of the closing muscles All teeth in horizontal harmony with the neutral zone www.indiandentalacademy.com
  8. 8. Five Requirements for Occlusal Stability Stable stops on all teeth when the condyles are in centric relation Anterior guidance in harmony with the border movement of the envelope of function Disclusion of all posterior teeth in protrusive movements www.indiandentalacademy.com
  9. 9. Disclusion of all posterior teeth on the nonworking (balancing) side Noninterference of all posterior teeth on the working side, with either the lateral anterior guidance, or the border movements of the condyle www.indiandentalacademy.com
  10. 10. How to Use the Requirements for Stability for Diagnosis In occlusal instability one or more teeth will either become loose, wear excessively, or move out of alignment unless: The patient provides a substitute for the unfulfilled requirement or The patient specifically eliminates the need for the unfulfilled requirement www.indiandentalacademy.com
  11. 11. Treatment Planning If there are requirements that are not fulfilled and there is no substitute, or if the need for the requirement has not been specifically eliminated, treatment plan should be designed to: I. Fulfill the requirement (if possible or practical) II. Substitute for the missing requirement III. Eliminate the need www.indiandentalacademy.com
  12. 12. Strategy for examination Unsavable teeth should be noted with an X on the mounted casts and cut off the cast before any occlusal decisions are made www.indiandentalacademy.com
  13. 13. Strategy for treatment planning Correction of Occlusal Disharmonies Five choices for correction 1) Reductive reshaping (equilibration, coronoplasty) 2) Repositioning (orthodontics) 3) Additive reshaping (restorative) www.indiandentalacademy.com
  14. 14. 4) Surgical repositioning of segments of the dento alveolar process without changing the skeletal base 5) Surgical repositioning of skeletal segments in relation cranial base www.indiandentalacademy.com
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  16. 16. First option: Reshape The cast can be reshaped to determine if it can achieve the equal contact on all the teeth without mutilating enamel. Second option: Reposition If reshaping cannot solve the problem completely, minor tooth movement combined with reshaping proves to be the best solution. www.indiandentalacademy.com
  17. 17. Substituting for holding contacts The tongue posturing between the teeth may actually stabilize an open bite by substituting for tooth contact. If the teeth are stable, the tongue is an acceptable substitute. Cheek biting, thumb sucking, pipe smoking and pencil biting. www.indiandentalacademy.com
  18. 18. Options for anterior guidance Treatment Options to Consider  Will reductive reshaping help?  Is orthodontic repositioning needed?  Are restorations needed?  Is positioning of the dento-alveolar segment needed?  Does skeletal base alignment need correction?  Is substitution with an occlusal splint needed?  Is anterior guidance needed? www.indiandentalacademy.com
  19. 19. Substitution as a treatment: Teeth can often be stabilized by an occlusal splint as an alternative to tooth-to contact and prevent supraeruption. www.indiandentalacademy.com
  20. 20. CHECKLIST FOR FIRST REQUIREMENT ANALYSIS Analysis #1: Stable Holding Contacts At maximum closure  Are there any teeth that do not contact?  Has the patient substituted for the missing contact?  Are the teeth that do not contact stable?  Are there any wear problems?  Are there any mobility problems? www.indiandentalacademy.com
  21. 21.  Are there any tooth migration problems?  Did the tongue cause the separation?  Is the patient a lip biter or cheek biter?  Is there a segmental occlusal splint?  Are there any noxious habits? www.indiandentalacademy.com
  22. 22. At centric relation The same teeth that contact at maximum intercuspation should contact in centric relation.  Can anterior teeth contact if posterior interferences are removed?  Are stable stops needed on anterior teeth?  Are there any wear problems on the lower incisal edges? www.indiandentalacademy.com
  23. 23. Treatment options Reductive reshaping (equilibration)  Can this treatment solve the problem? Will the treatment achieve anterior contact in centric relation?  Will the treatment mutilate good teeth?  Will the treatment help partially achieve the desired result? www.indiandentalacademy.com
  24. 24. Repositioning (orthodontics) Can routine orthodontics reposition the teeth for holding contacts? (Observe neutral zone consideration) Would a combination of reshaping and repositioning work better? www.indiandentalacademy.com
  25. 25. Additive reshaping (restorative) Can holding contacts be provided by restorations? Do teeth need restorations for other reasons? Would restored contours be acceptable regarding esthetics, crown/root ratio, etc,? Would a combination approach (e.g., reshaping and/or repositioning) work better? www.indiandentalacademy.com
  26. 26. Repositioning dento-alveolar segments Are needed corrections too severe to accomplish with simple orthodontics or a combination approach? Would a surgical approach be more advantageous? Could orthopedic appliances do the job? www.indiandentalacademy.com
  27. 27. Repositioning the skeletal base Is the skeletal base the problem? Decide which segments are wrong? Substitution Is a night time occlusal splint a reasonable substitute for corrective measures? www.indiandentalacademy.com
  28. 28. Analysis #2: Anterior guidance Are the incisal edges correctly positioned esthetically? Are the anterior teeth in a good neutral zone relationship? Is there any interference to the lip closure path? Do the anterior teeth have stable holding contacts? Will the best esthetic result interfere with the envelope function? Does the patient desire a change in anterior esthetics? www.indiandentalacademy.com
  29. 29. Analysis #3: Posterior disclusion in protrusive Can the anterior guidance separate the posterior teeth in protrusive? Is the occlusal plane a problem? Ascertain whether it can be accomplished with any of the following: Reductive reshaping of posterior inclines Orthodontic correction of occlusal plane Restorations Surgery www.indiandentalacademy.com
  30. 30. Analysis #4: Disclusion of working and balancing Sides The key is stable holding contacts, correct anterior guidance, and a correct occlusal plane. Do posterior teeth separate immediately in lateral excursions? www.indiandentalacademy.com
  31. 31. Multiple problems Never start any orthodontic or restorative procedure unless the end result can be visualized. A treatment plan should consist of an orderly sequence of procedures that are necessary to: 1. Eliminate pain 2. Eliminate infection 3. Restore all supporting tissues to healthy maintainability 4. Reshape, reposition, or restore the dentition when necessary for optimum maintainability, esthetics, comfort, and function www.indiandentalacademy.com
  32. 32. Problem solving First Appointment: Should be planned to accomplish the following: The patient's complaints are ascertained Present conditions are charted. Present restorations Prosthetics. Occlusion. TMJ www.indiandentalacademy.com
  33. 33. Periodontal condition. Oral lesions Caries. Mouth hygiene. Impressions, bite records, and facebow records for mounted diagnostic models are taken. A radiographic survey is completed. Photographs of the mouth as well as different views of the face are taken. www.indiandentalacademy.com
  34. 34. Second appointment When multiple problems exist, the following programmed approach to problem solving may be used: Each tooth should be evaluated individually. Can it be saved and made maintainable by any procedure? Teeth that cannot be saved or maintained should be indicated on the study model and chart. Questionable teeth should be indicated by a question mark being put on the model and chart. www.indiandentalacademy.com
  35. 35. The remaining teeth should be evaluated on the basis of stress direction and distribution. Evaluation should be made as to whether remaining teeth would best be served by fixed or removable prostheses or by implants. The problems should be re-evaluated. Sometimes the whole complexion of a case changes when unsavable teeth are removed. www.indiandentalacademy.com
  36. 36. Selecting which treatment approach to use Must weigh each alternative from several perspectives: Is it the best plan for achieving a maintainably healthy mouth? Is the cost of the plan reasonable or necessary for results it achieves? Is the time required to achieve a result logical in comparison with other plans?www.indiandentalacademy.com
  37. 37. Does the health of the patient warrant an extensive treatment plan? Is the prognosis favorable enough to make extensive procedures logical? Is the prognosis, without treatment, unfavorable enough to warrant an extensive treatment plan? www.indiandentalacademy.com
  38. 38. Diagnostic wax up www.indiandentalacademy.com
  39. 39. Diagnostic wax-up Gives the dentist an unmatched level of confidence when presenting the treatment plan to the patient. The best visual aid use to help the patient understand the goal of treatment. The comparison of unaltered casts with the planned casts is the perfect aid for explaining to specialists. The corrected diagnostic casts serve as model for fabrication of provisional restorations. www.indiandentalacademy.com
  40. 40. If orthodontic tooth movement is indicated, the three dimensional model of the treatment objective can be visualized to design the mechanics for moving teeth to a specific new position. Surgical decisions can be aided regarding movement of dento-alveolar segments or complete arches. www.indiandentalacademy.com
  41. 41. Procedure 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. www.indiandentalacademy.com
  42. 42. Step 4: Lock the centric latch when observing the casts. Start with equilibration. Can it achieve front tooth contact without mutilating the posterior teeth? Step 5: Determine the correct vertical dimension. Step 6: Return the condyles to centric relation and lock the centric lock. www.indiandentalacademy.com
  43. 43. 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. www.indiandentalacademy.com
  44. 44. Step 10 : Equilibration is the first treatment option to explore. www.indiandentalacademy.com
  45. 45. 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. www.indiandentalacademy.com
  46. 46. The occlusal plane established by the simplified occlusal plane analyzer. Model is trimmed back to the established new occlusal plane. www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48. 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. www.indiandentalacademy.com
  49. 49. Step 14: Start with the lower anterior teeth. Step 15: Re-evaluate the total occlusion with the upper cast to see it can be adapted to occlude with the lower arch. Step 16: Establish holding contacts on the upper anterior teeth. www.indiandentalacademy.com
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  52. 52. www.indiandentalacademy.com
  53. 53. Occlusal Splints There are only two types of occlusal splints: Permissive occlusal splints have a smooth surface on one side that allows the muscles to move the mandible without interference from deflective tooth inclines into centric relation. www.indiandentalacademy.com
  54. 54. Directive occlusal splints direct the lower arch into a specific occlusal relationship that in turn directs the condyles to a predetermined position. Directive splints have very limited use. Should be reserved for specific conditions involving intracapsular TMDs. www.indiandentalacademy.com
  55. 55. When occlusal splints are not necessary No history of problems in the TMJs, including no history of clicking, discomfort in the joints, restriction or deviation of jaw movement, No intracapsular disorder. No sign of tenderness or tension on load testing Not necessary to fabricate an occlusal splint prior to restorative dentistry orthodontics, or equilibration. www.indiandentalacademy.com
  56. 56. Occlusal splint is appropriate: If there is doubt about complete seating of the TMJ Long-standing intracapsular disorder that has been resolved. To stabilize hypermobile teeth and distribute the loading forces over more teeth. www.indiandentalacademy.com
  57. 57. 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. www.indiandentalacademy.com
  58. 58. Procedure Take a verified centric relation bite record. Mount the casts in centric relation with a facebow. www.indiandentalacademy.com
  59. 59. Outline the coverage area of the base. Fabricate a Biostar vinyl base on the cast www.indiandentalacademy.com
  60. 60. Remove the excess from the base, but do not remove it from the cast. Place it back on the articulator. Open the pin enough separate all posterior teeth from any contact with the base www.indiandentalacademy.com
  61. 61. 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. www.indiandentalacademy.com
  62. 62. Remove the base and smooth the edges. Remove undercuts into interproximal areas. The completed splint should fit perfectly and require almost no adjustment. www.indiandentalacademy.com
  63. 63. www.indiandentalacademy.com
  64. 64. Principles of full occlusal splint design The design must incorporate four main principles: The splint should allow uniform, equal-intensity contacts of all teeth against a smooth splint surface when the joints are completely seated in centric relation. The splint should have an anterior guidance ramp angled as shallow as possible for horizontal freedom of mandibular movement.www.indiandentalacademy.com
  65. 65. The splint should provide immediate disclusion of all posterior teeth in all excursive jaw movements from centric relation. The splint should fit the arch comfortably and have good stable retention. www.indiandentalacademy.com
  66. 66. How long must splint be worn? Splint should be worn until the following requirements attained: 1. All related pain is gone. 2. The joint structure is stable. 3. The bite structure is stable. www.indiandentalacademy.com
  67. 67. Occlusal splints for therapy must be worn 24 hours a day except to eat and brush until the occlusion and the TMJs become stable. Stability is determined by three verifications: 1. Elimination of painful symptoms 2. Verification of centric relation by load testing 3. Stability of the bite on the splint over the course of a few days (or weeks if joint damage has occurred) www.indiandentalacademy.com
  68. 68. www.indiandentalacademy.com
  69. 69. Occlusal equilibration Proper equilibration is selective Proper equilibration procedures can never harm a patient Proper equilibration never restricts Proper equilibration is stable www.indiandentalacademy.com
  70. 70. Equilibration procedures Equilibration procedures can be divided into four parts: 1) Reduction of all contacting tooth surfaces that interfere with the completely seated condylar position. 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. www.indiandentalacademy.com
  71. 71. Counseling of patients Proper diagnosis Point out loose teeth and relate them to premature contacts or lateral excursion interferences. Relate wear problems to occlusal disharmony with the comfortable joint position. www.indiandentalacademy.com
  72. 72. Study the occlusal relationship on properly mounted diagnostic casts. Demonstrate on the mounted casts the amount of tooth reshaping that will be required. Tell the patient to expect further adjustments. www.indiandentalacademy.com
  73. 73. Eliminating interferences to centric relation Centric relation interferences can be differentiated into two types: I. Interference to the arc of closure II. Interference to the line of closure www.indiandentalacademy.com
  74. 74. Interference to the arc of closure Any tooth structure that interferes with this closing arc has the effect of displacing the condyles down and forward. Produce what is commonly called an anterior slide www.indiandentalacademy.com
  75. 75. 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 www.indiandentalacademy.com
  76. 76. Interference to the line of closure Primary interferences that cause the mandible to deviate to the left or the right from the first point of contact in centric relation to the most closed position. www.indiandentalacademy.com
  77. 77. If the interfering incline causes the mandible to deviate off the line of closure toward the cheek, grind the buccal incline of the upper or the lingual incline of the lower, or both inclines. www.indiandentalacademy.com
  78. 78. If the interfering incline causes the mandible to deviate off the line of closure toward the tongue, the grinding rule is: Grind the lingual incline of the upper or the buccal incline of the lower; or both inclines. www.indiandentalacademy.com
  79. 79. Grinding rules Rule I: Narrow stamp cusps before reshaping fossae If the first reshaping is directed at opening out the fossae to accept bulky stamp cusps, it grinds away more enamel. If contouring of fossae walls is delayed until stamp cusps have been reshaped, excursive interferences can then be eliminated with less tooth reduction. www.indiandentalacademy.com
  80. 80. Rule 2: Don't shorten a stamp cusp Instead of shortening a stamp cusp, grind the sides of the stamp cusps. The cusps should be narrowed on the side that marks when the jaw closes to centric relation contact. If deviations from both the arc of closure and the line of closure at the same time. Upper teeth are adjusted on the inclines that face the same direction as the slide and lower teeth by grinding of inclines that face the opposite direction from the path of the slide. www.indiandentalacademy.com
  81. 81. Tilted teeth 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. www.indiandentalacademy.com
  82. 82. If lingual to the central fossa and if stability can be improved, the lower cusp tip is moved toward the buccal, and the lower cusp is reshaped by grinding its lingual inclines to move the contact buccally. www.indiandentalacademy.com
  83. 83. Rule 3: Adjust centric interferences first Three reasons for this: 1. By adjusting centric interferences first, we have the option of improving cusp-tip position. 2. When cusp-tip position is given first priority, occlusal grinding is more evenly distributed to both arches. 3. If cusp-tip contours and position are improved first in centric relation, eccentric interferences can be eliminated with speed and simplicity. www.indiandentalacademy.com
  84. 84. Rule 4: Eliminate all posterior incline contacts. Preserve cusp tips only. If all eccentric contacts on posterior teeth are to be eliminated, any posterior incline that marks in any excursion can be reduced. www.indiandentalacademy.com
  85. 85. www.indiandentalacademy.com
  86. 86. Lateral excursion interferences Lower posterior teeth path laterally is dictated by two determinants: 1. The border movements of the condyles, which act as the posterior determinant. 2. The anterior guidance, which acts as the anterior determinant Guiding the mandible with firm pressure during excursions will routinely pick up posterior interferences that are missed with unguided movements. www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88. Manipulation for lateral excursion interference Manipulate the mandible to centric relation, and verify centric relation with load testing. Close on the centric relation axis arc to the first point of contact. Slide the forefinger around to join the other three fingers on the working side. Use all four fingers to exert upward pressure on the working condyle. www.indiandentalacademy.com
  89. 89. Use the thumb and bent forefinger to exert pressure toward the working condyle. Ask the patient to let you slide the jaw to the left (or right). It might be necessary to have the patient help, but do not relax the upward pressure through the working side condyle. Have the assistant insert the dry ribbon in the dry mouth to record the interferences. Slide the jaw to the outer border position, and then have the patient squeeze hard back to centric. www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. Adjusting the anterior guidance All interferences to centric relation must be eliminated before the anterior guidance can be corrected. Steps in harmonization of the anterior guidance Step 1. Establish stable holding contacts on all anterior teeth if possible in centric relation. www.indiandentalacademy.com
  92. 92. Step 2. Extend centric contact forward if needed to permit unguided gentle closure into stable stops without striking the lingual incline first. Step 3. Equalize contact in the protrusive path Step 4. Adjust the lateral anterior guidance as needed to permit smooth, comfortable excursions www.indiandentalacademy.com
  93. 93. Protrusive interferences Only the front teeth should touch in protrusive excursions. Rule for eliminating protrusive interferences is DUML: Grind the Distal inclines of the Upper or, in some instances, the Mesial incline of the Lower teeth. Centric stops should be marked with a different- colored ribbon so that will not be ground. www.indiandentalacademy.com
  94. 94. Patient should be asked slide forward and back. The patient should do the sliding, but the dentist should maintain a firm hold on the mandible. Corrected by some degree of "hollow grinding" of the offending incline. The lower posterior teeth moving diagonally across the upper teeth. www.indiandentalacademy.com
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  96. 96. Verification of completion I. Clench test II. Anterior deprogramming splint www.indiandentalacademy.com
  97. 97. Role of the chairside assistant The assistant has three responsibilities: i. Keeping the mouth dry so that the ribbon will mark effectively. ii. Holding the marking ribbon in place while the dentist manipulates the jaw. iii. Keeping the teeth cool while the selective grinding is being performed. www.indiandentalacademy.com
  98. 98. Armamentarium for equilibration Ribbons AccuFilm. The thinness of the film prevents it from smudging around the sides of cusps and permits it to mark only surfaces that contact. Ribbon holder The Miller ribbon holder is excellent. Several holders should be loaded with two colors so that time is not lost at the chair replacing worn ribbons. www.indiandentalacademy.com
  99. 99. Marking paper Not generally the best material for marking interferences because the ink rubs off too easily and smudges. If the paper is not too easily penetrated or torn, it is acceptable as long as it is not too thick. Waxes Thin sheets of dark-colored wax can be placed over the occlusal surface of the teeth in one arch. www.indiandentalacademy.com
  100. 100. The opposing teeth are then tapped gently into the wax until it perforates. The perforations represent interfering contacts. They are then marked with a pencil and then reduced. Excellent material for finding interferences on sharp- line angles that are often difficult to pick up by other methods. www.indiandentalacademy.com
  101. 101. Pastes, sprays, and paint-on materials Can be painted or sprayed onto tooth contact, and then the material is perforated so that the contact areas are made visible. The use of such materials can be extremely accurate because the film thickness is so thin. Burs A small diamond wheel stone and a 12-sided football- shaped finishing bur work well for precise reduction and reshaping. www.indiandentalacademy.com
  102. 102. Computer-assisted dynamic occlusal analysis The T-scan® II system from Tekscan uses a sensor unit that records occlusal contacts on a thin Mylar film and relays the information to a computer. It is possible to determine the sequence and timing of which teeth contact and with what degree of comparative force. Comparisons can be made for occlusal contacts in centric relation versus maximal intercuspation. www.indiandentalacademy.com
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  104. 104. Solving Occlusal Wear Problems www.indiandentalacademy.com
  105. 105. Important considerations Severe wear does not cause a loss of vertical dimension of occlusion Severe wear does not eliminate all deflective occlusal interferences Severe attritional wear can only occur if upper teeth are in the way of lower teeth during functional or parafunctional movements of the mandible. www.indiandentalacademy.com
  106. 106. Severe attritional wear is not caused by bruxing or clenching unless teeth are in the way of mandibular movements. Posterior teeth cannot wear (from attrition) if posterior disclusion is perfected and the anterior guidance is stable. Do not steepen or restrict the envelope of function except as a last resort. Any restriction of the anterior guidance can result in wear, mobility, or movement of the anterior teeth and a loss of the critical disclusive effect on posterior teeth. www.indiandentalacademy.com
  107. 107. Identify the cause of the wear Types of Wear: i. Attritional wear ii. Wear from erosion iii. Abrasive wear iv. Toothpaste abuse www.indiandentalacademy.com
  108. 108. Treatment planning for wear problems Should be designed to accomplish six things: Equal-intensity contacts on all teeth in a verifiable centric relation. An anterior guidance that is in harmony with the patient‘s normal functional jaw movements. Immediate disclusion of all posterior contacts the moment the mandible moves in any direction from centric relation.www.indiandentalacademy.com
  109. 109. Restoration of any tooth surfaces that have problem wear through the enamel. Counseling, so that the patient understands that normal jaw posture keeps the teeth apart except during swallowing. Advice: "Lips together, teeth apart“ Nighttime occlusal splint if habitual nocturnal bruxism persists after occlusal correction. www.indiandentalacademy.com
  110. 110. Diagnostic wax-up Four primary questions should be answered in the following order: 1. Can the lower incisal edges be correctly contoured? 2. Can a definite holding stop be provided for each lower incisal edge against its upper lingual surface? 3. Can the upper incisal edges be corrected or maintained without interference to the existing neutral zone or lip- closure path? 4. Can an anterior guidance be worked out between the established centric stops and the upper incisal edges?www.indiandentalacademy.com
  111. 111. Analyzed first at the most closed VDO of the equilibrated casts. If the anterior relationships can be worked out without increasing VDO, that is ideal. Or it should be increased only as much as necessary. Can the anterior guidance (as waxed) disclude all posterior teeth in all excursions? If the anterior guidance cannot disclude the posterior teeth, can the problem be resolved by changes in the posterior segments? www.indiandentalacademy.com
  112. 112. Procedure Step 1: Casts mounted in centric relation make the starting point obvious. The lower anterior teeth are waxed up to establish definite labio-incisal line angles www.indiandentalacademy.com
  113. 113. Step 2: The lower teeth are prepared, and the provisional restorations are placed. Step 3: Minor changes can be made this stage, and the upper arch can be equilibrated to allow complete closure in centric relation.www.indiandentalacademy.com
  114. 114. Step 4: A, New impressions are taken of the upper arch and the provisionals in place. Refine the upper wax- up for copying in the upper provisional restorations after teeth are prepared. Step 5: Both upper and lower arches can be refined for best anterior guide function and esthetics. www.indiandentalacademy.com
  115. 115. Step 6: An index made on a cast of the lower anterior provisional restorations. Step 7: Lower restorations are placed and cemented. www.indiandentalacademy.com
  116. 116. Step 8: After verification of the correct anterior guidance, a centric relation bite record is made at the correct VDO with anterior teeth in contact. Step 9: The cast of the approved provisional restorations is mounted in centric relation. www.indiandentalacademy.com
  117. 117. Step 10: A customized anterior guide is made to communicate precise details of the anterior guidance to the technician. Step 11: This is then copied into the final restorations. Ceramic contouring is related to the matrix. www.indiandentalacademy.com
  118. 118. Restoring severely worn posterior teeth A. Pin-retained all-gold restorations. B. Increase in the VDO C. Crown-lengthening procedures D. Pulp extirpation and endodontic post and coping construction www.indiandentalacademy.com
  119. 119. Conservative correction of lower incisal wear When incisal wear penetrates through the enamel, the softer dentin begins to cup, leaving an elevated ring of unsupported enamel rods. This leads to chipping away of the enamel and makes the incisal edges unsightly and rough.www.indiandentalacademy.com
  120. 120. www.indiandentalacademy.com
  121. 121. www.indiandentalacademy.com
  122. 122. www.indiandentalacademy.com
  123. 123. www.indiandentalacademy.com
  124. 124. When should occlusal wear be restored? Will treatment be complicated by delay in restoring the wear? Is restoration necessary to control sensitivity? Is restoration required to satisfy esthetic desires? Is it relatively certain that restorations will eventually be required? www.indiandentalacademy.com
  125. 125. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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