FMR

1. Full Mouth Rehabilitation
Part 1
Presentation By: Dr. J. Koshy Joseph
II MDS

2. 1. Introduction
2. Definitions
3. Indications and contraindication for occlusal rehabilitation
4. Classification of patients requiring full mouth rehabilitation.
5. Biological considerations for occlusal rehabilitation
6. Functional Aspects for occlusal rehabilitation
CONTENTS – Part 1

3. 7. Centric Relation
8. Vertical dimension
9. Anterior guidance
11. Plane of occlusion
12. Philosophy of various occlusal schemes
13. Posterior occlusal morphology

4. CONTENTS – Part 2
14. Examination
15. Diagnosis
16. Treatment Planning in Occlusal Rehabilitation
17. Conclusion
18. References

6. Full mouth rehabilitation
Healthy Aesthetic Well functioning Self-maintaining
Occlusal Rehabilitation
Source: GPT 8

7. NEED FOR OCCLUSAL REHABILITATION
Vascular Tissue of periodontium can be stimulated only by
teeth in function.
Mutilated mouths-This stimulation is lacking
Realigned teeth through full mouth reconstruction improves
the general tone of supporting structures
Function Improves
Teeth feel STRONGER
Source: Irving Goldman et al, The Goal of Full Mouth Rehabilitation, J. Pros. Den. 1952,
March, Vol 2, No. 2.

8. Aim:
To re-establish a state of functional as
well as biological efficiency where teeth
and their periodontal structures, the
muscles of mastication, and the
temporomandibular joint (TMJ)
mechanisms all function together in
synchronous harmony.
Source: Kazis H, Kazis AJ (1960) Complete mouth rehabilitation through fixed
partial denture prosthodontics. J Prosthet Dent 10:296–303

9. 1. To maintain the health of periodontal tissues.
2. When in need for extensive dentistry which
includes restoration of multiple teeth, which are
missing, worn, broken-down or decayed.
Indications of Occlusal Rehabilitation

10. 6. Specific situations where the existing intercuspal
position is unacceptable. For eg.

11. • Malfunctioning mouths that do not need extensive
dentistry and have no joint symptoms should be best left
alone.
• Prescribing a full mouth rehabilitation should not be
taken as a preventive measure unless there is a definite
evidence of tissue breakdown.
• In short, it can be concluded that :
No pathology- No treatment.
Contra- Indications of Occlusal
Rehabilitation

12. 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
Classification of Patients requiring full
mouth rehabilitation

13. Classification by Charles Brecker In 1966
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.

14. 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 of
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.

15. Certain biological considerations are necessary when
planning and carrying out occlusal rehabilitation.
1. The indications for reorganizing the occlusion
2. The choice of an appropriate occlusal scheme
3. The occlusal vertical dimension
4. The need to replace missing teeth
5. The effects of the material used on occlusal stability
6. Control of parafunction and TMD
Biological considerations for Occlusal
Rehabilitation

16. Occlusal Approach for Restorative
Therapy
Conformative approach
• Occlusion is
reconstructed according
to the patient’s existing
intercuspal position
• Occlusion is modified by
localized occlusal
adjustments before
tooth preparation
Reorganized approach
• New occlusal scheme is
established around a
suitable condylar
position which is the
centric relation position.
• Operator has
opportunity to optimize
patients occlusion.
Source: Celenza FV, Litvak H (1976) Occlusal management in conformative
dentistry. J Prosthet Dent 36:164–170

17. Certain biological considerations are necessary when
planning and carrying out occlusal rehabilitation.
1. The indications for reorganizing the occlusion
2. The choice of an appropriate occlusal scheme
3. The occlusal vertical dimension
4. The need to replace missing teeth
5. The effects of the material used on occlusal stability
6. Control of parafunction and TMD
Biological considerations for Occlusal
Rehabilitation

19. Certain biological considerations are necessary when
planning and carrying out occlusal rehabilitation.
1. The indications for reorganizing the occlusion
2. The choice of an appropriate occlusal scheme
3. Increase in the occlusal vertical dimension
4. The need to replace missing teeth
5. The effects of the material used on occlusal stability
6. Control of parafunction and TMD
Biological considerations for Occlusal
Rehabilitation

20. FUNCTIONAL ASPECTS OF OCCLUSAL
REHABILITATION
• Centric Relation
• Vertical Dimension
• Incisal Guidance
• Occlusal Plane
• Occlusal Scheme
21

21. Centric relation (CRCP, RCP, RAP)
Centric occlusion (ICP, MIP, acquired
position of the mandible)
22

22. IMPORTANCE OF RECORDING THE
UPPERMOST POSITION
• The only position that permits an interference free
occlusion.
Failure to completely seat the condyles when harmonizing
an occlusion
OR
When condyles must displace forward and down slope to
achieve maximum intercuspation
There is disharmony between occlusion and TMJs.
This results in a muscle braced condyle disc assembly
instead of a bone braced relationship.
23

23. Recording Centric Relation
1. Manipulation of the mandible
1. Patient Guided methods
1. Schuyler Technique
2. Physiological technique
3. Gothic arch or arrow point tracing
2. Operator Guided methods
1. Chin Point guided technique
2. Three finger point guided technique
3. Bilateral manipulation technique
2. Interocclusal bite records

24. Techniques for making centric interocclusal
record
1. Wax bite procedure
2. Anterior stop techniques
3. Use of preadapted bases
4. Central bearing point techniques
25

25. VDO refers to the vertical position of the mandible in
relation to the maxilla when the upper and lower teeth are
intercuspated at the most closed position.
26
VERTICAL DIMENSION

26. Principles Behind Increasing Vertical
Dimension
• It is obligatory that two principles have to be
pursued during the increase of OVD:
(1)Starting point for reconstruction/increase in
OVD must be within centric relation.
(2) Reconstruction to be within the range of the
patient’s neuromuscular adaptation
27

27. INDICATIONS FOR
CHANGE OF VERTICAL
DIMENSION
28

28. 1.In extremely worn occlusions to provide enough room for
restorations & Esthetic needs of the patient cannot be
satisfied without crown length being increased
2.If loss of anterior facial height due to condylar displacement
that cannot be corrected by occlusal equilibration procedures.
3. Some orthodontic results may be difficult to achieve without
increasing the VD.
29

29. 4.In case of severe arch malrelationships or extreme occlusal
plane problems.
5. Anterior open bite requires a reduction of VD in order to get
acceptable result
6.For temporarily relieving the symptoms in intracapsular TMJ
disorders
30

30. ANTERIOR GUIDANCE
31
Anterior teeth are not just the key to esthetics but also
the key factor in protecting the posterior teeth
Must Be In Harmony With The Envelope Of Function

31. DEF-’ An imaginary surface that theoretically touches the
incisal edges of the incisors and the tips of the
occluding surfaces of the posterior teeth.’
2 Basic requirements of a proper plane of occlusion:
• 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.
32
OCCLUSAL PLANE

32. • The curvatures of the posterior plane of occlusion
are divided into
A. An anteroposterior curve called the Curve Of Spee
B. A mediolateral curve, referred as the Curve Of Wilson
• The composite of the curve of Spee, the curve Wilson,
and the curve of the incisal edges is properly referred to
as the Curve of occlusion.
• The curvatures of the anterior teeth are determined by
establishment of an esthetically correct smile line on the
upper and the relationship of the lower incisal edges to
the anterior guidance and the requirements for phonetics
33

33. The Curve Of Spee
 The anteroposterior curvature of
the occlusal surfaces, beginning at
the tip of the lower canine and
following the buccal cusp tips of the
bicuspids and molars and
continuing to the anterior border of
the ramus.
 Ideally follows an arc through the
condyle.
 The curvature of the arc would
relate, on average, to part of a
circle with a 4-inch radius.
34

34. • Curve of Spee too high in posterior: Forces the most
posterior teeth to carry the full stress imposed on them
by the musculature when the mandible is protruded.
• Curve of spee too low posteriorly:
It presents no problems, since it cannot interfere with
basic requirements of protrusive and balancing side
disclusion. If grossly overdone:
1. Create poor esthetic result
2. Excessive stress on upper teeth.
3. Reduce function by causing too much posterior teeth
separation in protrusion

35. The Curve Of Wilson
• The curve of Wilson is the
mediolateral curve that contacts
the buccal and lingual cusp tips
on each side of the arch.
• It results from inward inclination
of the lower posterior teeth,
making the lingual cusps lower
than the buccal cusps on the
mandibular arch.
37

36. Reasons for Inclination
 Resistance to loading
 Masticatory function.
38

37. OCCLUSAL SCHEMES
(AN OCCLUSAL SCHEME IS A PATTERN OF
OCCLUSAL CONTACT USED FOR
RECONSTRUCTION)

38. Gnathological Philosophy
Stuart (1964)
Centric Relation Contact Position (CRCP)and The
Intercuspal Position (ICP) (Centric
Occlusion) are Coincident
• Canine Guided Lateral Excursions
• Posterior Disclusion In All Excursions.
• Lingual Concavity Of Anterior Teeth Is
Determined By Condylar Guidance
• Wax Up Done In Fully Adjustable Articulator.
• Good For Restoring Cases With Large Horizontal
Component Of CR and IP.

39. Pankey Man Schuyler Concept
In 1929 C.H. Schuyler stated that maximum intercuspation must occur in the
retruded mandibular position (centric relation) under all circumstances
Schuyler’s principles were
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.

40. In order to accomplish these goals, the following sequence is advocated by
the P.M.S. philosophy:
PART 1:. Examination, diagnosis, treatment planning, prognosis
PART 2: Harmonization of the anterior guidance for best possible esthetics,
function, and comfort
PART 3: 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.
PART 4: Restoration of the upper posterior occlusion in harmony with the
anterior guidance and condylar guidance.

41. The advantages of the technique are as follows:
• It is possible to diagnose and plan treatment for the entire
rehabilitation before preparing a single tooth.
• It is a well-organized, logical procedure that progresses
smoothly with less wear
• There is never a need for preparing or rebuilding more than
eight teeth at a time.
• It divides the rehabilitation into separate series of
appointments. It is neither necessary nor desirable to do the
entire case at one time.
• There is no danger losing the patient's present vertical
dimension. The operator knows exactly where he is at all times.

42. • 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 constructed.
• All posterior occlusal contours are programmed by and are in harmony
with both condylar border movements and a perfected anterior guidance.
• There is no need for time-consuming techniques and complicated
equipment.
• Laboratory procedures are simple and controlled to an extremely fine-
degree by the dentist.

43. YOUDELIS
SCHLUGER S et al
• For advanced periodontal cases.
• Cr and ip are coincident.
• Anterior disclusion for protrusive and canine disclusion for
lateral excursions.
• Lateral Contacts Are Arranged Such that if Canine Disclusion Is
Lost Through Wear /Tooth Movement-posterior Teeth Drop
Into Group Function.
• Both Fully /Semi Adjustable Articulators Can Be Used.
• Useful –Parafunction Cannot Be Controlled/Canine
Compromised Periodontally

44. Freedom In Centric
(Ramfjord Sp)
• Area Of Freedom between CR And IP-0.5mm.
• Either Canine Guidance/Group Function, but Ant. Guidance
Will Be Delayed During Posterior Contact In Area Of Freedom.
• Cusp To Fossa Occlusion.
• Useful For Cases With Large Horizontal Component Of Slide.

45. Nyman and Lindhe concept 1983
• Used in advanced periodontal disease.
• Clinically hypermobility of teeth, unfavorable distribution of
teeth.
• Bridge on such abutment teeth exhibit mobility
• But such bridge hypermobility can be tolerated, provided it
does not interfere with patients comfort or bridge function
• Such mobile bridge can further exaggerate the periodontal
weaking but can be prevented by designing occlusion in such
a way to obtain & maintain stability.
• Even and simultaneous contacts all over the dentition in ICP
and excursion.

46. • If distal abutment teeth are missing in a cross arch bridge with
increased mobility, balance and functional stability obtained
by cantilever units.
• However cantilevers increased risk of failure.
• If increased mobility is not observed, balancing contacts on
non working side should be removed.
• When bridge exhibit increased mobility- fulcrum identified,
occlusion designed so that forces exerted by masticatory
muscles meet the bridgework simultaneously with balanced
load on both side of fulcrum

47. HOBO TWIN STAGE CONCEPT
(Hobo St)
• Two Stage Procedure
1. Occlusal Morphology Of Posterior Teeth Reproduced Without
Ant. Segment.
2. Ant. Morphology Reproduced
and Ant. GUIDANCE produce standard amount of disclusion.

48. HOBO’S TWIN TABLE PHILOSOPHY
Dr. Sumiya Hobo
• He proposed Twin table concept which developed anterior guidance to
create a predetermined, harmonious disclusion with the condylar path.
• The technique utilizes 2 different customized incisal guide tables.
• The first incisal table is termed INCISAL TABLE WITHOUT DISCLUSION. It is
fabricated by preparing die systems with removable anterior and posterior
segments
• This table helps us achieve uniform contacts in the posterior restorations
during eccentric movements
• used to fabricate restorations for posterior teeth

49. • The other incisal table is made when the articulator can
simulate border movements by placing 3 mm plastic
separators behind the condylar elements. This is termed THE
INCISAL GUIDANCE WITH DISCLUSION.
• Used to achieve incisal guidance

50. POSTERIOR OCCLUSAL MORPHOLOGY
Planning of occlusal contours distribution of lateral
stresses. Three basic decisions to make regarding the design of
posterior occlusal contours:
1.Selection of the type of centric holding contacts
2.Determination of the type and distribution of contact in
lateral excursions
3.Selection of an appropriate Occlusal Scheme for providing
stability to the occlusal form.
52

51. 1.Types of centric holding contacts:
53
Surface to surface contact
Tripod contact
Cusp tip to fossa contact

52. 2.Determination of the type and distribution of
contact in lateral excursions
• The job of discluding the nonfunctioning side is always
the responsibility of the working side.
• The dentist must decide how all this is done by selecting
one of the following choices for working side occlusion:
1. Group function
2. Partial group function
3. Posterior disclusion
54

53. 1. Group function
2. Partial group
function
3. Posterior disclusion
55

54. Posterior disocclusion
• Refers to no contact on any posterior teeth in any
position but centric relation.
• Two methods of accomplishing posterior disoccclusion:
1. Anterior guidance is harmonized to functional border
movements first, and then the lateral inclines of
posterior teeth are opened up so that they are
discluded.
2. Posterior teeth are built first and then disocccluded by
restriction of the anterior guidance. This method is
backward.
56

55. • Can be achieved by two different types of
anterior guidance:
a) Anterior group function
b) Canine protected occlusion
57

56. ANTERIOR GROUP
FUNCTION:
 Distributes wear over more teeth.
 Distributes the stresses to more
teeth.
 Distributes stress to teeth that are
progressively farther from the
condyle fulcrum.
58

57. CANINE GUIDED
OCCLUSION
• In natural cuspid-protected occlusions,
the pattern of function is rather vertical
• Any attempt at lateral movement is felt
by the pressoreceptors around the
cuspids which redirect the muscles to
more vertical function.
• The density of proprioceptors is
supposed to impart a unique capacity
to the cuspid to redirect any functional
pattern that would be destructive.
59

58. Advantages of Canine guided occlusion
• The cuspids have extremely good crown - root ratios
• Long fluted roots are in some of the densest bone of the
alveolar process.
• Their position in the arch, far from the fulcrum, makes it
more difficult to stress them.
• In short, they are very strong teeth. If their upper lingual
inclines are in harmony with the envelope of function,
they are usually quite capable of withstanding lateral
stresses without help from other teeth.
60

59. THANKYOU
- To be continued
61

60. Examination, Diagnosis And
Treatment Planning In Occlusal
Rehabilitation

61. CONTENTS – Part 2
14. Examination
15. Diagnosis
16. Treatment Planning in Occlusal Rehabilitation
17. Conclusion
18. References

62. Examination

63. Examination

66. Treatment plan is divided into-
• 1) Pre- prosthetic phase
• 2) Prosthetic phase
• 3) Maintenance phase

72. Measurement of Transverse Horizontal axis
USING
1.Arbitrary Face bows
2.Kinematic face bow
74

74. Recording centric relation
1. MANIPULATION OF THE
MANDIBLE
Necessary for equilibration
procedures or examining for
premature contacts
2. INTEROCCLUSAL BITE
RECORDS
Correct articulation of
mounted casts
A)Patient guided methods
B)Operator guided methods
76

75. A)Patient-guided recording of RCP
1. Schuyler technique
2.Physiological technique:
77

76. 3.Gothic arch (Arrow-point) tracing:

77. b)Operator-guided recording of RCP:
1) Chin-point guidance method
79

78. 2) Three finger chin-point guidance method

79. Bilateral manipulation
Most consistently repeatable and most easily
learned.
.
81

80. Bilateral manipulation
STEP 1
Recline the patient all the
way back; Point the chin up
STEP2
Working from a seated
position from behind the
patient; firmly stabilizes the
head 82

81. STEP 3
With the head firmly
stabilized, position the four
fingers of each hand on
the lower border of the
mandible
STEP 4
Bring thumbs together to form
a C with each hand
83

82. STEP 5
With very gentle touch,
the jaw is manipulated so
that it slowly hinges open
and close; no pressure
applied
STEP 6
Verify centric relation
position; Upward finger
pressure; downward
thumb pressure
84

83. STEP 7
When it is possible to freely and painlessly
arc the mandible while exerting firm
pressure; the dentist is ready to close the
mandible to the first point of contact. The
mandible should not translate off its
terminal hinge axis
85

84. Anterior guidance by a Lucia Jig:
Basis of the Lucia jig method
and the techniques that follow,
is to provide an anterior
reference point.
Forms a tripod with the
condyles.
With the teeth out of contact
all proprioceptive reception
from the teeth and
musculature is removed 86

85. 5.Anterior guidance
by a tongue blade :
6.Anterior guidance
by a Leaf Gauge:
7.Anterior guidance
by a OSU Woelfel Gauge:
87

86. Wax bite record
• Delar wax: brittle-
hard wax supplied in
sheets that are
thicker at the front
for more even
penetration teeth
from back to front.
88

87. 89

88. 90

89. Determining the Occlusal Place
1. Broadrick’s occlusal plane analyser
2. Simplified occlusal plane analyser

100. 102

101. 103

102. 104

103. Increasing occlusal vertical dimension

105. Determinants to increase VD
Gnathological concept
This involves the use of fully adjustable
articulators to determine condylar path from the
hinge axis and setting this path for a 5 degree
increase to ensure no posterior interferences.

106. Bioaesthetics
This works via a fixed numerical value based on
the incisal relationship. The distance between
the gingival margins of 18-20mm in an unworn
class one occlusion with upper incisal length of
12mm, lower incisal length 10mm, 4mm
overbite and 1mm overjet.
Determinants to increase VD

107. Centric relation based
According to Dawson, Centric relation is defines
as when the heads o the condyles are in their
most superior position within their sockets,
lateral pterygoid muscle is relaxed and the
elevator muscles are contracted with the disc
properly aligned.
Determinants to increase VD

108. Neuromuscular
Based on the principles of muscle activity
determined by electromyography.
Determinants to increase VD

109. ANTERIOR GUIDANCE
111
Anterior teeth are not just the key to esthetics but also
the key factor in protecting the posterior teeth
Must Be In Harmony With The Envelope Of Function

110. • Definition: ‘It is the influence of the contacting surfaces of
the anterior teeth on tooth limiting mandibular
movements’
• PROTRUSIVE ANTERIOR GUIDANCE AND LATERAL
ANTERIOR GUIDANCE
• Condylar paths do not dictate anterior guidance
• During the terminal hinge axis closure of the mandible if
all the lower anterior teeth contact simultaneously
against stable centric stops at the correct vertical
dimension, then the first requirement of good anterior
relationship has been fulfilled.
112

111. Sequencing the determination of
anterior guidance
113
AIM- TO PRECISELY LOCATE THE CORRECT INCISAL EDGE
POSITION

112. • 1st STEP-The first decision
determines the relationship
of the lower incisal edges to
the upper anterior teeth.
• 2ND STEP- determine the
upper half of the labial
surface
• 3rd STEP- contouring the
surface back until the lower
lip can easily slide by the
incisal third to seal contact
with the upper lip.
114

113. • 4TH STEP-Determining the contour
of the incisal plane
• 5TH STEP- harmonizing the
anterior guidance/determining
the contour of anterior guidance
• 6TH STEP-Final matrix decision is
the contour from the centric
relation stop to the gingival
margin.
115

114. Harmonizing the anterior guidance
• Preliminary steps:
 When indicated, the lower anterior teeth should be
reshaped or restored first.
 If restorations are not needed on the posterior teeth, they
must be equilibrated before the anterior guidance can be
worked out.
 All interferences to centric relation must be eliminated on
both anterior and posterior teeth to establish stable
contacts at the most closed position.
116

115.  Eccentric interferences are then removed on
the remaining natural posterior teeth.
IF restorations are needed on posterior
teeth,take advantage of them for precise
harmonization of anterior guidance.
 Prepare the posterior teeth in one arch before
completing the correction of anterior inclines.
117

116. FIVE STEPS TO
HARMONY
Step I. Establish
coordinated centric
relation stops on all
anterior teeth.
Step 2. Extend centric stops
forward at the same
vertical dimension to
include light closure from
the postural rest position
118

117. Step 3. Determine the incisal
edge position.
Step 4. Establish group
function in straight
protrusion.
Step 5. Establish ideal
anterior stress distribution
in lateral excursions 119

118. Treatment Philosophies

119. Hobo’s Twin stage philosophy

128. Hobo’s twin stage philosophy

145. Pankey Mann Schuyler Philosophy

153. Removable Onlay Occlusal Splints