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Basic Concept in Full Mouth Rehabilitation An Overview

Dr Ankush Jain*,Dr Umesh Palekar**, Dr Rajeev Srivastava***, Dr Vivek Choukse***


ABSTRACT: Full mouth rehabilitation continues to be the biggest challenge toany
clinician in restorative dentistry. It requires efficient diagnosis and elaborates treatment
planning to develop ordered occlusal contacts and harmonious articulation in order to
optimize stomathognathic function, health and esthetics which then translates to patient's
comfort and satisfaction. Aim of this article is to discuss about application and selection of
different technique for full mouth rehabilitation. Several techniques of full mouth
rehabilitations are available and a clinician should ascribe to one after a comprehensive
diagnosis of the patient's clinical condition and prospective consideration of his/her oral
college &Research centre, Indore.
health, function, comfort and esthetic requirements.

Key Words: Full mouth rehabilitation, Pankey-Mann-Schyuler philosophy, twin stage


procedure, functionally generated path technique

INTRODUCTION-

Full mouth rehabilitation continues to be the Eliminate pain and discomfort of teeth and
biggest challenge toany clinician in surrounding structures.
restorative dentistry. It requires efficient To correlate centric occlusion with the
diagnosisand elaborate treatment planning to unstrained centric relation
develop ordered occlusal contacts and To obtain the maximum distribution of
harmonious articulation in order to optimize occlusal stress in centric relation
stomathognathic function, health and To retain vertical dimensions
esthetics which then translates to patient's To establish smooth guiding tooth inclines
comfort and satisfaction. Thorough To reduce the steepness of inclines of
knowledge of the various concepts of guiding tooth surfaces so that occlusal
articulation is therefore integral to any full stresses may be more favourably applied to
mouth rehabilitation that is taken up to the supporting tissues
address the patient's problem related to To increase the number and size of food
restoration of multiple teeth that are either exits
decayed, worn, broken, discolored, missing To decrease the size of the occlusal contact
or suffer developmental deficits.1 surfaces.2
Several techniques of full mouth
rehabilitations are available and a clinician Indications for full mouth rehabilitation:
should ascribe to one after a comprehensive Collapsed occlusion due to loss of teeth
diagnosis of the patient's clinical condition Loss of vertical dimension
and prospective consideration of his/her oral Repeated fracture of restorations
health, function, comfort and esthetic Para functional habits
requirements.1 Lack of inter-occlusal space
Trauma to occlusion
OBJECTIVES Loss of occlusal function
Restore impaired occlusal function Unacceptable esthetics
Maintain healthy periodontium TMJ disorders
Developmental anomalies in dentition
*Post Graduate Student, Mal-occlusion (class-II malocclusion, class-
**Professor & HOD, III malocclusion)3
***Professor
Department of Prosthodontics, Modern dental

NJDSR Volume I number 4 January 2016 Page 1


Contra-indications for full mouth guidance in a manner that will not interfere
rehabilitation: with condylar guidance.

There are many malfunctioning mouths that Part-4: Restoration of the upper posterior
do not need extensive dentistry and have no occlusion in harmony with the anterior
joint symptoms. These cases are best left guidance and condylar guidance
alone. One or two "good" teeth may have to
ADVANTAGES-
be operated on in order to satisfactorily
accomplish our objective. In short, no
1. Possible to diagnose and plan treatment
pathology -no treatment.4
for the entire rehabilitation before a single
tooth is prepared.
PHILOSOPHIES OF OCCLUSAL
2. Well organised and a logical procedure.
REHABILITATION- 3. Never a need for preparing or rebuilding
more than eight teeth at a time.
I)PANKEY-MANN-SCHYULER
PHILOSOPHY
4. Divides the rehabilitation into separate
series of appointments.
One of the most practical philosophies for 5. No danger of getting lost at sea and
occlusal rehabilitation is the rationale or loosing the patients present vertical
treatment that was originally organized into dimension.
a workable concept by Dr. L.D. Pankey. The 6. Functionally generated path and centric
philosophy has had as its goal the fulfilment relation are taken on the occlusal surface
of the following principles of occlusion as of the teeth to be rebuilt at the exact
advocated by Schuyler: vertical dimension.
1. A static coordinated occlusal contact of 7. All posterior occlusal contours are
the maximum number of teeth when the programmed by and are in harmony with
mandible is in centric relation. anterior and condylar guidance.
2. An anterior guidance that is in harmony 8. There is no need for time consuming
with function in lateral eccentric position techniques and complicated equipment.
on the working side. 9. Laboratory procedures are simple and
3. Disclusion by the anterior guidance of all controlled to an extremely fine degree by
posterior teeth in protrusion. the dentist.5,6
4. Disclusion of all nonworking inclines in
II) TWIN STAGE PROCEDURE
lateral excursions
5. Group function of the working side The twin-stage procedure was developed by
inclines in lateral excursions. Hobo and Takayama in 1989. They derived a
kinematic formula to calculate anterior
Proper sequence advocated by PANKEY- guidance from condylar path.
MANN-SCHYULER philosophy:
Part1:Examination,diagnosis,treatment Factors that determine disclusion:
planning and prognosis. 1. Angle of hinge rotation
2. Cusp shape factor
Part-2:Harmonization of the anterior
guidance for best possible esthetics, function Angle of hinge rotation
and comfort.
Posterior disclusion occurs when anterior
Part-3: Selection of an acceptable occlusal guidance is steeper than condylarguidance.
plane and restoration of the lower posterior The mandible rotates around the
occlusion in harmony with the anterior intercondylar axis during
eccentricmovements when anterior guidance

NJDSR Volume I number 4 January 2016 Page 2


is steeper than condylar guidance. The fact Articulator adjustment values
thatcompensates for the difference in
steepness is the angle of hinge rotation.
For canine For Group
guided Function
Cusp shape factor occlusion: Occlusion

When slopes of posterior cusps are parallel CONDITION CONDITION


to condylar path inclination andanterior
guidance is parallel to condylar guidance, I II I II
the opposing cusps slide duringprotrusive Condylar path
movement without discluding, despite the
Sagittal
degree of steepness. condylar path
inclination 25 40 25 40
If anterior guidance is steeper than condylar
path, the posterior teeth disclude. Bennett angle
15 15 15 15
Anterior guide
table
However, if the cuspal inclination of molars
Sagittal
is parallel to anterior guidance, there isno inclination 25 45 25 45
posterior Disclusion even though anterior
Lateral wing
guidance is steeper than the condylarpath. 10 20 10 0
The posterior teeth disclude only when the
cusp inclination of the molar isparallel to the Contraindications of twin-stage procedure
condylar path and anterior guidance is
steeper than condylar path. The twin-stage procedure is contraindicated
in the following cases
Basic concept of twin stage procedure 1. Abnormal curve of Spee
2. Abnormal curve of Wilson
In order to provide disclusion, the cusp angle 3. Abnormally rotated tooth
should be shallower than the condylar path. 4. Abnormally inclined tooth.7
Since anterior teeth help produce disclusion,
when waxing of the occlusal morphology is III) FUNCTIONALLY GENERATED
done, to produce shallow cusp angle, the PATH:
anterior portion of the working cast becomes
an obstacle. Therefore a cast with a It is a method of rehabilitating the upper
removable anterior segment is fabricated. posterior teeth using functionally generated
The occlusal morphology of the posterior path record based on a modification of the
teeth without anterior segment is produced principles outlined by Meyer and Brenner in
so that the cusp angle is coincident with the 1933.
standard value of effective cusp angle. This
The functionally generated path technique is
is referred to as condition I.
to be followed after the anterior guidance
Secondly, the anterior morphology of the has been harmonized according to the
anterior segment is produced to provide patients esthetic and functional
anterior guidance with standard amount of requirements and after the lower posterior
disclusion. This is referred to as contours has been harmonized to the anterior
conditionII. guidance. Prepare teeth and make a master
cast. Make a wax tray over the prepared
The application of the two conditions teeth on the mastercast. Coat the trays
described to fabricate the cusp angle occlusal surface with a functional wax. Take
andanterior guidance are termed as Twin the tray to the mouth and carefully seat it
Stage Procedure. onto the teeth. Coach the patient to carve the
soft wax with movements of his opposing

NJDSR Volume I number 4 January 2016 Page 3


teeth. Chill, box, and seat the tray onto the Functionally generated path technique can
master cast. Fasten the master cast to an be used when restoring one quadrant at a
articulator. A simple hinge articulator may time.10
be used. Pour the boxed functional path and
fasten it to the articulator. Wax prostheses VI) SEGMENTED SIMULTANEOUS:
into the stone functional path as desired.
Cast the wax pattern, seat the metal It is combination of the desired
prosthesis on the master dies, and refine the characteristics of the full mouth
prosthesis to fit the stone functional path simultaneous rehabilitation and the
matrix.8,9 programmed quadrant approach into a single
IV) FULL MOUTH SIMULTANEOUS reconstructive technique.
TECHNIQUE10:
It involves full arch preparations, Technique:Tooth preparation and chair side
impression, provisional restorations and temporary fabrication: teeth are prepared and
mastercasts. temporary restorations are fabricated chair
side segment by segment during several
Advantages: appointments. The patients vertical
Flexibility in developing: dimensions of occlusion are maintained by
1. Occlusal plane using unprepared teeth or provisional
2. Occlusal scheme restorations as occlusal vertical stops.
3. Embrasure
4. Crown and esthetics Occlusal records: after teeth preparation
alginate impression are taken and face bow
Disadvantages: transfer are made. Casts are used for making
1. Arduous unpredictable patient visit heat processed acrylic resin treatment
2. Full arch anaesthesia restorations. Centric relations are recorded
3. Multiple occlusal records by removing chair side temporary
4. Possible loss of vertical dimension of restorations in opposing segments and
occlusion10 placing Duralay resin between maxillary and
mandibular preparations. When this resin has
V)QUADRANT/SEGMENTTECHNIQUE: set in onesegment it is used as an index to
maintain vertical relation while
It involves completing one quadrant before additionalquadrant relationships are
beginning another. recorded.

Advantages: Fabrication of heat processed treatment


restorations: a complete wax- up of the
Preparation and final impression of selected reconstruction is performed directly on the
teeth at one time will lead to- mounted casts and then heat processed in
1. Maintenance of vertical dimension acrylic resin.
2. Quadrant anaesthesia
3. Shorter predictable appointments Articulation of casts: alginate impressions
are made of occlusally adjusted heat
Disadvantages: treatment restorations and face bow transfer
is made. Relate the mandibular cast with the
Restriction of achieving ideal occlusion
upper. These casts are facsimile of final
when altering
reconstruction and are opposing cast for
1. Vertical dimension
framework waxing during metal framework
2. Occlusal plane
fabrication. Incisal guide table is set from the
3. Embrasure development
anterior guidance of the facsimile mounting.

NJDSR Volume I number 4 January 2016 Page 4


Final impression and working casts: 3 full REFERENCES
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Corresponding Author:
The occlusal rehabilitation procedure
requires proper dentistpatient relationship Dr Ankush Jain
because it is a long term procedure that P.G Student
needs patients co-operation.The object of Dept. of Prosthodontics
complete mouth rehabilitation must be the Modern dental college & research
reconstruction, restoration and maintenance centre, Indore
of the entire oral mechanism.

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