FULL MOUTH REHABILITATION

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

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.
2

3
• 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

4
• In this case, the mandible translates and
rotates around the intercondylar axis; the
maxillary and mandibular molars
dlsocclude.
• McHorris (1979) Incisal path should be 5
degrees steeper than the condytar path.
• However, when setting the sagittal lncisal
path inclination 5 degrees steeper than the
condylar path, the amount of disocclusion
during protrusive movement is only 0.2
mm, about one-fifth the standard value
(1.0 mm).
• If the incisal path is steeper than 5
degrees, the patient will complain of
discomfort.
Anterior guide component

5
• 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.

6
• 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

7
Influence of the amount of disclusion
Cusp
angle
Incisal
path
Condylar
path
Dependent factors
NON WORKING
SIDE
WORKING ISDE

Twin-tables technique -Hobo (1991)
• Posterior teeth are restored using
two customized incisal tables:
without disclusion; and with
disclusion
• They did not include freedom in
centric.
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.
• Was technique sensitive
8

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
9
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
10
Hobo S (1991) Twin-tables technique for occlusal rehabilitation.Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303

11
• 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
12

Factors that determine
disclusion
• Angle of hinge rotation
• Cusp shape factor
• Anterior guidance is steeper than condylar
guidance.
• The mandible rotates around the
intercondylar axis .
• The fact that compensates for the
difference in steepness is the angle of
hinge rotation
Cusp shape factor
• Posterior teeth disclude only when the
cusp inclination of the molar is parallel to
the condylar path and anterior guidance is
steeper than condylar path.
13

During protrusive movements,
condyle rotates
along horizontal axis if anterior
guidance (/?) is steeper than
condylar path ((Y). Angle of hinge
rotation compensates for
this angular difference.
During protrusive movement,
condyle translates
without rotation when anterior
guidance (~3) and condylar
path (fi) are parallel.
14

When cusp inclination of molars
is parallel to anterior guidance,
there is no posterior disclusion
despite
steeper anterior guidance (fi)
than condylar path ((Y).
Posterior disclusion is evident when
cusp inclination of molars is parallel
to condylar path and anterior
guidance (8) is steeper than condylar
path ((Y).
15

Contraindications
• In the above contraindicated cases, the
vertical axis of the posterior teeth may have
inclined abnormally.
• As a result, the effective cusp angle may vary
to some extent even though the cusp angle
of a n atural 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
16
• Abnormal curve of Spee
• Abnormal curve of Wilson
• Abnormally rotated tooth
• Abnormally inclined tooth

Evaluation of twin stage procedures
The articulator test
• In the articulator test, after completion of
the posterior occlusal wax-up on casts
mounted on an articulator (under
Condition 1 ), and adjusting the articulator
(under Condition 2), the specific amount
of disocclusion occurring during various
eccentric movements was determined.
• This is an in vitro test.
The intra oral test
• In the intraoral test, when the results of
test 1 were completed and satisfactory, the
restoration made on the articulator was
cemented in the patient's mouth.
• Then it was tested to determine if the
amount of disocclusion was reproduced as
occurred in test 1 .
• This is an in vivo test.
17

Solving deep overbite
problems
• Care must be taken to maintain neutral zone relationship of upper anterior teeth.
• Deep overbites are almost always related to strong lip pressures and a tight neutral
zone.
• Phonetic relationship of incisal edges is critical for deep overbite patients.
• Supraeruption of lower incisors often requires correction.
• If lower incisors are shortened, stops must be provided.
• If stops cannot be provided, a removable substitution may be needed to prevent
supraeruption, or splinting may be considered.
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. The patient may
wear the provisionals as long
as necessary to determine that
they are 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

Deep overbite with tissue contact
• Lower incisors erupt up into soft tissue
lingual to the upper anterior teeth. It is not
a problem if:
 The upper lingual tissue has been
unaffected by the contact.
 The contacted tissue is dense, firm, flat,
and shows no sign of inflammation.
• The lower incisor tissue contact is
simultaneous with contact against the lingual
surface of the cingulums of the upper
incisors.
• The incisal edges of the lower incisors are
smooth with no sharp edges.
• The incisal plane of the lower anterior teeth
is acceptable esthetically and must be in
conformity with the rest of the occlusal
plane.
27

28

29

30

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
31

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.
32

Bite planes to solve deep overbite problems
• Discomfort from tissue impingement and if future problems are imminent.
• Least complicated way of preventing supraeruption of the lower anterior teeth.
• Fabrication is carried out on centrically mounted models.
• The appliance is most esthetically acceptable when it is made of clear acrylic resin. It must provide
stable centric contacts for all lower teeth, and it should be equilibrated so that there is no interference
to any excursive movement.
33

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.
34

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 .
35

• 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
36

Extreme anterior overjet treatment choices
• Some overjet problems can be corrected by closing the vertical dimension of occlusion (VDO) to permit the arc of closure
to move the lower anterior teeth forward into contact with the upper anterior teeth
Reshape
• This is very often the best solution, sometimes in combination with restorative dentistry.
Orthodontics
• to restore holding contacts or to splint incisors to teeth that have contact in centric relation.
Restorative dentistry
• to provide palatal bar stops for lower incisors
Removable appliances
• to move the maxilla back or the mandible forward or to reposition the maxillary anteriors back with an osteotomy
Surgery
37

The problems of anterior overjet
Problem 1
• Lower teeth with no stabilizing
contact with the upper teeth
either in centric relation or
near centric relation have
tendency to supraerupt, drift
out of alignment, and
frequently impinge on the
palatal tissues.
Problem 2 Problem 3
• Excessive overjet
relationships make
it difficult or
impossible for the
anterior guidance
to do its job of
posterior
disclusion.
associated with excessive anterior
overjet is esthetics.
The classic bucktooth appearance
has long been used by cartoonists
to depict stupidity.
It is not a pleasant appearance,
and it is often the real reason why
patients seek treatment.
38

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
39

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
40

A rubber band attaches to the appliance to move the teeth
into the contoured slots in the lingual plate. Use of such
appliances
is a simple way to achieve dramatic results, but alternative
methods using bands or brackets must always be
considered if final positioning requires horizontal bodily
movement of roots.
Results of repositioning show an improved incisal plane as
incisal edges move down as they are pulled back into a position
that permits contact with the lower incisors. Note: The
appliance increases the VDO to allow room to move the upper
teeth back. The lingual contours are then reshaped to
ideal contact with lower incisors.
41

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. Nothing is left to chance.
42

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.
43

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
44

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.
45

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 intercuspation46

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.
47

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
48

• 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.
49

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.
50

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).
51

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
52

• 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
53

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.
• Restorative recontouring of teeth in an end-to-
end bite an cause special problems if the
stresses are moved off the direction of the long
axis.
• The stresses are so confined to the long axis
that the periodontal fibers and the bone
trabeculae are not aligned to resist lateral stress.
• Suddenly changing a tooth's contour to subject
it to lateral forces may produce unwanted
effects of tenderness or hypermobility until the
fibers realign and the bone becomes more
resistant to the lateral forces.
54

• 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.
55

Special considerations
Stability
• Whether an end-to-end occlusion is stable
depends principally on two factors:
1. Harmony with the neutral zone
2. Noninterference with the envelope of
function
Skeletofacial profile
• Requires cephalometric analysis as well
as mounted diagnostic casts.
• The purpose of the cephalometric
evaluation is to determine whether the
end-to-end relationship is caused by an
underdeveloped maxilla or an
overdeveloped mandible, or some
combination of both.
The decision to alter the occlusal relationship should be
based on a careful evaluation of the following factors:
56

Function
It is rare for a patient with a stable
end-to-end relationship to
complain of inadequate function.
Esthetics
• The irony of an anterior end-to-
end occlusion is that although
many dentists believe it should be
"corrected," most patients believe it
is the ideal relationship.
57

• 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
58

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
59

• Evaluate each method and select the most practical way to fulfill the requirements for
stability.
• The goal is posterior disclusion of the balancing side either by the anterior guidance or by
the posterior teeth on the working side.
• 4. Anterior guidance can sometimes be steepened if it is not steeper than the lateral path
originally found during excursions dictated by posterior teeth
60

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.
61

 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
62

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.
63

• 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.
64

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
65

• 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.
66

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.
67

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.
68

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?
69

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.
70

No Anterior Guidance
Most prognathic patients limit their function to vertical "chop chop"
movements
Provide balancing incline disclusion.
The necessary lift can usually be provided by the working-side inclines.
Group function of the working inclines is usually the occlusion of choice.
71

Why increasing the VDO works?
• If the increased VDO at the anterior
teeth is offset by upward movement of
the condyles from maximal
intercuspation to centric relation, the
interference with elevator muscle
contracted length may be minimal or
none.
• Even if increasing the VDO cannot be
offset completely by upward condylar
repositioning, the increased VDO can
be well tolerated as the muscles return
it to their original contracted length.
• If all teeth are in contact in centric
relation, the corrected occlusion will
be maintained with minimal
adjustments required
72

73

• 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.
74

• 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.
75

• 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.
76

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:
77

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:
78

• Determining the best treatment choice for posterior crossbite. In most
instances, it is "leave it alone" unless there are interferences to centric relation
or excursions.
• Analyzing cusp/fossae relationships in crossbite cases. The lower lingual cusp
and the upper buccal cusp become the stamp cusps.
Treatment objective
• Cross bite occlusions follow the same rules as normal occlusions with regard to
the requirements for stability. They just use different cusps for holding
contacts. 79

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.
80

• 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).
81

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 0f the arch.
• 5. We can change the axial inclination of the anterior teeth.
Five possible ways of solving the space problem:
82

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.
83

• 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.
84

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. This will serve as a retainer until
the bone stabilizes.
After approval, permanent restorations will
85

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.
86

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.
87

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.
88

Crowded anterior teeth with severe posterior
interferences
89

SUMMARY
Procedural steps in full mouth rehabilitation
Case history
and clinical
examination
Diagnostic
impressions
Evaluate vertical
dimension and
Occlusal
interference for
slide in centric
Facebow
record, Inter
occlusal
record
Diagnostic
mounting on a
semi
adjustable
articulator
Occlusal
equilibration for
removal of gross
interference
Occlusal splint
to confirm loss
of vertical
dimension
Selection of
occlusal
scheme
Diagnostic wax-
up at estimated
vertical relation
of occlusion
Evaluate for crown
height, retention
form,surgical
crown lengthening,
intentional root
canal treatment
Multidisciplinar
y approach
Approach to
FMR Segmental
Quadrant wise
Determine
material for
restorations
Shade
selection 92

Shade selection
Prepare lower anterior teeth
Provisionalization
Prepare upper anterior teeth
Provisionalization
Evaluation of anterior guidance,
plane of occlusion, and occlusal
scheme on provisional
restorations
Recording and transferring
anterior guidance record of
provisional
Final impression of upper and
lower anteriors
Evaluate anterior plane for
occlusion, phonetics, esthetics and
function
Interocclusal record to mount on
articulator
Final impression of upper and
lower posteriors
Temporary cementation of final
anterior restorations
Bisque tryin
Metal tryin
Metal tryin
Bisque tryin
93

•
Evaluate for function, esthetics
and comfort
Remounting
Maintenance phase
Final cementation of restorations
Temporaty cementation of upper
and lower final posterior
restorations
Follow up
94

CASE REPORTS – Bruxism
• 45-year-old male patient with a habit of bruxism
• Attrition :
• Marginally less in the posteriors as compared to the anterior teeth
• Total collapse of the vertical dimension
• Lower anterior teeth were totally razed to the gingival level
• Upper lateral incisors & canines were also very badly destroyed
95

CASE REPORTS
• Second molars : Intercuspating occlusion
• First molars : > 40% attrition on the occlusal surfaces with no intercuspation
• Upper right lateral incisor & canine : attrided to the gingival level
• Lower Anterior : Right f
• irst premolar - left canine were totally razed to gingival level
• Remaining teeth : > 40% of loss of crown structure
96

CASE REPORTS
• Phase I
• Endontic
• Reestablishment of Vertical dimension
• Occlusal equilibration
• Phase II
• CLP
• Upper and lower incisors
• Endodontics
• Glass fiber posts + Adhesive restorations
• Post & core on upper right canine & lower canine
97

Amelogenesis Imperfecta
 Incisal aspects …completely worn away exposing the pulp chambers
 Occlusal aspects of all the posterior teeth were also severely worn
 Cervical & proximal enamel was found to be normal
 Attrition of the molars resulted in a decrease of the vertical dimension of
occlusion
 Interocclusal distance : At physiologic rest position = 7.3 mm
 Centric Occlusion = Maximum intercuspal position
 Gingival status: Good and well maintained
 Oral hygiene : satisfactory
99

CASE REPORTS
Panoramic Radiographic Examination
Enamel of the teeth appeared to have the same radiodensity as dentin
Morphology of the roots were normal
Pulp chambers were normal with no evidence of calcification
Cementum, lamina dura, & bony trabeculations were within normal limits 100

CASE REPORTS Inadequate crown height for the fabrication of the prosthesis
 Apically positioned flap
 Crown lengthening
 Increase of crown height by approximately 2 mm was achieved
 Caries excavation was done for all carious teeth
 Endodontic therapy was carried out as required
 Bite registration using Type II modeling wax
 Increased vertical dimension of 5 mm with 3 mm of freeway space
 Splint fabricated with heat-cured Polymethyl methacrylate acrylic resin
 Patient used the splint for three months
101

CASE REPORTS
 Full-mouth, heat-cured provisional restorations were fabricated at the desired vertical dimension (with 3
mm freeway space) using methyl methacrylate acrylic resin & were temporarily cemented
102

CASE REPORTS• Maxillary anterior teeth: cast post cores
• Mandibular anterior teeth : prefabricated posts
• Premolars & right first molar : Composite core build-ups to
increase the crown height
Crown preparation:
Porcelain-fused-to-metal (PFM) : Maxillary & mandibular anteriors,
premolars, and maxillary first molars
All-metal restorations: remaining teeth
103

Failure and success in full mouth rehabilitation
• dependent on technical and
biophysical factors.
• Technical failures may be loss of
restorations and retainers or
fracture of metal or porcelain
components.
• Caries, fracture of abutments,
periodontal disease and extractions
are classified as biological failures.
• Health of periodontium is influenced by
the oral hygiene practice of the patient,
crown position and margin, contour and
occlusion of the restoration.
• Hygiene instructions combined with
repeated prophylaxis every six months
prove successful in maintaining oral
health. Adequate plaque control
program to prevent secondary caries is
essential
105

Conclusion
• The patient needing extensive restorations is often neglected and overlooked by a
general practitioner due to lack of specialized training. Its important to know that
achieving success in full mouth rehabilitation requires a multidisciplinary approach.
The ultimate goal of any dental treatment is to provide optimum oral health1.
• to attain this ooral health it is important to have properly scheduled recall visits and
oral hygiene maintenance . Restorations must be meticulously fabricated considering
mechanical and biological factors,which will ultimately lead to long term success of
full mouth rehabilitation
106

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
107

• PHILOSOPHIES IN FULL MOUTH REHABILITATION – A
SYSTEMATIC REVIEW Int J Dent Case Reports 2013; 3(3): 30-39
• The Dahl principle revisited Irish Dentist July 2011
• ORAL REHABILITATION Part I. Use of the P-M Instrument in Treatment
Planning and in Restoring the Lower Posterior Teeth J. Pros. Den. Jan.-Feb., 1960
• Increasing occlusal vertical dimension — Why, when and how D R Bloom
& J N Padayachy British Dental Journal 200, 251 - 256 (2006)
• Broadrick occlusal plane analyzer 2008 whipmix corporation
• Twin – tables technique for occlusal rehabilitation : part 1 – Mechanism
of anterior guidance J PROSTHET DENT 1991, vol 66 pg 299-303
• Functionally generated paths for Ceramometal restorations J PROSTHET
DENT 1999, vol 81 pg 33-36
•
108

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