FMR/ Full mouth rehabilitation final.7.1.2021pptx

FULL MOUTH
REHABILITATION
NAMITHA.AP
3RD MDS
DEPT.OF PROSTHODONTICS
1

Contents
• Hobos’s Philosophy
• Twin table technique
• Twin stage technique
• Solving deep overbite problems
• Solving anterior overjet problems
• Solving anterior open bite problems
• Treating end to end occlusions
• Treating splayed or separated anterior
teeth
• Treating the crossbite patient
• Treating crowded,irregular, or
interlocking anterior teeth
• Related articles
• Concluion
• References
2

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.
3

4
• 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

5
• 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 condylar 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.
Anterior guide component

6
• 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.

7
• 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
GUIDE
COMPONENT
CUSP SHAPE
COMPONENT
WIDE
DISOCCLUSION

8
Influence of the amount of disclusion
Cusp
angle
Incisal
path
Condylar
path
Dependent factors
NON WORKING
SIDE
WORKING IiDE

Twin-tables technique -Hobo (1991)
• Posterior teeth are restored using two
customized incisal tables: without
disclusion; and with disclusion
• One incisal table is used to incorporate
a cusp-shape factor and the other is
used for the angle of hinge rotation.
9

12
• Limitations
• The cusp angle was fabricated parallel to the
measured condylar path, and the cusp angle
became too steep
• To obtain a standard amount of disclusion
with steep cusp angle, the incisal path has to
be set at an angle that is extremely steep
• The customized guide tables were fabricated
by means of resin molding (technique
sensitive)

Standard values of effective cusp angles on molars
• 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-
Cusp angle Cusp angle on molars
(deg)
Protrusive effective cusp angle 25
Working side effective cusp angle 15
Non working side effective cusp angle 20
13
a standard value for cusp angle
was determined such that it may
compensate for wear of natural
dentition due to caries, abrasion
and restorative works.
By using the standard cusp angle,
it was possible to establish the
standard amount of disclusion

Twin – Stage Procedure
Hobo and Takayama 1989
Advanced version of the Twin-Table
technique
A kinematic formula to calculate anterior
guidance from condylar path
Incorporated easily with commonly used
clinical techniques such as facebow
transfer, various centric recording
methods, and cusp-fossa waxing
INDICATIONS
• single crowns
• fixed prosthodontics
• Implants
• complete-mouth reconstructions,
• complete dentures
Contraindicated for malocclusion cases
14
Hobo S (1991) Twin-tables technique for occlusal rehabilitation.Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303

15
• 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.
Different adjustment values of an articulator were determined for each occlusal scheme to reproduce the standard amount of disclusion

Condition 1
• The occlusal morphology of
the posterior teeth without
anterior segment is produced
so that the cusp angle is
coincident with the standard
value of effective cusp angle.
This is referred to as
‘condition 1’
Condition 2
• Secondly, the anterior
morphology of the anterior
segment is produced to
provide anterior guidance
with standard amount of
disocclusion. This is referred
to as ‘ condition 2’
The application of the two conditions described to fabricate the cusp angle and anterior guidance are termed as ‘
twin stage procedure
16

Contraindications
• vertical axis of the posterior teeth may have
inclined abnormally.
• Effective cusp angle may vary to some extent
even though the cusp angle of a natural
tooth varies minimally.
• In such condition the standard effective cusp
angle presented in the twin-stage procedure
may not be applicable - occlusion of a
restoration may be inaccurate
20
• Abnormal curve of Spee
• Abnormal curve of Wilson
• Abnormally rotated tooth
• Abnormally inclined tooth

Solving deep overbite
problems
• Care must be taken to maintain neutral zone relationship of upper anterior teeth.
• strong lip pressures and a tight neutral zone
• Phonetic relationship of incisal edges is critical
• 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.
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.453,454
21

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.
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.455
22

The first treatment option:
Reshape
 It is often necessary to
reshape the lingual of upper
restorations to provide a
holding contour and
shorten the lower incisors if
they have erupted up too far
to make contact.
The second treatment option:
Reposition
• If the upper incisors have
been wedged forward,
they can be moved back so
lower incisor contact can
be achieved.
• Changes the neutral zone
as the lower lip will be able
to slide in front of the
labial surfaces to hold
them back as the lips seal.
The first goal of treatment is to achieve stable holding contacts on all anterior teeth.
23

• A simple but effective appliance for
moving the anterior teeth back into
a predetermined position against
contoured slots in the palatal part of
the appliance. A rubber band directs
the teeth into the slots.
The complete lack of holding
contacts on the straight lingual
contours of the original
restoration.
The anterior teeth are brought
lingually, their lingual contours
has to be recontoured to permit
anterior teeth contact into a stop.
24

• Teeth are prepared and
provisional restorations are
used refine the anterior
guidance and esthetic
concerns.
The third treatment option: Restore
• After the teeth have been brought
into an acceptable alignment by
reshaping and repositioning.
To achieve contact on all lower
anterior teeth, it is often necessary
to move one or more teeth
forward. Any tooth that is
not in contact will supraerupt.
25

After the teeth have been
repositioned for centric
relation contact, the final
details are worked out in
provisional restorations.
(comfortable, functional, and
esthetically acceptable)
After approval, the details must be communicated precisely to the technician via
casts of the approved provisional mounted in centric relation.
A putty silicone index communicates the exact incisal edge positions.
A customized anterior guide table communicates the lingual contours, leaving
nothing to chance for fabrication of the finished restorations.
26

27
Deep overbite with tissue contact
Lower incisors erupt up into soft tissue lingual to the upper anterior teeth.

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
28

29
DEEP OVERBITE PROBLEMS ASSOCIATED WITH AN ANTERIOR SLIDE

30

Solving deep overbite problems
by splinting
• Teeth that have supraerupted into the
palatal tissue can be shortened to
relieve the pressure against the soft
tissues.
• Splinting is often the most practical
method of stabilizing such lower
anterior teeth.
Includes
• Full coverage
• Resin bonded lingual restorations
• Modifications in partial denture e.g.
continuous clasp splinting and
Swing-lock design.
31

32
Bite planes to solve deep
overbite problems
• Discomfort from tissue impingement
• Least complicated way of preventing supraeruption of
the lower anterior teeth.
• 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.

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.
33

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 .
34

• 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
the problem.Use the nasion perpendicular analysis
35

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
36

Overjet with lower incisor contact on
palatal tissue with esthetic concerns.
The lower lip locks behind the
upper anterior teeth, affecting
speech and causing exposure to
unesthetic drying of the
incisors" labial surfaces.
Option
1
Analysis on mounted casts
showed the need to narrow the incisors to
make room for
moving the incisor segment lingually.
Option
2
After narrowing the incisors to a predetermined
width, an appliance is made with a lingual plate
contoured to receive the teeth into their
predetermined position as they are moved lingually.
Reposition
Reshape
37

A rubber band attaches to the appliance to
move the teeth
into the contoured slots in the lingual plate
(Simple way to achieve dramatic results)
Bands or brackets - if final positioning requires
horizontal bodily movement of roots.
An improved incisal plane as
incisal edges move down as they are pulled back
into a position that permits contact with the
lower incisors.
38
lingual contours are then reshaped to
ideal contact with lower incisors.

Option 3
Restore
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 restorations are tested for a
smooth functioning anterior
guidance, making sure that
immediate disclusion of the
posterior teeth is achieved.
This may require some reshaping
of posterior surfaces.
The putty silicone index communicates incisal
edge position and contour. The custom
anterior guide table communicates the exact
lingual contours.
The mounted cast of approved provisionals
provides exact details to the technician
Final restorations copy all of the
details.
39

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
vinyl. It requires no clasps because it snaps over the
teeth and engages the undercuts for retention.
Finished restorations (far right) showing
improved relationship to smile line.
40

Solving anterior open bite problems
• The most important determination is what
caused the open bite.
• Always evaluate the condition of the
temporomandibular joints (TMJs).
• Loss of condylar height usually causes
progressive anterior separation.
• If a habit pattern caused the open bite,
correction will be unsuccessful unless the
habit is eliminated.
• Skeletal malrelationships can usually be
successfully treated.
• There are many degrees of open bite
depending on tongue or lip habits that
intrude teeth or prevent their eruption.
• Many anterior open bites are stable.
• A major problem of anterior open bite is
trauma to posterior teeth.
• A second major problem is lack of an
anterior guidance for posterior disclusion
41

Treatment objectives
1. Maximize the number of equal-
intensity occlusal contacts on both sides
of the arch.
2. Correct a "reverse smile line" on upper
anteriors for esthetic improvement.
3. If only one arch is malaligned, close
the anterior relationship by correcting the
arch that is wrong.
4. If a habit pattern cannot be broken,
the occlusion must conform to the habit.
5. Achieve posterior disclusion in
protrusive by determining the anterior
guidance as far forward as possible.
6. If anterior guidance cannot be
achieved for disclusion of the balancing
side, use group function of the working
side posterior teeth.
7. If condylar breakdown is progressive,
correction of the occlusion must keep up
with it.
42

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.
Tongue posture at maximal intercuspation43

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.
44

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
45

• Anterior open bite.
Contact in centric relation
is only on second molars.
Esthetics is a major
concern of the patient.
First treatment option: Reshape.
Contour of space indicates that the tongue will
not be a problem if the space is closed.
The question to ask: How much closure can we
get by reduction of the posterior teeth? This can
be determined on the mounted casts.
it is practical to shorten the molars to gain anterior contact.
Adjustment on the casts shows that contact in the canines could
be achieved by judicious reshaping of the molars to close the bite
This overlay can then be shaped in the
mouth to show the patient in advance what
a change in the incisal plane would
do for the smile.
46

Surgical option
• Inclination of opening toward the front
suggests that a successful result can be
achieved by closing the vertical space
between the anterior teeth.
• The first treatment option of reshaping
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.
Important rule: Don’t
change what is right to
fit what is
wrong. Analysis shows
that the height of the
lower incisal
plane is correct.
47

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).
48

Treating end to end occlusions
Important considerations:
• Anterior end-to-end relationships may
be very stable if they are in harmony
with centric relation.
• Lateral anterior guidance is achieved by
sliding sideways against ,the flat incisal
edges.
• Condylar guidance can usually
combine with flat anterior guidance to
disclude all posterior teeth.
• The principal problem is failure to disclude
the posterior teeth in excursions, so care
must be taken to make sure the occlusal
plane and fossae contours are correctly
related for disclusion by the condylar path
on the balancing side.
• This typically requires flatter occlusal
contours for disclusion on the working side
because working side disclusion is achieved
solely by the lateral anterior guidance.
Anterior end-to-end relationships
49

• 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
50

Restoring end- to-end anterior teeth
• Minimal changes in incisal edge position can effect gross improvements in anterior function.
• Moving the upper incisal edges forward and the lower incisal edges inward can extend the
protrusive contact by a couple millimeters or more.
• Even a horizontal zero-degree guidance can fulfill all the disclusive needs of the posterior
teeth if occlusal contours are also kept flat enough and the occlusal plane is correct.
• The stresses are so confined to the long axis that the periodontal fibers and the bone
trabeculae are not aligned to resist lateral stress
51

• 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.
52

53
• Harmony with the neutral zone
• Noninterference with the envelope of function
STABILITY
• Requires cephalometric analysis as well as mounted diagnostic casts.
SKELETOFACIAL PROFILE
• stable end-to-end relationship- NO complain of inadequate function
• underdeveloped maxilla or an overdeveloped mandible, or some combination of both.
FUNCTION
• most patients believe it is the ideal relationship
ESTHETICS
Thedecisiontoaltertheocclusalrelationshipshouldbe
basedonacarefulevaluationofthefollowingfactors:

• 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.
Neutral zone
54

Posterior end-to-end relationships
1. Are all teeth stable or unstable? (Look
for wear or hypermobility)
2. Can the anterior guidance disclude
the posteriors? If so, an end-to-end
occlusion is not a problem.
3. If anterior guidance cannot disclude
the posterior teeth in lateral excursions,
correct the posterior relationship by the
best choice of:
• Reshaping
• Repositioning
• Restoring (with centralized cusps)
• Surgery
55

• 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.
• Anterior guidance can sometimes be steepened if it is not steeper than the lateral path
originally found during excursions dictated by posterior teeth
56

Restoring end-to-end
posterior teeth
• Lower Cusp Tip to Upper Flat Surface
 Provide almost normal lower posterior
occlusal form, with slight modifications to
flatten and broaden upper cusp tips to
serve as stops for the more rounded lower
cusps.
• Overjet can be provided to hold the cheek
away from the contacts.
• Adequate as long as the teeth are
positioned in harmony with the cheeks
and tongue.
The goal is to provide as much stability as possible in centric relation and as much relief as possible in
excursions.
57

 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.
Centralization of the Lower Cusps
58

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.
59

• 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.
60

Maximal intercuspation
• There is a long slide from the first
contact at the most closed position.
Centric relation
• The true arc of closure to anterior contact in
centric relation can then be determined on
mounted casts.
EQULIBRATION
OF CASTS
ANTERIOR
GUIDANCE
61

• DIAGNOSTIC WAX UP NEUTRAL ZONE
CONSIDERATIONS
Splayed anterior teeth are usually in
the most balanced relationship
between tongue and lip pressures.
THE DIAGNOSTIC
WAX-UP COMPLETED
Prepared teeth. Note
centric relation contact on
centrals
and canines.
62

Matrix used as reduction guide and for direct
fabrication of provisional restorations
Provisional restorations in place
Patient can test the provisionals to be
sure that appearance,
phonetics, and function are all acceptable.
Functional esthetics. Mounted cast of the
approved provisional restorations eliminates
all guesswork for the
technician.
The putty silicone index precisely
communicates the incisal
edge position and contour that can
then be copied in the
wax-up on the master die model.
A customized anterior guide
table dictates the exact
configuration
of the lingual contours.
63

Precise doctor/technician communication yields precise
results. The finished restorations follow the exact guidelines
that were worked out in the mouth and tested in function.
The putty matrix simplifies communication in a way that is
verifiable by both the technician and the dentist
Lingual contours on the restorations match what
was worked out in the mouth and communicated
via the customized anterior guide table.
64

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?
65

Problems with anterior crossbites
Esthetics
• Elimination of the
"bulldog look" of
prognathism
• surgery seems to be
the only practical
method if the
prognathism is severe.
No centric contact on anterior teeth
• In more severe malrelationships, there is no
anterior contact.
• The usual problem associated with lack of
centric contact is supraeruption of the teeth.
• This is rarely a problem with anterior crossbites
because the upper lip substitutes for the contact
and holds the lower anterior teeth in place.
66Most prognathic patients limit their function to vertical "chop chop" movements

• 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.
67

• 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.
68

• 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.
69

Small rubber bands are
used to pull the lateral
incisors into the slots
designed to receive
them
Alignment of
the teeth
progresses
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.
1. Selective shaping and occlusal equilibration
2. Orthodontic repositioning of the teeth within
the present bone framework
3. Restorative reshaping
4. A combination of the above procedures
The conservative approaches for resolving
anterior cross bite problems can be summarized
as follows:
70

Surgical Correction of Anterior Crossbite
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.
There are three methods for correcting an anterior crossbite surgically:
71

72
• In most instances, it is "leave it alone" unless there are
interferences to centric relation or excursions.
• 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.
Posterior crossbites

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.
73

• 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).
74

Treating crowded, irregular, or interlocking
anterior teeth
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 of the arch.
5. We can change the axial inclination of the anterior teeth.
Five possible ways of solving the space problem:
75

Narrowing
crowded teeth
Several techniques that can be used
for moving teeth into their
predetermined correct position in
the arch:
 Finger pressure
 Ligatures and rubber bands
 Removable appliances
 Bands
 Cemented brackets
 Vinyl repositioners
• Invisible retainers
Flexible ethylene vinyl acetate (EVA) polymer
joined to a semi rigid polycarbonate material.
• Invisalign
It utilizes a series of computer-generated
sequences for tooth movement to achieve an
ideal alignment of teeth in both arches.
76

• 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.
77

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.
The anterior guidance was refined so a
cast could be made
and mounted in centric relation to
fabricate a custom anterior
guide table.
Preparations were then completed.
A provisional restoration was copied
from the diagnostic wax-up.
serve as a retainer until the bone
stabilizes.
After approval, permanent
restorations will copy it. 78

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.
A centric relation bite is made using bilateral manipulation with
load testing to verify centric relation.
79

Casts are mounted in centric relation with an earbow for
location of centric relation condylar axis.
A silicone index is made to relate the casts to centric
relation at first point of tooth contact.
The index is used in the computer-generated jaw
relationship to
which the teeth will be aligned. This corrects for
discrepancies inherent
in unmounted casts related to maximum intercuspation.
Series of Invisalign® overlays to be used in sequence.
80

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.
Teeth after movement to the
predetermined treatment goal.
Planning included use of
laminates for final esthetic
position and contour on right
and left laterals and canines.
Teeth prepared for laminates.
Finished result of very conservative
treatment. Central incisors were
bleached to lighten color, avoiding any
need for restorations on them.
Note the uniform occlusal contact in
centric relation, made possible
by aligning the teeth to a correct maxillo-
mandibular relationship.
81

Crowded anterior teeth with severe posterior
interferences
82

85
Full-mouth rehabilitation of a case of generalized enamel
hypoplasia using a twin-stage procedure
Aswini kumar kar, hari parkash, and Veena jain
Related articles

Full Mouth Rehabilitation with Group Function
Occlusal scheme in a patient with severe Dental Fluorosis
Sudhir N, Hari Parkash
87

89
Full mouth rehabilitaion of worn dentition
using pankey mann schuyler
technique & broadrick flag method- a case
report.
Kiran Kaushik, Pankaj Dhawan, Pankaj Madhukar,Piyush
Tandan
Dr. Shivam Singh Tomar and Dr. Divyesh Mehta

Full Mouth Rehabilitation With Dental Implants for a Patient With
Skeletal Class III Malocclusion: A Case Report
Sompop Bencharit,Dale J. Misiek, Linda A. Simon, Arabella Malone-Trahey
91

93
• This case report presents a
comprehensive treatment for a
patient with severe skeletal class III
malocclusion.
• The patient also had problems with
worn dentition in the maxilla and
compromised periodontal support
in the mandible.
• Functional occlusion and esthetics
were restored with orthodontic
treatment, orthognathic surgery,
implants, and complex fixed
prosthodontics therapy

94
Full-mouth rehabilitation using twin-stage technique
Ashish Kalra, Harbir Singh Sandhu, Nanda Kishore Sahoo, AK Nandi, Shilpa Kal

Conclusion
• The patient needing extensive restorations is often neglected and overlooked by a
general practitioner due to lack of specialized training.
• multidisciplinary approach
• Ultimate goal - optimum oral health
• 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
96

97
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
• 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

98
• Bencharit S, Misiek DJ, Simon LA, Malone-Trahey A. Full mouth rehabilitation with
dental implants for a patient with skeletal class III malocclusion: a case report.
Journal of Oral Implantology. 2012 Feb;38(1):63-70.
• 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
• Kalra A, Sandhu HS, Sahoo NK, Nandi AK, Kalra S. Full-mouth rehabilitation
using twin-stage technique. Int J Oral Health Sci 2019;9:40-4.

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