Full Mouth Rehabilitation (Centric Relation).pptx

In full mouth rehabilitation, recording centric relation (CR) is a crucial step, as it provides a repeatable, stable position of the mandible relative to the maxilla, independent of tooth contact. This ensures that the rehabilitation is built on a stable occlusal foundation. The process begins with patient relaxation and deprogramming of the masticatory muscles using tools like a leaf gauge or Lucia jig to eliminate habitual closing patterns. The bimanual manipulation technique is commonly used, where the clinician gently guides the mandible into CR. Multiple CR records are taken for verification, typically using elastomeric bite materials for precision. Once validated, the records are used to mount models on a semi-adjustable articulator, establishing a dependable basis for creating functional, aesthetic, and harmonious restorations.

1. F ULL MOUTH REHABILITATION DR. SATVIKA PRASAD DEPT. OF PROSTHODONTICS MMCDSR CENTRIC RELATION

2. Introduction Objectives of FMR Indications of occlusal rehabilitation Classification of patients requiring occlusal rehabilitation Etiology of extremely worn dentition Diagnosis and treatment planning Occlusal plane Various occlusal plane analyzer Increasing vertical dimension – why, when, how ? Centric relation Methods to guide mandible in centric relation Contents Method of taking centric bite records Mandibular deprogramming Load testing Anterior jig Leaf gauge Central bearing point technique Types of centric Centric relation v/s centric occlusion Significance of CR Conclusion Reference

3. is defined as the restoration of the form and function of the masticatory apparatus to as nearly a normal condition as possible. [GPT-8] FULL MOUTH REHABILITATION :-

4. Full mouth rehabilitation entails the performance of all the procedures necessary to produce a healthy , esthetic , well functioning , self maintaining masticatory mechanism . Mouth rehabilitation seeks to convert all unfavourable forces on the teeth which inevitably induce pathologic conditions , into favourable forces which permit normal function and therefore induce healthy conditions. INTRODUCTION

5. Equalization of forces directed against the supporting structures Any disharmony at the occlusal or incisal aspects of the tooth will direct forces against these mal-aligned surface and thus subject the supporting structure to traumatic injuries Any impairment of buccal and lingual harmony will be reflected by injury to the gingival tissue and subsequently to the deeper tissue involved in supporting the tooth OBJECTIVES OF FMR :-

6. Restore impaired or lost occlusal function Improve upon unsatisfactory and objectionable esthetics that involve the occlusion Preserve the longevity of the remaining teeth Maintain a healthy periodontium Eliminate pain and discomfort in the teeth, the surrounding areas and underlying structures Preserve and harmonize TMJ Indications of occlusal rehabilitation

7. Classification of patients requiring occlusal rehabilitation:-

8. A]. Brecker’s classification (1966):-

9. B]. Turner & Missirlian classification Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1985;52:467-74.

10. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1985;52:467-74.

11. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1985;52:467-74.

12. Etiology of extremely worn dentition Occlusal wear is most often attributed to attrition. Attrition is defined as “the wearing away of one tooth surface by another tooth surface” . The causes are Congenital abnormalities- Amelogenesis imperfecta Dentinogenesis imperfecta Parafunctional occlusal habit- Abrasion Erosion Loss of posterior contact- posterior collapse that results from missing, tipped, rotated, broken down teeth, malposition, and occlusal interference exerts undue force on anterior teeth resulting in teeth mobility and excessive wear of clinical crown

13. DIAGNOSIS AND TREATMENT PLANNING

14. Diagnosis Medical history Dental history Behavior evaluation Radiographs- complete mouth periapical radiographs and OPG Photographs – color of teeth & gingiva is recorded and photographs are necessary to recall to patient’s state of mouth prior to restorative dentistry. Clinical examination- diagnostic wax-up Computer imaging- helpful to demonstrate the various treatment options.

15. Before diagnostic wax-up, the occlusal discrepancies in centric and eccentric occlusion should be eliminated. The planning of subgingival margins or surgical crown lengthening required can be done. The wax is used to appropriately shape all crowns and final prosthesis is planned.

16. Treatment plan

17. Pre- prosthetic phase- To develop proficiency in diagnosing the need of occlusal rehabilitation, P eriodontist, O rthodontist, E ndodontist, O ral surgeon and P rosthodontist must all be integrated in establishing an environment conductive to oral health. ( POEO P )

18. Prosthetic phase Immediate treatment In some cases like AI in a child, postponing treatment until adulthood may cause adverse psychological effect and impair correct relationship between maxillary and mandibular teeth. Preformed Ni-Cr crowns are placed on 1 st permanent molars & 2 nd deciduous molars to stabilize occlusion and halt attrition. VD is not altered. As anterior teeth and premolars erupt, polycarbonate resin crowns are given. 2 nd molar is fitted with Ni-Cr to preserve vitality. After all permanent teeth are erupted, these restorations serve as transitional treatment until adulthood. Immediate treatment Definitive treatment

19. Definitive treatment- Once all teeth have erupted and adulthood is reached, the size of the pulp horn decreases compared to newly erupted teeth, so a definitive treatment can be planned.

20. Diagnostic impression, Face bow transfer Articulation

21. OCCLUSAL PLANE The average plane established by the incisal and occlusal surfaces of the teeth. Generally, it is not a plane but represents the planar mean of the curvature of these surfaces. The surface of wax occlusion rims contoured to guide in the arrangement of denture teeth

22. Various occlusal plane analyzer

23. Broadrick’s occlusal plane analyzer (BOPA) Given by DR. LAWSON K BROADRICK It is used for analyzing the curve of Spee & developing an acceptable curve of occlusion.

24. Prior to the following procedures, mount study casts to articulator with a facebow transfer and centric relation record. Remove maxillary cast from articulator during survey procedures. The Broadrick Occlusal Plane Analyzer, consists of: (1) Broadrick Plane, (1) Compass with leads and Center Point, (1) Locator Pin, (1) Cup Pin, and (12) Plastic Record Cards.

25. Ref.-Broadrick occlusal plane analyzer instructions - panadent

26. Simplified occlusal plane analyzer (SOPA) This simplified method reduces the time required for occlusal plane analysis because the analysis point for surveying the occlusal plane is already related to the condylar axis.

27. Step 1 – remove the upper cast from the articulator. Step 2 – insert a flag onto the SOPA base (Fig.1). Each flag has 2 sides and space for patient information. The graph is in mm increments. Tighten the lock screw Step 3- place the SOPA on the upper bow sliding the key into the articulator slot (Fig. 2; 3[A,B]) Step 4- the compass has standard radius of 4”. This setting is standard for evaluating the final cusp tip heights on an ideal lower occlusal plane. Step 5- touch the compass lead to the tip of the lower cuspid. Position the compass point (D) on the center line [for the 4”] of the SOPA flag. This automatically establishes the position for the compass point in correct relation to the condyle. {note:- if the cuspid is missing, it should be waxed up, keeping the height in harmony with the remaining anterior teeth}

28. Step 6 – arc the compass lead to the back molar (Fig. 5). This establishes the optimum occlusal plane height for the posterior teeth. {note- if the molar is missing, the occlusal plane can be scribed on a wax rim.} If the back of the occlusal plane needs to be raised or lowered, return the compass lead to cuspid tip. Holding that position, arc the compass point forward or backward on the SOPA flag along the same horizontal line while using the compass lead as the pivot [move the compass point anterior for a higher occlusal plane or posterior for a lower occlusal plane] As long as the pointer maintains contact on the width of the flag, the occlusal plane will be acceptable and if not, the casts may not be properly mounted in relation to the condylar axis Step 7 – when an acceptable level for the back of the occlusal plane has been established, draw a line on the cast from cuspid point backward (Fig.6) Step 8 – repeat for the opposite side Ref- Denar simplified occlusal plane analyzer - whipmix

29. Occlusal Plane Analyzer: A customized device for determining the occlusal plane Custom made occlusal plane analyzer Gupta R. Occlusal Plane Analyzer: A customized device for determining the occlusal plane. International Journal of Prosthodontics and Restorative Dentistry. 2011 Jul 5;1(2):97-100.

30. 1 fox plane 4 long screws attached to four ends of occlusal plane relator arm 3 metal plates 2 oblique plates Serves to analyze the parallelism of occlusal plane with ala- tragus 1 horizontal plate Help in relating occlusal plane to inter-pupillary line Metal collars were placed above and below the plates to help them to secure it in place Arrowhead marks using tungsten carbide bur, were made which helped in determining the parallelism of the plates by measuring the distance between them A key was also provided to open the metal collars

31. Patient is seated in an upright position in a dental chair. The occlusal plane analyzer is placed in the patient's mouth and held in position between the two occlusal rims (Fig. 3). Turns are given to the metal collars of the two screws supporting the side metal plates, thus opening the plate until it coincided with ala of the nose anteriorly and middle point on the tragus of the ear posteriorly. The distance between the arrowheads on the two plates is then checked using metallic scale or vernier calipers (Fig. 4). This was repeated for the arrowheads on the other side of the same plate. Same distance between the two plates indicated parallel opening.

32. Can vertical dimension be altered ?

33. Increasing vertical dimension - WHY, WHEN, HOW ? VD is unrelated to TMDs and there is no evidence to suggest that by changing VD one can treat TMD. However, VD can be increased or decreased for the best functional and aesthetic anterior contact in centric relation The VDO is determined by the repetitive contracted length of closing muscles, hence increase in VDO cannot be maintained, as the jaw to jaw relationship will always return to the original dimension , i.e. MUSCLES always WIN

34. Wear of tooth does not result in loss of VD, as the alveolar process lengthens to make up for it. But the position of the condyles does affect muscle length and hence the VDO. When looking at the changes in VD, it is paramount to mount the study casts in CR

35. Centric Relation Maxillomandibular relationship, independent of tooth contact, in which the condyles articulate in the anterior-superior position against the posterior slopes of the articular eminences in this position, the mandible is restricted to a purely rotation movement

36. There are 2 aspects of taking centric relation:- Proper manipulation of mandible as in equilibration position when no bite record is taken Manner of taking bite record for correct articulation of mounted models.

37. Methods to guide the mandible in centric relation Chinpoint guidance method Bilateral manipulation method / Triad jig technique Unguided method – brill introduced a muscular position which allows patient’s natural muscle functions to position the mandible into centric position.

38. CHINPOINT GUIDANCE METHOD

39. BIMANUAL MANIPULATION / TRIAD JIG

40. CENTRIC RELATION – WHEN & WHY ? Centric relation is controlled by – Musculature Proprioception

41. 47 teeth preparation is done crown Crown placement is done, if patient complains about high points, doctor tells the patient that within few days it will accommodate itself, now we have different mandible closure than the earlier CR, so it will result in hit and slide motion which will in turn result in instability of stomatognathic system. CR v/s MIP

42. “Chain Is As Strong As Its Weakest Link” In order to accommodate with the change something has to give, if the give is in -

43. Method for taking centric bite records Most patients have a reflex closure, an engram determined and guided by the teeth. Proprioceptive mechanism determines path of mandibular closure and is responsible for awareness of position of mandible in space. To enable the condyles to be placed in an unstrained position, the musculature must first be deprogrammed from its habitual closing pattern.

44. Mandibular deprogramming With anterior stop Without anterior stop Short Intermediate Long

45. Short deprogramming 5-20 minutes Customized anterior deprogramming splint Customized Lucia jig Leaf gauge Cotton rolls Intermediate deprogramming 2-20 days (except while eating) Patient has more than 1 MIP Kois appliance Hard heat pressed sheet Lip technique{by lucaz lassmann } Long deprogramming 2-6 months [patient have TMD’s, internal derangement or disc problems] Permissive splint Don’t start FMR until the patient is deprogrammed & its CR is stable. i.e. CR should coincide with MIP

46. KOIS DEPROGRAMMER (KD) Kois Deprogrammer The Kois Deprogrammer (KD) is a palatal-coverage maxillary acrylic device with a flat plane lingual to the anterior teeth. It separates the dental arches and provides a single lower-central incisor contact against the anterior bite plane How Does it Work? Proprioceptors in the periodontium provide feedback that programs the muscles to close in MIP. Without reinforcement through repeated tooth contact, the feedback and the influence of the dentition on the condylar position is lost. Tooth-deflecting inclines can trigger discoordination of the masticatory muscles. Until these muscles relax and function in a coordinated manner, the patient may be incapable of achieving a CR position. The KD breaks this cycle by disocluding the teeth and allows the muscles to return to normal function. The KD protocol also verifies that the muscles of mastication are deprogrammed. This ensures that the condyles are allowed to “move” to the CR position, being unaffected by uncoordinated muscles, tooth interferences, or operator error .

47. Deprogrammer Protocol The deprogrammer is inserted on the maxillary arch similar to a maxillary Hawley appliance. The anterior platform should be adjusted horizontal to the occlusal plane. The single mandibular tooth contact should be as close to the midline as possible. There should be only one point of contact. The platform should not cause the mandible to deviate laterally. It should allow the mandible to move freely in an anterior, posterior, and lateral direction. The surface should be flat and should extend far enough anteriorly and posteriorly that the patient cannot lose contact with either end. The platform should be thick enough to prevent contact with the opposing teeth when the patient relaxes into CR. Approximately 1 mm of clearance should remain, and the clinician should be sure to check. If the platform is too thick, some patients can develop vague muscular pain. Do not make the platform any thicker than is necessary. The platform should facilitate a passive anterior-posterior slide without deviation. This is evaluated with articulating paper.  

48. When Is the Patient Deprogrammed? The patient is deprogrammed when he or she reproduces the same single spot on the platform without guidance or support. The spot needs to be absolutely flat with no slide whatsoever and the spot must be repeatable. The patient should be asymptomatic and will know when he or she continues to contact the same spot on a tooth immediately after removing the KD. Patients marking in more than one place are not deprogrammed. They will then need to wear the deprogrammer more hours per day, or for more days The pattern seen here is typical of a patient who is not deprogrammed. This patient will need to wear the appliance for a longer period of time during the day This patient has been successfully deprogrammed and is ready for bite records

49. LIP TECHNIQUE

50. It wont change the VDO

51. WITHOUT ANTERIOR STOP Dawson manipulation- Ask the patient to relax Palpate the angle of mandible by little fingers Place the thumb in the symphysis area It will create a “OWL EYE EFFECT” Star to hinge the mandible without applying much force. DO NOT APPLY JERKY MOVEMENTS We’ll achieve neuromuscular relaxation, which does not say that we are at CR.

52. So to be at centric now we’ll have to perform a “LOAD TESTING”, which a continuation of dawson manipulation. Now once neuromuscular relaxation is achieved, start applying upward force on the back and downward force on the thumb. Slowly increase the force. Torque force is generated and the mandible is positioned in CR Pain on slight force- stop load testing and use permissive splint/ muscle deprogrammer Pain on moderate force Pain on firm force It is still protecting the joint & condyle is still not in CR

53. In this load testing can be false + ve or false – ve because the clinician can apply too much force very less force. So to overcome this subjective issue, do load testing with anterior deprogrammer in position. Ask the patient to clench on the anterior deprogrammer as hard as possible. So whichever muscle is still active in edge to edge position will now bring about a movement of force. So the force from the lower incisors will travel through the body of the mandible into the condyles and dissipate into the disc. Now do the bimanual manipulation. If the patient shows any symptomatic response i.e. tension or tenderness around condyle, then the load test is + ve . So we are still not in CR, therefore we will not record the CR bite. So in this case, ask the patient to wear the deprogrammer for a longer period of time, now here the concept of short, intermediate and long time deprogramming comes. Now when we’ll record CR? once the patient give us load test – ve to firm pressure, i.e. there is no symptomatic response. That both the condyle are in CR, so we’ll record CR bite

54. The four basic techniques for making a centric bite record are:- Wax-bite procedure Anterior stop technique Use of pre-adapted bases Central bearing point technique If load test is – ve , we will record CR bite

55. Wax bite procedures Most popular procedure because of its simplicity. Hard wax is used OR Delar wax OR Aluminium reinforced wax block ( BiteAl - 7mm wax block) Modification of wax bite- can be used with ZOE paste to reline for greater accuracy When we are recording the bite, we use it with the anterior deprogrammer, at increased VD, so we don’t have to stack numerous wax sheets

56. Lucia explains 2 stage procedure in which tenax wax is used for indentation of upper teeth and soft wax is then added to indent the lower teeth. This method is not suitable for patients having extremely mobile teeth or large edentulous area.

57. ANTERIOR STOP TECHNIQUE Is the easiest to learn and offers greatest flexibility Accuracy can be achieved even with loose teeth, posterior edentulous areas and patients with TMJ discomfort. This technique allows the condyle to seat up without any possible deviation from posterior teeth. Can be made of- Acrylic, hard compound Bite can be recorded from- Platser , ZOE paste, self cure acrylic or wax and heavy bodied silicone

58. Other available methods: Directly fabricated anterior deprogramming device (using thermoplastic sheet) A Pankey jig – Dr. Keith Thorton . A best-bite appliance.- a kit is available with an injection material t o stabilizing the appliance Lucia jig – Lucia (1964) modified by Dr. Peter Meff . NTI (Nociceptive Trigeminal Inhibition). Leaf gauge – Dr. Hart Long (1970). 1 5 4 3 2 6

59. ANTERIOR JIG Principle- Anterior jig prevents posterior teeth from occluding and thus disrupts the proprioceptive memory. As the anterior stop is rigid on contact with lower incisor teeth, anterior resistance is created and a mandibular leverage is created with naturally braced tripod effect along with 2 condyles Jig breaks the patient’s habitual closure pattern and acts as the third leg of the tripod by creating resistance while stopping the closure

60. Procedure- A ball of red compound is softened and added to upper incisors so that their lingual surfaces are completely covered. The patient closes into the compound until the posterior teeth barely miss the contact while in supine position the lower central incisors contact the smooth lingual incline of the jig at only point. The jig incline must stop the mandible before posterior tooth contact and should be angled 45-60 degrees posteriorly and superiorly from the occlusal plane.

61. The jig can also be made of auto polymerizing acrylic resin on mounted casts and then adjusted intraorally After the jig is made posterior bite record is taken

62. LEAF GAUGE Leaf gauge was first introduced by DR. James H. Long in 1973 It is the most useful and practical alternative to anterior jig. Can be used for- Centric relation interocclusal records Occlusal equilibration Relieve painful spasm of lateral pterygoid muscle Previously they were made of unexposed x- ray films after developing to remove emulsion coating. Clear film was then cut into 1cm x 5 cm sections Recently, leaf gauges of uniform 0.1mm thickness which are subsequentially numbered are described They are convenient and measure the exact vertical opening between the incisors.

63. Procedure- Arbitrary number of leaves are placed at the maxillary anterior midline parallel to the lingual plane of central incisors. Patient is instructed to close on back teeth until lower incisors touch on back side of leaf gauge. Leaves are added or subtracted until the patient can barely feel a posterior tooth touch while closing firmly on leaf gauge. Often the patient can feel a posterior tooth contact in 15-52 seconds after the jaw is closed with a ‘half hard’ closing force. This procedure is repeated after adding a leaf gauge until the patient can close for 2-5 minutes without feeling a posterior tooth contact.

64. PRE ADAPTED BASES Heated strip of dead soft wax should be added over in the edentulous region to indent the lower teeth in centric occlusion without tooth tot tooth contact. It is made with triple layer of extra hard baseplate wax adapted on an accurate model usually of upper arch to avoid dislodgement by the tongue It is indicated whenever there is a danger that teeth will move or soft tissues be compressed by the bite record.

65. CENTRAL BEARING POINT TECHNIQUE It enables free movement of the mandible without influence of teeth proprioceptive. Drawback is that vertical dimension must be increased considerably to accommodate the clutches and bearing point apparatus If the terminal axis is not recorded precisely it will result in mounting error.

66. Types of centric

67. Centric relation Centric occlusion There is no teeth intercuspation There is maximum intercuspation Its a maxillo-mandibular relation (bone to bone relation) Teeth to teeth relation From which lateral jaw movements can be made There is no freeway space The condyles are in the most retruded [recently became most anteriorly in GPT] unstrained position in the glenoid fossa

68. LONG CENTRIC / FREEDOM FROM CENTRIC / AREA CENTRIC Sometimes after giving the prosthesis the patient feels that their jaw or mouth is locked in and feel restricted, it is because the clinician has forgot to incorporate the long centric in prosthesis. CR = CO ( Panky , Mann ) ( Beyron ) ( Schyuler )

69. Firstly we will mark the centric with a blue color articulating paper in reclining position by asking him to do “TAP, TAP, TAP” But if the patient bites in gently sometimes the lower incisors hit upper incisors before the centric mark. Ask the patient to be in upright position without head rest , mark the point with red articulating paper by doing “TAP, TAP, TAP” . If both the points coincide that means patient does not need any long centric

70. But if the points does not coincide , then we have to incorporate long centric. How? Use a knife edge inverted cone carborundum stone bur and reduce the area between the red and blue dot of about 0.5mm. If long centric is not incorporated then it can lead to – Fremitus Mobility Fracture Of upper teeth Defined as “freedom to close the mandible either into centric relation or slightly anterior to it without varying the vertical dimension of occlusion”

71. POINT CENTRIC / GNATHOLOGICAL CENTRIC OCCLUSION The condyles should seat in a rearmost position in the mandibular fossae exactly at the time when maximum intercuspation of the teeth occurs in the retruded contact position ( Lucia , Granger ) CR = CO = MIP

72. FREEDOM IN CENTRIC Schuyler first introduced the Concept Of 'Freedom in Centric" and supported the theory that centric relation was rather a biological area of the TMJ than a point . In this concept, "there is a flat area in the central fossae upon which opposing cusps contact which permits a degree of freedom (0.5-1 mm) in eccentric movements uninfluenced by tooth inclines". It relies on cusp-to-surface mechanics.

73. SIGNIFICANCE OF CENTRIC RELATION Is the ideal arch to arch relationship and an optimum functional position of jaws for the health, comfort and function of the TMJ and musculature Is a hinge position . In CR condyles exhibit only pure rotation without any translation. Mandibular movements return or terminate in centric It is thus, a reproducible position and therefore serves as a reliable reference to develop occlusion in complete dentures

74. CONCLUSION There are semantic, conceptual and practical reasons for concluding that the term 'centric relation' is flawed. Those flaws have a significant impact on dental practice. So to overcome it, definition of CR needs to be clinically oriented, to lessen the confusion and controversies. The clinician should be confident about his CR recording and understanding, which in turn shall be helpful in his ability to plan several treatment procedures.

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