full mouth rehabilitation and different philosophies

1. FULL MOUTH
REHABILITATION
Under The Guidance Of
Dr Akshey K Sharma
Dr Pardeep Bansal
Dr Poonam Bali
Dr Rajnish Bansal
Dr Gagandeep K Chahal
Dr Rajnanda Khuller
Presented by
Asmita sodhi
Pg student

2. CONTENTS
• Introduction
• Goals
• Indications
• Classification of patients
• Objectives of Occlusal schemes
• Philosophies for full mouth rehabilitation
• Treatment Philosophies

3. The goal of dentisty is increasing the sapan of
functioning just as the goal of medicine is to
increase the life span of the functioning
individual.
Planning and executing the restorative
rehabilitation of a decimated occlusion is
probably one of the most intellectually and
technically demanding tasks facing a restorative
dentist.

4. DEFINITION
ACCORDING TO GPT-9
Full mouth rehabilitation is defined as the
restoration of the form and function of the
masticatory apparatus to as nearly a normal
condition as possible
FULL MOUTH REHABILITATION

5. OPTIMAL
ORAL
HEALTH
ANATOMIC
HARMONY
FUNCTIONAL
HARMONY
OCCLUSAL
STABILITY
BEST
ESTHETICS

6. INDICATIONS
FULL MOUTH REHABILITATION

7. • RESTORATION OF MULTIPLE TEETH –
MISSING,WORN ,BROKEN
DOWN,DECAYED.
BEFORE AFTER
FULL MOUTH REHABILITATION

8. •TO REPLACE IMPROPERLY
DESIGNED AND EXECUTED CROWN
AND BRIDGE WORK.
BEFOR
E
AFTER
FULL MOUTH REHABILITATION

9. DEVELOPMENTAL DEFECTS
BEFORE AFTER
FULL MOUTH REHABILITATION

10. DISCOLOR DENTITION
Full mouth rehabilitation with whiter teeth.
BEFORE AFTER
FULL MOUTH REHABILITATION

11. OCCLUSAL REHABILITATION
FULL MOUTH REHABILITATION

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

13. Temporomandibular disorder

15. Classification by Turner and Missirlain
(1984)
• The patients were classified into three categories –
• Category 1 - Excessive wear with loss of vertical
dimension.
• Category 2 - Excessive wear without loss of vertical
dimension of occlusion but with space available.
• Category 3 - Excessive wear without loss of vertical
dimension of occlusion but with limited space available

16. Category 1 - Excessive wear with loss of vertical
dimension.
• A typical patient in this category has few posterior teeth
and unstable posterior occlusion. There is excessive wear
of anterior teeth.
• Closest speaking space of 3mm and interocclusal
distance of 6mm.
• there is some loss of facial contour that results in
drooping of the corners of mouth.
• Patients with dentinogenesis imperfecta with excessive
occlusal attrition, around 35 years of age and appearing
prognathic in centric occlusion also belongs to this
category.

18. Category 2- Excessive wear without loss of
vertical dimension of occlusion but with space
available
• Patient has adequate posterior support and
history of gradual wear.
• Closest speaking space of 1mm and
interocclusal distance of 2-3mm.
• Continuous eruption has maintained
occlusal vertical dimension leaving
insufficient interocclusal space for
restorative material.
• History of bruxism
• Parafunctional oral habits

19. Category 3 –- Excessive wear without loss of
vertical dimension of occlusion but with limited
space available
• Posterior teeth exhibit minimal wear but anterior teeth
show excessive gradual wear
• Centric relation and centric occlusion are coincidental
with closest speaking space 1mm and interocclusal
distance 2-3mm.
• It is most difficult to treat because vertical space must
be obtained for restorative material.
• Vertical space obtained by
• Orthodontic movement

20. Classification by Brecker
Clinical Procedures In Occlusal
Rehabilitation Charles Brecker In 1966
• Group I
• Class I – Patients with collapse of vertical dimension of
occlusion because of shifting of existing teeth caused by
failure to replace missing teeth.
• Class II – Patients with collapse of vertical dimension of
occlusion because of loss of all posterior teeth in one or
both jaws with remaining teeth in unsatisfactory occlusal
relationship.
• Class III – Patients with collapse of vertical dimension of
occlusion because of excessive attritional wear of
occlusal surfaces.

21. • Group II
• Class I – Patients with all or sufficient natural teeth
present, with satisfactory occlusal relationship.
• Class II – Patients with limited teeth present but in
satisfactory occlusal relationship requiring aid in the
form of occlusal rims.
• Group III – Patients requiring maxillofacial surgery of
orthodontic treatment as an aid in restoring the lost
vertical dimension.
• Group IV – Patients in whom sectional treatment is
required over extended periods of time because of status
of health of the patient, age or economic factor.

22. OBJECTIVES OF OCCLUSAL
REHABILITATION
• Static centric occlusion in harmony with the
maxillomandibular relation.
• An even distribution of stress in centric
occlusion over the maximum number of
teeth.
• Lateral and anteroposterior freedom of
movement in C O.
FULL MOUTH REHABILITATION

23. OBJECTIVES…
• Masticatory efficency which involves uniform
contact and an even distribution of stress on
eccentric functional tooth inclines which are
coordinated with the incisal guidance and
normal fuctional condylar movements.
FULL MOUTH REHABILITATION

24. Objectives….
• 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 Traumatogenic Load
On The Structures Supporting The Dentition.
Full Mouth Rehabilitation

25. Constants
•Patients present in our practices with functional
determinants that are unchangeable by the restorative
dentist as part of their present condition.
•THESE CONSTANTS INCLUDE
1.INTERCONDYLAR DISTANCE,
2. HINGE AXIS POSITION
3.THE RELATIONSHIP OF THE MAXILLA TO THE
MANDIBLE IN CENTRIC RELATION
4. THE PATH OF THE CONDYLE-DISK ASSEMBLY IN
THE GLENOID FOSSAE.
• These constants must be evaluated, recorded, and
transferred to a patient simulation device accurately
enough to permit diagnostic planning prior to treatment
and the fabrication of dental restorations during
treatment.

26. OCCLUSAL SCHEMES
(AN OCCLUSAL SCHEME IS A PATTERN OF
OCCLUSAL CONTACT USED FOR
RECONSTRUCTION)
FULL MOUTH REHABILITATION

27. Gnathological Philosophy
(Stuart Ce1964)
• Centric Relation Contact Position (CRCP)and The
Intercuspal Position (ICP) (Centric
Occlusion).Are Coincident
• Canine Guided Lateral Excursions
• Posterior Disclusion In All Excursions.
• Lingual Concavity Of Anterior Teeth Is
Determined By Condylar Guidance
• Wax Up Done In Fully Adjustable Articulator.
• Good For Restoring Cases With Large Horizontal
Component Of Cr And Ip.
Full Mouth Rehabilitation

29. In 1929 C.H. Schuyler stated that maximum
intercuspation must occur in the retruded
mandibular position (centric relation) under all
circumstances
Schuyler’s principles were
1. A static co-ordinated occlusal contact of the
maximum number of teeth when the mandible is in
centric relation.
2. An anterior guidance that is in harmony with
function in lateral eccentric position on the working
side.
3. Disclusion by the anterior guidance of all posterior
teeth in protrusion.
4. Disclusion of all non-working inclines in lateral
excursions.
5. Group function of the working side inclines in
lateral excursions.

30. In order to accomplish these goals, the following
sequence is advocated by the P.M.S. philosophy:
PART 1. Examination, diagnosis, treatment planning,
prognosis
PART 2. Harmonization of the anterior guidance for
best possible esthetics, function, and comfort
PART 3. Selection of an acceptable occlusal plane and
restoration of the lower posterior occlusion in harmony
with the anterior guidance in a manner that will not
interfere with condylar guidance.
PART 4. Restoration of the upper posterior occlusion
in harmony with the anterior guidance and condylar
guidance. The functionally generated path technique is
so closely allied with this part of the reconstruction that
it may almost be considered part of the concept.

32. The advantages of the technique are many. Some of the major ones are as follows:
• It is possible to diagnose and plan treatment for the entire rehabilitation before
preparing a single tooth.
• It is a well-organized, logical procedure that progresses smoothly with less wear
and (car on the patient, operator, and technician.
• There is never a need for preparing or rebuilding more than eight teeth at a
time.
• It divides the rehabilitation into separate series of appointments. It is neither
necessary nor desirable to do the entire case at one time.
• There is no danger of "getting at sea" and losing the patient's present vertical
dimension. The operator knows exactly where he is at all times.
• The functionally generated path and centric relation are taken on the occlusal
surface of the teeth io be rebuilt at the exact vertical dimension to which the case
will be constructed.
• All posterior occlusal contours are programmed by and are in harmony with
both condylar border movements and a perfected anterior guidance.
• There is no need for time-consuming techniques and complicated equipment.
• Laboratory procedures are simple and controlled to an extremely fine- degree by
the dentist.

33. YOUDELIS
SCHLUGER S et al
• FOR ADVANCED PERIODONTAL CASES.
• CR AND IP ARE COINCIDENT.
• ANTERIOR DISCLUSION FOR
PROTRUSIVE AND CANINE DISCLUSION
FOR LATERAL EXCURSIONS.
FULL MOUTH REHABILITATION

34. Youdelis…
• Lateral Contacts Are Arranged Such That If
Canine Disclusion Is Lost Through Wear /Tooth
Movement-posterior Teeth Drop Into Group
Function.
• Both Fully /Semi Adjustable Articulators Can Be
Used.
Useful –Parafunction Cannot Be
Controlled/Canine Compromised Periodontally
Full Mouth Rehabilitation

35. Freedom In Centric
(Ramfjord Sp)
• Area Of Freedom B/W Cr And Ip-0.5mm.
• Either Canine Guidance/Group Function,but
Ant. Guidance Will Be Delayed During
Posterior Contact In Area Of Freedom.
• Cusp To Fossa Occlusion.
• Useful For Cases With Large Horizontal
Component Of Slide.
Full Mouth Rehabilitation

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

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

39. Occlusal scheme RCP–ICP relationship Excursive contacts Comments
Gnathological (1964) Coincident, with tripod contacts Canine-guided lateral excursions,
posterior disclusion in all
excursions. Anterior and
posterior contacts are mutually
protected1
Good for restoring cases without
a large horizontal component of
RCP–ICP slide. Real purists
would insist on the use of a fully
adjustable articulator and all that
goes with it.
Youdelis (1977) Coincident, with tripod contacts As for gnathological, but
designed to drop into group
function if canines wear or move
Useful option where excursive
parafunction cannot be
controlled or where the canine is
compromised
Pankey–Mann–Schuyler (1963) Area of freedom2 between ICP
and RCP (<0.5 mm) and
morphology functionally
generated
Anterior guidance determined
functionally on temporaries.
Either canine guided or group
function
The potential for error with the
functionally generated path
technique, which is used to
determine the occlusal
morphology of posterior teeth is
considerable
Area of freedom in centric (1982)Area of freedom between ICP and
RCP (0.5 mm ± 0.3 mm); cusp to
fossa occlusion
Either canine guided or group
function, but anterior guidance
will be delayed during posterior
contact in area of freedom
Useful where there has been a
large horizontal component in
the RCP–ICP slide before
treatment. Area of freedom needs
careful adjustment
Balanced occlusion (1960) Area of freedom between ICP and
RCP
Balanced working and non-
working contacts in lateral
excursions. Balanced anterior
and posterior contacts in
occlusion
Keeps complete dentures stable
during excursions, but difficult to
manage in the natural dentition
and risk of non-working-side
overloading
Nyman and Lindhe (1983) RCP and ICP must have even
contact
Bilaterally balanced excursive
contacts determined in
provisional (long-term
temporary) restorations and then
copied into definitive restorations
This is used in cross arch bridges
where there is advanced, but
controlled, periodontal disease.
Balanced contacts give stability to
an otherwise mobile bridge

40. HOBO TWIN STAGE CONCEPT
(Hobo St)
(Theory Of Disclusion)
• Two Stage Procedure:
• Occlusal Morphology Of Posterior Teeth
Reproduced Without Ant. Segment.
• Ant. Morphology Reproduced With
Ant.Segment And Ant. GUIDANCE-
PRODUCE Std AMT OF DISCLUSION.
FULL MOUTH REHABILITATION

41. HOBO’S TWIN TABLE PHILOSOPHY
Another philosophy was given by Dr. Sumiya
Hobo
which is followed in rehabilitation of dentate
patients. He proposed Twin table concept which
developed anterior guidance to create a
predetermined, harmonious disclusion with the
condylar path.

42. •The technique utilizes 2 different customized
incisal guide tables. The first incisal table is termed
INCISAL TABLE WITHOUT DISCLUSION. It is
fabricated by preparing die systems with removable
anterior and posterior segments
• It is fabricated by preparing die systems with
removable anterior and posterior segments. This table
helps us achieve uniform contacts in the posterior
restorations during eccentric movements
• used to fabricate restorations for posterior teeth

43. Incisal table without disclusion

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

45. Incisal table with disocclusion

46. Examination ,
Diagnosis , And Treatment
Planning In Occlusal
Rehabilitation
FULL MOUTH REHABILITATION

47. • Preclinical examination.
• Accurate diagnostic casts
• Colored pictures
• Radiographic evaluation
• Detailed oral examination
• Case presentation
• Pt acceptance for the extensive treatment
plan and cost factor
• Treatment planning
FULL MOUTH REHABILITATION

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

49. PRELIMINARY MOUTH PREPARATION
• MOUTH HYGIENE INSTRUCTIONS
• CARIES CONTROL
• NECESSARY EXTRACTIONS
• ORAL PROPHYLAXIS
• MINOR TOOTH MOVEMENT
• EQUILIBRATION
FULL MOUTH REHABILITATION

50. Treatment philosophies

51. Restoring all upper posterior teeth only
1. Preliminary
mouth
preparation
2. Selective grinding
3. Prepare all upper
posterior
4. Correctness of
anterior guidance
should be verified
and modify
5. If canine guided-
set condylar path
at 20degrees
complete wax up
6. Or complete the
restoration on
fully adjustable
articulator out of
excursion
7. For group
function- use FGP
8. Place posterior
restorations and
do necessary
modifications

52. Restoring all upper but no lower
teeth
1. Preliminary mouth
preparation
2. Selective grinding of
lowers
3. Prepare upper
posterior
4. Correct anterior
guidance
5. Do “alternate tooth
preparation” in
anteriors
6. Centric record,
articulate lower cast
with first upper cast
7. Customize guide
table
8. Articulate final cast
9. Duplicate anterior
restorations by using
throw- away patterns
10. Replace upper
posteriors as
described
11. Reevaluate disclusion
and guidance and do
necessary corrections
in patients mouth

53. Restoring all posterior but no anterior
Preliminary mouth preparation
Broadrick occlusal plane analysis
Prepare lower teeth accordingly
Harmonize anterior guidance
Complete lower wax patterns and restorations
Place lower restorations
Prepare upper posteriors
Complete upper posterior restorations
Remove balancing contacts
Redefine working contacts

54. Restoring all lower teeth but no upper
teeth
1. Preliminary mouth preparation
2. Redefine interferences in the
upper arch
a. correct marginal ridges
b. equilibrate occlusion
c. harmonious anterior guidance
4. Every other lower anterior
tooth should be prepared,
through away patterns
5. CR record with ant. teeth in
contact
6. Remaining teeth should be
prepared
7. Articulate working cast
8. Place through away patterns
9. By using this guide prepare
lower ant restorations
10. Prepare and place posterior
restorations
11. Remove balancing contacts
12. Redefine working contacts

55. Preparing all upper teeth and lower
posterior teeth only
1. Priliminary mouth
preparation
2. Restablish anterior
guidance
3. Prepare every other
maxillary ant tooth
4. Place through away wax
pattern
5. Prepare all anterior
teeth
6. Establish
predetermined anterior
guidance
7. Prepare mandibular
posteriors
8. By using brodrick
occlusal plane analyser
establish occlusal plane
9. complete lower
restorations
10. Prepare maxillary
posteriors
11. Establish desired
occlusion
12. Place all restorations
13. Redefine balancing and
working side contacts

56. PREPARING ALL UPPER AND LOWER TEETH
1. Preliminary mouth preparation
2. Prepare lower anterior teeth
3. If the anterior relation is acceptable,
prepare the lower wax patterns against
unprepared maxillary ant
4. If unacceptable relation, reestablish the
anterior guidance
5. Place provisional restorations in the
redefined anterior guidance
6. Complete the lower restorations by
exactly duplicating the incisal edge
position of provisional restorations
7. Place lower restorations against upper
provisionals to verify the ant guidance

57. 8. Prepare and restore upper anterior teeth (exactly
duplicate the pattern of provisionals)
9. Place upper anterior restorations
10. Refine the anterior guidance.
11. Prepare lower posterior teeth by taking guidance of
Broadrick occlusal plane analyzer
12. Reestablish the occlusal plane.
13. Complete lower posterior restorations
14. Complete upper posterior restorations accordingly
15. Refine centric, working and nonworking contacts

58. Treatment techniques
Simultaneous restoration of both arches
(Bailey, Grubb, Linkow)
Advantages Disadvantages
Freedom in creating esthetic
occlusal plane
Arduous, unpredictable,
patient visits
Freedom in occlusal scheme Full arch anaesthesia
Freedom in intra-arch tooth
spacing and inter-arch
crown position
Increased chair time, full
arch temporaries required
Maximum freedom in
creating and controlling
porcelain esthetics
Multiple occlusal records,
highly accurate cross arch
impressions

59. Individual quadrants (Pankey,
Mann, Dawson, Granger)
Advantages Disadvantages
Reduced chair time Restriction for achieving
ideal occlusion when
altering occlusal plane
Sequential provisional
restorations
Less freedom in controlling
porcelain aesthetics
Quadrant anaesthesia
Vertical Dimension is
controlled
Impression procedures are
easier

60. Segmented simultaneous arch
technique (Binkly & Binkly)
• Combines desired features of bothe the
techniques
• Simplifies essential basic procedures for
reconstruction

61. Freedom to produce occlusal
scheme
. .
Freedom in tooth spacing and
intra arch crown position
. .
Freedom for porcelain work . .
Teeth preparation quadrant
wise
. .
Chair side temporaries . .
Easier final impression . .
Control of VDO . .
Anesthesia by quadrant . .
Control of appointment length . .

62. References
Okeson J P:Management of temperomandibular joint
Sumiya Hobo : Twin – tables technique for occlusal
rehabilitation : part 1 – Mechanism of anterior guidance j
prosthet dent 1991, vol 66 pg 299-303.
Sumiya Hobo : Twin – tables technique for occlusal
rehabilitation : part 11 –Clinical procedures
j prosthet dent 1991, vol 66 pg 471-477
Philosophies in full mouth rehabilitation – a systematic review
Int J Dent Case Reports 2013; 3(3): 30-39
Occlusion for fixed prosthodontics:A historical perspective of the
gnathological influence J Prosthet Dent 2008;99:299-313