FMR/ Full mouth rehabilitation final.7.1.2021pptx

full mouth rehabilitation

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

2. Contents Hobos’s Philosophy Twin table technique Twin stage technique Solving deep overbite problems Solving anterior overjet problems Solving anterior open bite problems Treating end to end occlusions Treating splayed or separated anterior teeth Treating the crossbite patient Treating crowded,irregular , or interlocking anterior teeth Related articles Concluion References 2

3. 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. 3

4. 4 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

5. 5 In this case , the mandible translates and rotates around the intercondylar axis; the maxillary and mandibular molars dlsocclude . McHorris (1979) I ncisal path should be 5 degrees steeper than the condylar 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

6. 6 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 .

7. 7 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.

8. 8 Influence of the amount of disclusion Dependent factors NON WORKING SIDE WORKING I iDE

9. Twin-tables technique -Hobo ( 1991) Posterior teeth are restored using two customized incisal tables: without disclusion; and with disclusion One incisal table is used to incorporate a cusp-shape factor and the other is used for the angle of hinge rotation. 9

10. 10

11. 11

12. 12 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 (technique sensitive)

13. 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 13 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

14. Twin – Stage Procedure Hobo and Takayama 1989 A dvanced version of the Twin-Table technique A kinematic formula to calculate anterior guidance from condylar path I ncorporated 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 14 Hobo S (1991) Twin-tables technique for occlusal rehabilitation.Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303

15. 15 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

16. 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 16

17. 17

18. 18

19. 19

20. Contraindications vertical axis of the posterior teeth may have inclined abnormally. E ffective cusp angle may vary to some extent even though the cusp angle of a natural 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 20 Abnormal curve of Spee Abnormal curve of Wilson Abnormally rotated tooth Abnormally inclined tooth

21. Solving deep overbite problems Care must be taken to maintain neutral zone relationship of upper anterior teeth. strong lip pressures and a tight neutral zone Phonetic relationship of incisal edges is critical 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

22. 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

23. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.456,457 23

24. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.456,457 24

25. 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 . Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.456,457 25

26. After the teeth have been repositioned for centric relation contact , the final details are worked out in provisional restorations . ( 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.456,457 26

27. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.459 27 Deep overbite with tissue contact Lower incisors erupt up into soft tissue lingual to the upper anterior teeth.

28. Deep overbite problems associated with an anterior slide Such a problem calls for a three-step solution: We must equilibrate to permit the mandible to close without deflection from posterior teeth. We must shorten the lower incisors to position the incisal edges in an optimum relationship to previsualized centric stops on the upper incisors. We must restore the upper lingual contours to establish stable centric stops Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.456,457 28

29. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.460 29 DEEP OVERBITE PROBLEMS ASSOCIATED WITH AN ANTERIOR SLIDE

30. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.460,461 30

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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.464 31

32. 32 Bite planes to solve deep overbite problems Discomfort from tissue impingement Least complicated way of preventing supraeruption of the lower anterior teeth. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.464,465

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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.465 33

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 . Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.467 34

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 35

36. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.469 36

37. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.469 Applying the principles 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 37

38. A rubber band attaches to the appliance to move the teeth into the contoured slots in the lingual plate (Simple way to achieve dramatic results ) B ands or brackets - if final positioning requires horizontal bodily movement of roots. A n improved incisal plane as incisal edges move down as they are pulled back into a position that permits contact with the lower incisors . Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.474 38 lingual contours are then reshaped to ideal contact with lower incisors.

39. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.474,475 39

40. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.475 40

41. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.475 41

42. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.475 42

43. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.482 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 intercuspation 43

44. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 44

45. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 45

46. Applying the principles 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 46

47. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 47

48. 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). Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 48

49. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 49

50. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 50

51. 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 . The stresses are so confined to the long axis that the periodontal fibers and the bone trabeculae are not aligned to resist lateral stress 51 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483

52. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.483 52

53. 53 The decision to alter the occlusal relationship should be based on a careful evaluation of the following factors:

54. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.496 54

55. 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 : • R eshaping • Repositioning • Restoring (with centralized cusps) • Surgery Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.497 55

56. 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. Anterior guidance can sometimes be steepened if it is not steeper than the lateral path originally found during excursions dictated by posterior teeth Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.498 56

57. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.498 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. 57

58. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.498 58

59. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.501,502 59

60. Applying the principles 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 . Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.504 60

61. 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 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.505 61

62. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.506 62

63. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.501,502 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. 63

64. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.508 64

65. 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? Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.513 65

66. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.514 66 Most prognathic patients limit their function to vertical "chop chop" movements

67. Applying the principles 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.518 67

68. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.518 68

69. 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. 69

70. 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: Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.518 70

71. 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. Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31 . PAGE NO.522 There are three methods for correcting an anterior crossbite surgically: 71

72. 72 In most instances, it is "leave it alone" unless there are interferences to centric relation or excursions. 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. Posterior crossbites

73. 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. 73

74. 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 ). 74

75. 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 of the arch. 5. We can change the axial inclination of the anterior teeth. Five possible ways of solving the space problem: 75

76. 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. 76

77. Applying the principles 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. 77

78. 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 . serve as a retainer until the bone stabilizes. After approval, permanent restorations will copy it. 78

79. 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. 79

80. 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. 80

81. 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. 81

82. Crowded anterior teeth with severe posterior interferences 82

83. 83

84. 84

85. 85 Full-mouth rehabilitation of a case of generalized enamel hypoplasia using a twin-stage procedure Aswini kumar kar , hari parkash , and V eena jain Related articles

86. 86

87. Full Mouth Rehabilitation with Group Function Occlusal scheme in a patient with severe Dental Fluorosis Sudhir N, Hari Parkash 87

88. 88

89. 89 Full mouth rehabilitaion of worn dentition using pankey mann schuyler technique & broadrick flag method- a case report. Kiran Kaushik , Pankaj Dhawan , Pankaj Madhukar,Piyush Tandan Dr . Shivam Singh Tomar and Dr. Divyesh Mehta

90. 90

91. Full Mouth Rehabilitation With Dental Implants for a Patient With Skeletal Class III Malocclusion: A Case Report Sompop Bencharit,Dale J. Misiek , Linda A. Simon, Arabella Malone- Trahey 91

92. 92

93. 93 This case report presents a comprehensive treatment for a patient with severe skeletal class III malocclusion. The patient also had problems with worn dentition in the maxilla and compromised periodontal support in the mandible. Functional occlusion and esthetics were restored with orthodontic treatment, orthognathic surgery, implants , and complex fixed prosthodontics therapy

94. 94 Full‑mouth rehabilitation using twin‑stage technique Ashish Kalra , Harbir Singh Sandhu, Nanda Kishore Sahoo , AK Nandi, Shilpa Kal

95. 95

96. Conclusion The patient needing extensive restorations is often neglected and overlooked by a general practitioner due to lack of specialized training. multidisciplinary approach U ltimate goal - optimum oral health 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 96

97. 97 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 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

98. 98 Bencharit S, Misiek DJ, Simon LA, Malone- Trahey A. Full mouth rehabilitation with dental implants for a patient with skeletal class III malocclusion: a case report. Journal of Oral Implantology . 2012 Feb;38(1):63-70. 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 Kalra A, Sandhu HS, Sahoo NK, Nandi AK, Kalra S. Full-mouth rehabilitation using twin-stage technique. Int J Oral Health Sci 2019;9:40-4.

99. 99