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

NJDSR Volume I number 4 January 2016 Page 1

Contra-indications for full mouth
rehabilitation:
There are many malfunctioning mouths that
do not need extensive dentistry and have no
joint symptoms. These cases are best left
alone. One or two "good" teeth may have to
be operated on in order to satisfactorily
accomplish our objective. In short, no
pathology -no treatment.4
PHILOSOPHIES OF OCCLUSAL
REHABILITATION-
I)PANKEY-MANN-SCHYULER
PHILOSOPHY
One of the most practical philosophies for
occlusal rehabilitation is the rationale or
treatment that was originally organized into
a workable concept by Dr. L.D. Pankey. The
philosophy has had as its goal the fulfilment
of the following principles of occlusion as
advocated by Schuyler:
1. A static coordinated 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 nonworking inclines in
lateral excursions
5. Group function of the working side
inclines in lateral excursions.
Proper sequence advocated by PANKEY-
MANN-SCHYULER philosophy:
Part1:Examination,diagnosis,treatment
planning and 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
NJDSR Volume I number 4 January 2016
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
ADVANTAGES-
1. Possible to diagnose and plan treatment
for the entire rehabilitation before a single
tooth is prepared.
2. Well organised and a logical procedure.
3. Never a need for preparing or rebuilding
more than eight teeth at a time.
4. Divides the rehabilitation into separate
series of appointments.
5. No danger of getting lost at sea and
loosing the patients present vertical
dimension.
6. Functionally generated path and centric
relation are taken on the occlusal surface
of the teeth to be rebuilt at the exact
vertical dimension.
7. All posterior occlusal contours are
programmed by and are in harmony with
anterior and condylar guidance.
8. There is no need for time consuming
techniques and complicated equipment.
9. Laboratory procedures are simple and
controlled to an extremely fine degree by
the dentist.5,6
II) TWIN STAGE PROCEDURE
The twin-stage procedure was developed by
Hobo and Takayama in 1989. They derived a
kinematic formula to calculate anterior
guidance from condylar path.
Factors that determine disclusion:
1. Angle of hinge rotation
2. Cusp shape factor
Angle of hinge rotation
Posterior disclusion occurs when anterior
guidance is steeper than condylarguidance.
The mandible rotates around the
intercondylar axis during
eccentricmovements when anterior guidance
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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
master cast. Fasten the master cast to an
articulator. A simple hinge articulator may
be used. Pour the boxed functional path and
fasten it to the articulator. Wax prostheses
into the stone functional path as desired.
Cast the wax pattern, seat the metal
prosthesis on the master dies, and refine the
prosthesis to fit the stone functional path
matrix.8,9
IV) FULL MOUTH SIMULTANEOUS
TECHNIQUE10:
It involves full arch preparations,
impression, provisional restorations and
mastercasts.
Advantages:
Flexibility in developing:
1. Occlusal plane
2. Occlusal scheme
3. Embrasure
4. Crown and esthetics
Disadvantages:
1. Arduous unpredictable patient visit
2. Full arch anaesthesia
3. Multiple occlusal records
4. Possible loss of vertical dimension of
occlusion10
V)QUADRANT/SEGMENTTECHNIQUE:
It involves completing one quadrant before
beginning another.
Advantages:
Preparation and final impression of selected
teeth at one time will lead to-
1. Maintenance of vertical dimension
2. Quadrant anaesthesia
3. Shorter predictable appointments
Disadvantages:
Restriction of achieving ideal occlusion
when altering
1. Vertical dimension
2. Occlusal plane
3. Embrasure development
NJDSR Volume I number 4 January 2016
Functionally generated path technique can
be used when restoring one quadrant at a
time.10
VI) SEGMENTED SIMULTANEOUS:
It is combination of the desired
characteristics of the full mouth
simultaneous rehabilitation and the
programmed quadrant approach into a single
reconstructive technique.
Technique:Tooth preparation and chair side
temporary fabrication: teeth are prepared and
temporary restorations are fabricated chair
side segment by segment during several
appointments. The patients vertical
dimensions of occlusion are maintained by
using unprepared teeth or provisional
restorations as occlusal vertical stops.
Occlusal records: after teeth preparation
alginate impression are taken and face bow
transfer are made. Casts are used for making
heat processed acrylic resin treatment
restorations. Centric relations are recorded
by removing chair side temporary
restorations in opposing segments and
placing Duralay resin between maxillary and
mandibular preparations. When this resin has
set in onesegment it is used as an index to
maintain vertical relation while
additionalquadrant relationships are
recorded.
Fabrication of heat processed treatment
restorations: a complete wax- up of the
reconstruction is performed directly on the
mounted casts and then heat processed in
acrylic resin.
Articulation of casts: alginate impressions
are made of occlusally adjusted heat
treatment restorations and face bow transfer
is made. Relate the mandibular cast with the
upper. These casts are facsimile of final
reconstruction and are opposing cast for
framework waxing during metal framework
fabrication. Incisal guide table is set from the
anterior guidance of the facsimile mounting.
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Final impression and working casts: 3 full
arch final impressions are made for each
arch, with tooth preparation recorded in one
segment. Heat processed treatment
restorations remains except where
impressions are being made. Working casts
are thus obtained and mounted to previously
mount opposing facsimile model of heat
cured treatment restorations.
Metal framework fabrication: it consists of
total of six working casts or three per arch,
with each cast containing one segment of
dies. Occlusion for each quadrant is then
refined by attaching appropriate mandibular
and maxillarycast with patterns. Pattern are
thus cut back to facilitate porcelain
application later. Castings are obtained.
Full arch cast fabrication: full arch intraoral
elastomeric impressions are made of seated
frameworks. Frameworks are reseated in
impression and dies are made by flowing
Duralay resin into lubricated
framework.Porcelain application and try in is
done for occlusal adjustments. Restorations
are then permanently cemented.10
CONCLUSION
For proper diagnosis, treatment planning and
execution of full mouth rehabilitation, a
thorough understanding of operative and
restorative procedures is required.
All functioning factors including teeth,
muscles of mastication, temperomandibular
joint and periodontal structures are
interrelated, so each of them should be given
enough attention to establish functional
harmony. At the same time esthetic
requirements of the patient should be
fulfilled within physiological limits.
The occlusal rehabilitation procedure
requires proper dentistpatient relationship
because it is a long term procedure that
needs patients co-operation.The object of
complete mouth rehabilitation must be the
reconstruction, restoration and maintenance
of the entire oral mechanism.
NJDSR Volume I number 4 January 2016
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Corresponding Author:
Dr Ankush Jain
P.G Student
Dept. of Prosthodontics
Modern dental college & research
centre, Indore
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