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GOALS OF FULL MOUTH REHABILITATION

(Goldman J Prosthet Dent mar-1952)

The origins of the modern practice of renewing and reorganizing the teeth by
prostheses began with the idea of raising the bite to rectify closure resulting
from excessive wear of the occlusal surfaces. Later, such closure was associated
with hearing loss, noted by Costen. This view, though later questioned, served
to stimulate interest increasing the length of the patients own teeth and thus in
increasing the vertical dimension.
In correcting articular disturbances, the best procedure came to be the
retention of the remaining natural teeth in so far as this was possible. These
teeth were rebuilt to harmonize with the movements of the joints in order to
protect them from further injury.
With our present understanding of traumatic occlusion and its deleterious
effect upon the supporting structures, the procedure known as "bite raising" has
shifted in emphasis and broadened in scope and is now designated by a term
that describes it accurately. Full mouth reconstruction, as of now includes
therapy which will, by improving the relationship of the teeth, improve the
condition and health of the supporting structures.
When the teeth have been realigned through full mouth reconstruction,
the general tone of the supporting tissues invariably improves. The factors that
account for this improvement are the removal of excessive lateral forces and the

elimination of plunger cusps and similar forces attendant upon the realignment
of full mouth reconstruction lessen continuous injury to the supporting
structure. But these factors, though helpful in improving the condition of these
structures, are less important than the increased stimulation of and circulation in
the tissues that are brought about by the improved function.
The masticating apparatus that is normal, healthy, and functioning is able
not only to carry out the work for which it is designed, but also to maintain
itself in health. The various structures involved, through their form and
arrangement, provide for both the synchronization of, and mutual protection
against, all forces. When function is good, a generous blood circulation
furnishes the tissue with the elements needed to keep them in a healthy
condition. When function is disturbed by malocclusion, the relation between the
mutually protective parts of the masticating apparatus is disrupted; moreover,
because of lessened use, blood circulation is diminished.
As indicated by O'Rourke, the force of persons masticatory muscles
remains fairly constant. It is the use of the force that changes under conditions
of traumatic occlusion. The patient's ability or willingness to use his muscular
force is dependent upon the comfort, or absence of pain, he experiences each
time he brings his jaws together.
Mutilated mouths with chronically inflamed supporting structures, due to
traumatic occlusion, will support very little force without producing some

discomfort. The result is continuous subnormal use of, or at best failure to make
vigorous use of, the teeth and jaws. The vascular tissues of the periodontium can
be stimulated only by the teeth in function. Such stimulation is lacking when
this function is impaired by the inability of the patient to use the musculature in
chewing because of the tenderness of these tissues.
The results, in the words of Merritt, are atrophy of the alveolar process,
malocclusion of the teeth, dental caries, impacted and missing teeth, periodontal
lesions, and so on. Unfortunately, subnormal function lowers vitality at the same
time that it increases susceptibility to disease.
Patients who have had full mouth rehabilitation commonly say that their
mouths feel "stronger". The masticatory muscles have obviously not been
strengthened by therapy. What has happened is that patients can exert greater
force with comfort and without anticipation of pain than they could before and
that therefore they do exert greater force.
The individual patient's reaction to the therapeutic benefit of improved
tooth arrangements and improved functioning should inspire us, in terms of
human satisfaction as well as of scientific progress, to strive continuously for
improvement in the techniques of full mouth rehabilitation.
It should be kept in mind that although the operations of all mouth
rehabilitation procedures are performed on tooth units, they have one basic

objective: the equalization of the forces directed against the supporting


structures. Any disharmony at the occlusal or incisal aspects of a tooth will
direct forces against these mal-aligned surfaces and thus subject the supporting
structure to traumatic injuries. Similarly, any impairment of buccal or lingual
harmony will be reflected in injury to the gingival tissue and subsequently to the
deeper tissues involved in supporting the tooth. The proximal contact anatomy
is also vital in maintaining the health of the underlying soft tissue. Poor contact
relationships encourage food impaction with resultant periodontal tissue loss.
Dentistry seeks to increase the life span of the functioning dentition, as
medicine increases the life span of the functioning individual. For this reason,
full mouth rehabilitation of the neglected adult mouth is regarded as of
increasing importance, for it is only through this procedure that adult patients
with dentitions in varying stages of degeneration can be restored to dental
functioning and dental health.

Mouth rehabilitation seeks to convert un-favourable forces on the teeth,


which inevitably induce pathologic conditions, into favourable forces permitting
normal function and hence induce healthy conditions. The favourable forces
increase tolerance of the supporting structures to masticatory pressures.
Restoration of normal function of the masticating apparatus is the ultimate aim
of full mouth rehabilitation.
These goals were summarised by Lucia as:-

1. Freedom from disease in all masticatory system structures


2. Maintainable healthy periodontium
3. Stable TMJS
4. Stable occlusion
5. Maintainable healthy teeth
6. Comfortable function
7. Optimum aesthetics

Some of the most important functional objectives of an occlusal rehabilitation


are:
(Oral rehabilitation ; clinical determination of occlusion by Sumiya Hobo & Hisao Takayama)

(1) A static centric occlusion in harmony with the centric maxillomandibular


relation.
(2) An even distribution of stress in centric occlusion over the maximum
number of teeth.
(3) Lateral and anteroposterior freedom of movement in centric occlusion.
(4) Masticating efficiency which involves uniform contact and an even
distribution of stress on eccentric functional tooth inclines which are
coordinated with the incisal guidance and normal functional condylar
movements.

(5) Reduction of the buccolingual width of the occlusal surfaces of the teeth,
and a reduction of the balancing incline contacts as a means for reducing a
potentially traumatogenic load on the structures supporting the dentition.
Factors that limit the treatment of occlusions Limitations have a direct bearing
upon any plan of treatment for each patient requiring restoration in a
dysfunctioning occlusion. There are atleast 7 primary factors which limit the
plan of treatment in occlusal rehabilitation no matter what concept is followed

1. Differences in occlusal levels between the anterior and posterior teeth


2. Asymmetries in the body
3. The natural and unnatural wear of tooth
4. The patients individual pattern of chewing
5. The patients intolerance to any change in occlusion by prosthodontic means
6. The patient wishes
7. The economic factor.

Guidelines before undertaking any rehabilitation case;-

1. Do not alter the occlusion of the patient unless you are certain that such
change is necessary.

2. Do not rehabilitate the occlusion beyond the limits of the patients interocclusal clearance (free way space).

3. Occlusions are like fingerprints-no two are alike, and therefore, all cases
cannot be treated the same.

4. If the existing occlusal curve is not a factor in any temporomandibular joint


disturbance; if it contributes to a healthy periodontium; and if it participates in a
comfortable and functional occlusion, then it is advisable to duplicate that curve
in occlusal rehabilitation.

5. Corrective and restorative dentistry is controlled by many inescapable limits


and the doctor and the patient must take these limitations into consideration.

6. Do not hesitate to consult with other practitioners in the planning of your


case.

7. Complete the occlusal rehabilitation as quickly as possible.

8. All patients who come to your office do not require occlusal rehabilitation.

9. It is not necessary to cut and cover every tooth on a patient in order to


rehabilitate his occlusion.

10. Do not resort to a full coverage restoration if one that conserves more tooth
structure is indicated.

11. If the patients occlusion has functioned for many years in a chopping up
and down motion, do not present him with a so called balanced occlusion that
will skid and slide in lateral and protrusive excursions.

12. Inform the patient that nothing of a material nature lasts indefinitely, and
that restorations may last two years in one patient and perhaps ten years in
another.