FULL MOUTH REHABILITATION
The personality of an individual is often judged by his looks.
A beautiful smile always gives pleasure.
However, the personality may be falsely interpreted by ugly and impaired teeth.
Awful teeth negate the good looks of an individual. The evolution in dentistry has made it possible to enhance the face value by ameliorating the teeth through restorative and cosmetic treatment.
Both function and health can be restored to badly degraded, diseased mouths by utilizing modern techniques of oral rehabilitation. In times past, some of these “dental cripples” were condemned to full mouth extraction and complete dentures because the success of rehabilitation procedures was dubious.
Recent advances in dental technology, materials and equipment however, have simplified the task of rebuilding, restoring, and rehabilitating diseased mouths. This has enabled dentists to preserve many teeth which would have been sacrificed.
The success mission of full mouth rehabilitation requires a multidisciplinary approach. The ultimate goal of any dental treatment is to provide optimum oral health.
‘To restore to good condition or to restore to former privilege’- delineates the word rehabilitate.
‘Full mouth rehabilitation’ is a term used for extensive and intensive restorative procedures in which the occlusal plane is modified in many aspects in order to accomplish “equilibration”.
The modification of the occusal plane can be done by full coverage crowns, multiple crowns, multiple splinting of the teeth, modification of arch form by labial or lingual positioning of crowns and various procedures for ‘ repositioning’ the mandible.
Full mouth rehabilitation seeks to convert all unfavorable forces on teeth, into favorable forces which permit normal function and thereby inducing healthy condition.
The goal behind is the preservation of the teeth and the supporting structures in harmony with the muscles, bones, joints and ligaments of the mouth and jaws.
All current experimentation and research in dentistry is inspired by a common purpose that is to develop the most effective program of oral health service for curing as well as preventing disease.
However, the road leading to this is long and thorny, filled with a history of trial, error and adjustments. Many investigators and clinicians have developed procedures based on multitude of theoretic considerations.
TO GO FOR A FULL MOUTH REHAB
- Maintaining and achieving the health of periodontal tissues is the biggest reason for full mouth rehabilitation.
- Temperomandibular joint disturbance is another reason.
- As in the people with missing teeth, worn down teeth and old fillings that need replacement.
- For a beautiful smile, multiple front worn down teeth and missing teeth.
Contraindication for full mouth rehabilitation
No pathology- No treatment.
Malfunctioning mouths that do not need extensive dentistry and have no joint symptoms should be best left alone. Prescribing full mouth rehabilitation should not be taken as a preventive measure unless there is a definite evidence of tissue breakdown.
CLASSIFICATION OF PATIENTS REQUIRING OCCLUSAL REHABILITATION
Classification by Turner and Missirlain (1984)
The people are 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
Category 1 –
A typical patient of 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 and there is some loss of facial contour that results in drooping of the corners of mouth.
One of the patients in my dental practice with dentinogenesis imperfecta with excessive occlusal attrition, around 35 years of age and appearing prognathic in centric occlusion also belongs to this category. Closest speaking space of 5mm and interocclusal distance of 9mm indicates there is loss of occlusal vertical dimension with concomitant occlusal wear.
Category 2– 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. Manipulation of mandible into centric relation will often reveal significant anterior slide from centric relation to maximum intercuspation.
Category 3 – Posterior teeth exhibit minimal wear but anterior teeth show excessive gradual wear over a period of 20-25 years. 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.
Classification by Breaker
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.
Class I –All or sufficient natural teeth present, with satisfactory occlusal relationship.
Class II –Limited teeth present but in satisfactory occlusal relationship requiring aid in the form of occlusal rims.
People requiring maxillofacial surgery or orthodontic treatment as an aid in restoring the lost vertical dimension.
Patients in whom sectional treatment is required over extended periods of time because of status of health of the patient, age or economic factor.
The problems can be easily solved with a planned approach–
The first appointment is the listening time.
The patient’s problems, his point of view, long term expectations and opinion on esthetics are to be judged.
Impressions, radiographs, bite records and facebow records are to be taken for study and treatment plan.
Clinical examination of the whole mouth and the articulation should be checked.
The diagnosis and tentative treatment plan is made.
At the second appointment, individual tooth is meticulously examined and evaluated to determine whether they should be extracted or can be restored.
Determination is made whether the remaining teeth would best be served by fixed or removable prosthesis.
A decision must be made between a fixed partial denture and removable partial denture; overdenture or overlay denture and also whether the use of implants is advocated.
This decision primarily depends on various factors such as number of teeth present, length of the roots and the health of periodontal disease. The general metabolic and systemic disease must be taken into consideration.
The cost factor is a very big matter of consideration in full mouth rehabilitation with the modernization in dentistry.
The decision to choose between a fixed and removable prosthesis is a frequently occurring clinical dilemma.
This decision was simpler earlier. When firm abutments were available on either side of edentulous area, fixed restorations were given. In long span cases and periodontally weak abutments, removable prosthesis was given.
However, today advancements in endodontic and periodontic skills has provided healthier abutments making fixed treatment possible.
Fixed prosthesis even in poor anterior ridge condition can be made esthetic by ridge augmentation. Implants can make the use of fixed partial dentures where as earlier the only treatment option available was removable.
The advent of implant prosthesis has gifted with increased the option of choices.
Evaluation of implant site is done with clinical and radiographic examination for the quality and quantity of available bone.
Treatment planning aspects of implant placement must be done with a consideration for restoration.
Distal extension cases and long edentulous span restorations which needed removable prosthesis can now be fixed with implants.
Completely edentulous patients can also be rehabilitated using fixed metal ceramic rehabilitation on multiple implants.
Hybrid prosthesis which combines the principles of conventional fixed prosthesis to which resin is added to mimic soft tissue esthetics is also one of the best available option.
After considering all the treatment options available, decision regarding the treatment plan which will best suit that particular patient is to be followed is finalized.
Comprehensive treatment plan must be established prior to start of the treatment . Communication and patient education is must in order to match the dentist’s and patient’s definition of success.
Treatment plan can be divided into-
1) Pre- prosthetic phase
2) Prosthetic phase
3) Maintenance phase
Pre- prosthetic phase
To develop proficiency in diagnosing the need of occlusal rehabilitation, periodontist , orthodontist , endodontist , oral surgeon and prosthodontist must all be integrated in establishing an environment conducive to oral health.
Minor orthodontic tooth movement can significantly enhance the prognosis of subsequent restorative treatment.
A tooth can be uprighted, rotated, moved laterally, intruded or extruded to improve axial alignment, creating favorable pontic space and direct the occlusal forces along the long axis of teeth.
Orthodontic movement by use of modified Dahl appliance can be used to regain lost vertical dimension of occlusion.
The goal of every dentist is to maintain a healthy dentition in a healthy mouth.
Scaling and root surface curettage bring back the gingival health.
Surgical crown lengthening may be indicated to improve esthetics and provide adequate retention when clinical crown is short.
Free autogeneous gingival graft may be used to increase width of inadequate attached gingiva.
Ridge augmentation is indicated when ridge is deformed. Proper pontic fit and esthetic consideration indicate need for surgical intervention.
Each tooth is examined for caries, decalcification, erosion, attrition, abrasion, exposed root surface or fractures and restored if required so.
Elective endodontic treatment may be necessary for supraerupted or malaligned teeth .
Extremely worn down teeth with inadequate support for restoration may require post and core after endodontic treatment.
Oral surgical considerations
If any infected root pieces, hopelessly mobile teeth, impacted or unerupted supernumerary teeth present, are removed.
Elective soft tissue surgery especially alteration of muscle attachments and alveoplasty of ridges may be done to accommodate prosthesis.
Surgical repositioning of a segment of teeth or alveolus may be indicated if dentofacial deformity exists along with extreme wear.
Prosthetic full mouth rehabilitation can be divided into-
- Immediate treatment
- Definitive treatment
In some conditions like amelogenesis imperfecta in a child, postponing the treatment until adulthood may cause adverse psychological effect on the child and impairs relationship of maxillary and mandibular teeth.
Therefore, preformed nickel-chromium crowns are placed on the first permanent molars and the second deciduous molars to stabilize occlusion and halt attrition.
As anterior teeth and premolars erupt, polycarbonate resin crowns are given.
Second molar is fitted with nickel crown to preserve vitality.
After all permanent teeth are erupted, these restorations serve as transitional treatment until adulthood.
Once all teeth have erupted and adulthood is reached, the size of pulp horns decreases compared to newly erupted teeth. A definitive treatment can then be planned.
Basic steps in full mouth rehabilitation
- Case history and clinical examination
- Diagnostic impressions
- Evaluate vertical dimension and Occlusal interference for slide in centric
- Facebow record Interocclusal record
- Diagnostic mounting on semiadjustable articulator
- Occlusal equilibration for removal of gross interference
- Occlusal splint to confirm loss of vertical dimension
- Selection of occlusal scheme
- Diagnostic wax-up at estimated vertical relation of occlusion
- Evaluate for crown height, retention form, surgical crown lengthening, intentional root canal treatment
- Multidisciplinary approach
- Oral surgical- extraction
- Orthodontic-tilted teeth, rotation, intrusion, extrusion
- Periodontal – scaling, root planning, crown lengthening
- Endodontic – control of caries, root canal treatment
- Approach to full mouth rehabilitation
- Quadrant wise
- Determine material for restorations
- Shade selection
- Prepare lower anterior teeth
- Prepare upper anterior teeth
- Evaluate anterior plane for occlusion, phonetics, esthetics and function
- Determination of occlusal plane for posterior teeth
( Pankey –Mann technique)
- Prepare lower posterior teeth
- Prepare upper posterior teeth
- Evaluation of anterior guidance, plane of occlusion, and occlusal scheme on provisional restorations
- Recording and transferring anterior guidance record of provisionals
- Final impression of upper and lower anteriors
- Metal tryin
- Bisque tryin
- Temporary cementation of final anterior restorations
- Final impression of upper and lower posteriors
- Interocclusal record to mount on articulator
- Metal tryin
- Bisque tryin
- Temporary cementation of upper and lower final posterior restorations
- Evaluate for function, esthetics and comfort
- Final cementation of restorations
- Follow up
Success or failure following full mouth rehabilitation
Failure in full mouth rehabilitation case may be dependent on technical and biophysical factors.
Technical failures may be loss of restorations and retainers or fracture of metal or porcelain components.
Caries, fracture of abutments, periodontal disease and extractions are classified as biological failures.
Health of periodontium is influenced by the oral hygiene practice of the patient, crown position and margin, contour and occlusion of the restoration.
Hygiene instructions combined with repeated prophylaxis every six months prove successful in maintaining oral health.
Adequate plaque control program to prevent secondary caries is essential.
Provided the recall schedules and oral hygiene maintenance is properly done and restorations are meticulously fabricated considering mechanical and biological factors, full mouth rehabilitation can provide a long term success.
Patients with loss of occlusal vertical dimension due to unstable posterior occlusion or congenital disease–
exhibit excessive wear of anterior teeth.
A removable occlusal overlay splint or a treatment partial denture that restores the occlusal vertical dimension is given for 6-8 weeks and the patient is evaluated for comfort and function.
When patient is comfortable with removable prosthesis, teeth are prepared and provisional fixed restoration is given.
This restoration allows more critical appraisal of patient comfort, function, esthetics and hygiene for additional 2-3 months.
Then the final restorations can be given mimicking the treatment restorations.
Patients with bruxism having a long history of gradual tooth wear–
Continuous eruption of teeth leave seemingly insufficient space for restorative materials unless the vertical dimension is increased.
Anterior slide is present from centric relation to centric occlusion.
Equilibration or stability of posterior teeth for stability in centric relation, in combination with enameloplasty of opposing teeth can provide sufficient space for restorative materials.
Tooth preparation is critical for short clinical crowns with attrition. Strict parallism of axial walls is required.
Periodontal surgery that includes gingivoplasty and gingivectomy may require to gain clinical crown length is sometimes required for retention and esthetics.
Because of excellent periodontal support seen in most patients with wear, 2-3mm of supporting bone can usually be removed without jeopardizing periodontal support.
Programmed occlusion is also essential to successful treatment. Use of dynamic recordings of mandibular movement and a fully adjustable articulator are recommended for this type of rehabilitation.
Patients exhibiting excessive gradual wear of anterior teeth but mimimum posterior wear – Centric relation and centric occlusion are coincidental.
Restoring this patient is most difficult because vertical space must be obtained for restorative materials. This can be accomplished by orthodontic movement, restorative repositioning, periodontal surgery, and programmed occlusal vertical dimension modification.
Increasing the occlusal vertical dimension to achieve space for restorative materials where there has apparently been no loss of occlusal vertical dimension is seldom advisable; but if deemed necessary, the increase should be minimal and for restorative needs only.
Trial restorations are crucial and must be evaluated for longer period of time to ensure patient accommodation to the altered occlusal vertical dimension.
Minimal increase in occlusal vertical dimension may result in tooth movement subsequent to final restoration. Therefore frequent postoperative evaluation for occlusal interferences and wear is essential. It is advisable to fabricate a protective hard resin occlusal splint for the patient as a preventive measure.