full mouth rehabilitation/ academy general dentistry

Part III
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Contents
Requirements for Occlusal Stability
Programmed treatment planning
Diagnostic wax up
Occlusal Splints
Occlusal equilibration
Solving Occlusal Wear Problems

How to recognize a stable occlusion
All five signs of stability must be evident.
1) Temporomandibular joints (TMJs) are healthy and
stable
2) All teeth are firm
3) No excessive wear is present
4) All teeth have stayed in their present position
5) Supporting structures are maintainably healthy

Three Signs of Instability
1) Hypermobility of one or more teeth
2) Excessive wear
3) Migration of one or more teeth
i. Horizontal shifting
ii. Intrusion
iii. Supraeruption

Five requirements for equilibrium
of the masticatory system
Stable, comfortable TMJs (even when loaded)
Anterior guidance in harmony with functional
movements of the mandible
Non interference of posterior teeth
 Equal intensity contacts in centric relation

 Posterior disclusion when the condyle leaves centric
relation
All teeth in vertical harmony with the repetitive
contracted length of the closing muscles
All teeth in horizontal harmony with the neutral zone

Five Requirements for Occlusal
Stability
Stable stops on all teeth when the condyles are in
centric relation
Anterior guidance in harmony with the border
movement of the envelope of function
Disclusion of all posterior teeth in protrusive
movements

Disclusion of all posterior teeth on the nonworking
(balancing) side
Noninterference of all posterior teeth on the working
side, with either the lateral anterior guidance, or the
border movements of the condyle

How to Use the Requirements for
Stability for Diagnosis
In occlusal instability one or more teeth will either
become loose, wear excessively, or move out of
alignment unless:
The patient provides a substitute for the
unfulfilled requirement
or
The patient specifically eliminates the need for
the unfulfilled requirement

Treatment Planning
If there are requirements that are not fulfilled and
there is no substitute, or if the need for the
requirement has not been specifically eliminated,
treatment plan should be designed to:
I. Fulfill the requirement (if possible or practical)
II. Substitute for the missing requirement
III. Eliminate the need

Strategy for examination
Unsavable teeth should be
noted with an X on the
mounted casts and cut off
the cast before any occlusal
decisions are made

Strategy for treatment planning
Correction of Occlusal
Disharmonies
Five choices for correction
1) Reductive reshaping
(equilibration, coronoplasty)
2) Repositioning (orthodontics)
3) Additive reshaping
(restorative)

4) Surgical repositioning of segments of the dento
alveolar process without changing the skeletal base
5) Surgical repositioning of skeletal segments in
relation cranial base

First option: Reshape
The cast can be reshaped to
determine if it can achieve the
equal contact on all the teeth
without mutilating enamel.
Second option: Reposition
If reshaping cannot solve the
problem completely, minor tooth
movement combined with
reshaping proves to be the best
solution. www.indiandentalacademy.com

Substituting for holding contacts
The tongue posturing between
the teeth may actually stabilize
an open bite by substituting for
tooth contact.
If the teeth are stable, the
tongue is an acceptable
substitute.
Cheek biting, thumb sucking,
pipe smoking and pencil biting.

Options for anterior guidance
Treatment Options to Consider
 Will reductive reshaping help?
 Is orthodontic repositioning needed?
 Are restorations needed?
 Is positioning of the dento-alveolar segment needed?
 Does skeletal base alignment need correction?
 Is substitution with an occlusal splint needed?
 Is anterior guidance needed?

Substitution as a
treatment:
Teeth can often be
stabilized by an occlusal
splint as an alternative to
tooth-to contact and
prevent supraeruption.

CHECKLIST FOR FIRST
REQUIREMENT ANALYSIS
Analysis #1: Stable Holding Contacts
At maximum closure
 Are there any teeth that do not contact?
 Has the patient substituted for the missing contact?
 Are the teeth that do not contact stable?
 Are there any wear problems?
 Are there any mobility problems?

 Are there any tooth migration problems?
 Did the tongue cause the separation?
 Is the patient a lip biter or cheek biter?
 Is there a segmental occlusal splint?
 Are there any noxious habits?

At centric relation
The same teeth that contact at maximum
intercuspation should contact in centric relation.
 Can anterior teeth contact if posterior interferences
are removed?
 Are stable stops needed on anterior teeth?
 Are there any wear problems on the lower incisal
edges?

Treatment options
Reductive reshaping (equilibration)
 Can this treatment solve the problem?
Will the treatment achieve anterior contact in centric
relation?
 Will the treatment mutilate good teeth?
 Will the treatment help partially achieve the desired
result?

Repositioning (orthodontics)
Can routine orthodontics reposition the teeth for
holding contacts? (Observe neutral zone
consideration)
Would a combination of reshaping and repositioning
work better?

Additive reshaping (restorative)
Can holding contacts be provided by restorations?
Do teeth need restorations for other reasons?
Would restored contours be acceptable regarding
esthetics, crown/root ratio, etc,?
Would a combination approach (e.g., reshaping
and/or repositioning) work better?

Repositioning dento-alveolar segments
Are needed corrections too severe to accomplish with
simple orthodontics or a combination approach?
Would a surgical approach be more advantageous?
Could orthopedic appliances do the job?

Repositioning the skeletal base
Is the skeletal base the problem?
Decide which segments are wrong?
Substitution
Is a night time occlusal splint a reasonable substitute
for corrective measures?

Analysis #2: Anterior guidance
Are the incisal edges correctly positioned esthetically?
Are the anterior teeth in a good neutral zone
relationship?
Is there any interference to the lip closure path?
Do the anterior teeth have stable holding contacts?
Will the best esthetic result interfere with the envelope
function?
Does the patient desire a change in anterior esthetics?

Analysis #3: Posterior disclusion in
protrusive
Can the anterior guidance separate the posterior teeth in
protrusive?
Is the occlusal plane a problem?
Ascertain whether it can be accomplished with any of the
following:
Reductive reshaping of posterior inclines
Orthodontic correction of occlusal plane
Restorations
Surgery www.indiandentalacademy.com

Analysis #4: Disclusion of working and
balancing Sides
The key is stable holding contacts, correct anterior
guidance, and a correct occlusal plane.
Do posterior teeth separate immediately in lateral
excursions?

Multiple problems
Never start any orthodontic or restorative procedure unless
the end result can be visualized.
A treatment plan should consist of an orderly sequence of
procedures that are necessary to:
1. Eliminate pain
2. Eliminate infection
3. Restore all supporting tissues to healthy maintainability
4. Reshape, reposition, or restore the dentition when
necessary for optimum maintainability, esthetics,
comfort, and function

Problem solving
First Appointment: Should be planned to
accomplish the following:
The patient's complaints are ascertained
Present conditions are charted.
Present restorations
Prosthetics.
Occlusion.
TMJ

Periodontal condition.
Oral lesions
Caries.
Mouth hygiene.
Impressions, bite records, and facebow records for
mounted diagnostic models are taken.
A radiographic survey is completed.
Photographs of the mouth as well as different views of
the face are taken.

Second appointment
When multiple problems exist, the following
programmed approach to problem solving may be
used:
Each tooth should be evaluated individually. Can it be
saved and made maintainable by any procedure?
Teeth that cannot be saved or maintained should be
indicated on the study model and chart.
Questionable teeth should be indicated by a question
mark being put on the model and chart.

The remaining teeth should be evaluated on the basis
of stress direction and distribution.
Evaluation should be made as to whether remaining
teeth would best be served by fixed or removable
prostheses or by implants.
The problems should be re-evaluated. Sometimes the
whole complexion of a case changes when unsavable
teeth are removed.

Selecting which treatment
approach to use
Must weigh each alternative from several
perspectives:
Is it the best plan for achieving a maintainably healthy
mouth?
Is the cost of the plan reasonable or necessary for
results it achieves?
Is the time required to achieve a result logical in
comparison with other plans?www.indiandentalacademy.com

Does the health of the patient warrant an extensive
treatment plan?
Is the prognosis favorable enough to make extensive
procedures logical?
Is the prognosis, without treatment, unfavorable
enough to warrant an extensive treatment plan?

Diagnostic wax up

Diagnostic wax-up
Gives the dentist an unmatched level of confidence
when presenting the treatment plan to the patient.
The best visual aid use to help the patient understand
the goal of treatment.
The comparison of unaltered casts with the planned
casts is the perfect aid for explaining to specialists.
The corrected diagnostic casts serve as model for
fabrication of provisional restorations.

If orthodontic tooth movement is indicated, the three
dimensional model of the treatment objective can be
visualized to design the mechanics for moving teeth to
a specific new position.
Surgical decisions can be aided regarding movement
of dento-alveolar segments or complete arches.

Procedure
Step 1: Mount upper and lower
casts with centric relation bite
record and facebow. Duplicate
the casts to preserve the
original conditions.
Step 2: Verify the accuracy of
the mounting.
Step 3: Examine the occlusal
relationship on the casts.

Step 4: Lock the centric latch
when observing the casts. Start
with equilibration. Can it
achieve front tooth contact
without mutilating the posterior
teeth?
Step 5: Determine the correct
vertical dimension.
Step 6: Return the condyles to
centric relation and lock the
centric lock.

Step 7: Observe the teeth that
were reshaped.
Step 8: Remove unsavable
teeth from the casts. From the
clinical exam, all teeth that
cannot be saved are marked
with an X.
Step 9: Mark decisions that
have been made to use certain
types of restorations.

Step 10 : Equilibration is
the first treatment option
to explore.

Step 11: Examine the plane of
occlusion. If the casts were
mounted with a facebow that
was parallel with the eyes, the
incisal plane and the occlusal
plane will relate to the bench
top.

The occlusal plane
established by the
simplified occlusal plane
analyzer.
Model is trimmed back to
the established new
occlusal plane.

Step 12: Establish stable
holding contacts on the
anterior teeth.
Step 13: Correct lower incisal
edges if needed. This refers
to both position and
contour.

Step 14: Start with the lower
anterior teeth.
Step 15: Re-evaluate the total
occlusion with the upper
cast to see it can be adapted
to occlude with the lower
arch.
Step 16: Establish holding
contacts on the upper
anterior teeth.

Occlusal Splints
There are only two types of
occlusal splints:
Permissive occlusal splints
have a smooth surface on one
side that allows the muscles to
move the mandible without
interference from deflective
tooth inclines into centric
relation. www.indiandentalacademy.com

Directive occlusal splints
direct the lower arch into a
specific occlusal relationship
that in turn directs the condyles
to a predetermined position.
Directive splints have very
limited use.
Should be reserved for specific
conditions involving
intracapsular TMDs.

When occlusal splints are not
necessary
No history of problems in the TMJs, including no
history of clicking, discomfort in the joints, restriction
or deviation of jaw movement,
No intracapsular disorder.
No sign of tenderness or tension on load testing
Not necessary to fabricate an occlusal splint prior to
restorative dentistry orthodontics, or equilibration.

Occlusal splint is appropriate:
If there is doubt about complete seating of the TMJ
Long-standing intracapsular disorder that has been
resolved.
To stabilize hypermobile teeth and distribute the
loading forces over more teeth.

Fabrication of occlusal splints
Three very common errors are:
The splint does not fit the teeth properly, so it is
uncomfortable or loose, or it rocks in place.
The occlusal contacts on the splint are not in harmony
with centric relation.
An intracapsular structural disorder was not
diagnosed, so centric relation was not achievable.

Procedure
Take a verified centric
relation bite record.
Mount the casts in
centric relation with a
facebow.

Outline the coverage
area of the base.
Fabricate a Biostar
vinyl base on the cast

Remove the excess from the
base, but do not remove it
from the cast.
Place it back on the
articulator. Open the pin
enough separate all
posterior teeth from any
contact with the base

Mix resin and position it
on the base just behind
the upper anterior teeth
to contact and be
slightly indented by
lower anterior teeth in
centric relation.

Remove the base and
smooth the edges.
Remove undercuts into
interproximal areas.
The completed splint
should fit perfectly and
require almost no
adjustment.

Principles of full occlusal splint design
The design must incorporate four main
principles:
The splint should allow uniform, equal-intensity
contacts of all teeth against a smooth splint surface
when the joints are completely seated in centric
relation.
The splint should have an anterior guidance ramp
angled as shallow as possible for horizontal freedom of
mandibular movement.www.indiandentalacademy.com

The splint should provide immediate disclusion of all
posterior teeth in all excursive jaw movements from
centric relation.
The splint should fit the arch comfortably and have
good stable retention.

How long must splint be worn?
Splint should be worn until the following
requirements attained:
1. All related pain is gone.
2. The joint structure is stable.
3. The bite structure is stable.

Occlusal splints for therapy must be worn 24 hours a
day except to eat and brush until the occlusion and the
TMJs become stable.
Stability is determined by three verifications:
1. Elimination of painful symptoms
2. Verification of centric relation by load testing
3. Stability of the bite on the splint over the course of a
few days (or weeks if joint damage has occurred)

Occlusal equilibration
Proper equilibration is selective
Proper equilibration procedures can never harm a
patient
Proper equilibration never restricts
Proper equilibration is stable

Equilibration procedures
Equilibration procedures can be divided into four parts:
1) Reduction of all contacting tooth surfaces that
interfere with the completely seated condylar position.
2) Selective reduction of tooth structure that interferes
with lateral excursions.
3) Elimination of all posterior tooth structure that
interferes with protrusive excursions.
4) Harmonization of the anterior guidance.

Counseling of patients
Proper diagnosis
Point out loose teeth and relate them to premature
contacts or lateral excursion interferences.
Relate wear problems to occlusal disharmony with
the comfortable joint position.

Study the occlusal relationship on properly mounted
diagnostic casts.
Demonstrate on the mounted casts the amount of
tooth reshaping that will be required.
Tell the patient to expect further adjustments.

Eliminating interferences to
centric relation
Centric relation interferences can be differentiated
into two types:
I. Interference to the arc of closure
II. Interference to the line of closure

Interference to the arc of closure
Any tooth structure that
interferes with this closing arc
has the effect of displacing the
condyles down and forward.
Produce what is commonly
called an anterior slide

The basic grinding rule
to correct an anterior
slide is always MUDL:
Grind the Mesial
inclines of Upper teeth
or the Distal inclines
of Lower teeth

Interference to the line of closure
Primary interferences that
cause the mandible to
deviate to the left or the
right from the first point
of contact in centric
relation to the most
closed position.

If the interfering incline
causes the mandible to
deviate off the line of
closure toward the cheek,
grind the buccal incline of
the upper or the lingual
incline of the lower, or
both inclines.

If the interfering incline
causes the mandible to
deviate off the line of
closure toward the tongue,
the grinding rule is:
Grind the lingual incline
of the upper or the buccal
incline of the lower; or
both inclines.

Grinding rules
Rule I: Narrow stamp cusps before reshaping
fossae
If the first reshaping is directed at opening out the
fossae to accept bulky stamp cusps, it grinds away
more enamel.
If contouring of fossae walls is delayed until stamp
cusps have been reshaped, excursive interferences can
then be eliminated with less tooth reduction.

Rule 2: Don't shorten a stamp cusp
Instead of shortening a stamp cusp, grind the sides of
the stamp cusps.
The cusps should be narrowed on the side that marks
when the jaw closes to centric relation contact.
If deviations from both the arc of closure and the line of
closure at the same time. Upper teeth are adjusted on
the inclines that face the same direction as the slide and
lower teeth by grinding of inclines that face the
opposite direction from the path of the slide.

Tilted teeth
If the mark on the upper
tooth is buccal to the
central fossa, the buccal
surface of the lower tooth
is ground to move the cusp
tip lingually if the shaping
can be accomplished
without shortening the
cusp tip out of centric
contact. www.indiandentalacademy.com

If lingual to the central
fossa and if stability can
be improved, the lower
cusp tip is moved toward
the buccal, and the lower
cusp is reshaped by
grinding its lingual
inclines to move the
contact buccally.

Rule 3: Adjust centric interferences first
Three reasons for this:
1. By adjusting centric interferences first, we have the
option of improving cusp-tip position.
2. When cusp-tip position is given first priority,
occlusal grinding is more evenly distributed to both
arches.
3. If cusp-tip contours and position are improved first
in centric relation, eccentric interferences can be
eliminated with speed and simplicity.

Rule 4: Eliminate all posterior incline contacts.
Preserve cusp tips only.
If all eccentric contacts on posterior teeth are to be
eliminated, any posterior incline that marks in any
excursion can be reduced.

Lateral excursion interferences
Lower posterior teeth path laterally is dictated by two
determinants:
1. The border movements of the condyles, which act as the
posterior determinant.
2. The anterior guidance, which acts as the anterior
determinant
Guiding the mandible with firm pressure during excursions
will routinely pick up posterior interferences that are
missed with unguided movements.

Manipulation for lateral excursion
interference
Manipulate the mandible to centric relation, and verify
centric relation with load testing.
Close on the centric relation axis arc to the first point
of contact.
Slide the forefinger around to join the other three
fingers on the working side. Use all four fingers to
exert upward pressure on the working condyle.

Use the thumb and bent forefinger to exert pressure
toward the working condyle.
Ask the patient to let you slide the jaw to the left (or
right). It might be necessary to have the patient help,
but do not relax the upward pressure through the
working side condyle.
Have the assistant insert the dry ribbon in the dry
mouth to record the interferences. Slide the jaw to the
outer border position, and then have the patient
squeeze hard back to centric.

Adjusting the anterior guidance
All interferences to centric relation must be eliminated
before the anterior guidance can be corrected.
Steps in harmonization of the anterior guidance
Step 1. Establish stable holding contacts on all anterior
teeth if possible in centric relation.

Step 2. Extend centric contact forward if needed to
permit unguided gentle closure into stable stops
without striking the lingual incline first.
Step 3. Equalize contact in the protrusive path
Step 4. Adjust the lateral anterior guidance as needed to
permit smooth, comfortable excursions

Protrusive interferences
Only the front teeth should touch in protrusive
excursions.
Rule for eliminating protrusive interferences is DUML:
Grind the Distal inclines of the Upper or, in some
instances, the Mesial incline of the Lower teeth.
Centric stops should be marked with a different-
colored ribbon so that will not be ground.

Patient should be asked slide
forward and back. The patient
should do the sliding, but the
dentist should maintain a firm
hold on the mandible.
Corrected by some degree of
"hollow grinding" of the offending
incline.
The lower posterior teeth moving
diagonally across the upper teeth.

Verification of completion
I. Clench test
II. Anterior deprogramming splint

Role of the chairside assistant
The assistant has three responsibilities:
i. Keeping the mouth dry so that the ribbon will mark
effectively.
ii. Holding the marking ribbon in place while the
dentist manipulates the jaw.
iii. Keeping the teeth cool while the selective grinding is
being performed.

Armamentarium for equilibration
Ribbons
AccuFilm. The thinness of the film prevents it from
smudging around the sides of cusps and permits it to
mark only surfaces that contact.
Ribbon holder
The Miller ribbon holder is excellent. Several holders
should be loaded with two colors so that time is not
lost at the chair replacing worn ribbons.

Marking paper
Not generally the best material for marking
interferences because the ink rubs off too easily and
smudges. If the paper is not too easily penetrated or
torn, it is acceptable as long as it is not too thick.
Waxes
Thin sheets of dark-colored wax can be placed over the
occlusal surface of the teeth in one arch.

The opposing teeth are then tapped gently into the
wax until it perforates. The perforations represent
interfering contacts.
They are then marked with a pencil and then reduced.
Excellent material for finding interferences on sharp-
line angles that are often difficult to pick up by other
methods.

Pastes, sprays, and paint-on materials
Can be painted or sprayed onto tooth contact, and
then the material is perforated so that the contact
areas are made visible. The use of such materials can
be extremely accurate because the film thickness is so
thin.
Burs
A small diamond wheel stone and a 12-sided football-
shaped finishing bur work well for precise reduction
and reshaping.

Computer-assisted dynamic
occlusal analysis
The T-scan® II system from Tekscan uses a sensor unit
that records occlusal contacts on a thin Mylar film and
relays the information to a computer.
It is possible to determine the sequence and timing of
which teeth contact and with what degree of
comparative force.
Comparisons can be made for occlusal contacts in
centric relation versus maximal intercuspation.

Solving Occlusal Wear
Problems

Important considerations
Severe wear does not cause a loss of vertical dimension
of occlusion
Severe wear does not eliminate all deflective occlusal
interferences
Severe attritional wear can only occur if upper teeth
are in the way of lower teeth during functional or
parafunctional movements of the mandible.

Severe attritional wear is not caused by bruxing or
clenching unless teeth are in the way of mandibular
movements.
Posterior teeth cannot wear (from attrition) if posterior
disclusion is perfected and the anterior guidance is stable.
Do not steepen or restrict the envelope of function except
as a last resort. Any restriction of the anterior guidance can
result in wear, mobility, or movement of the anterior teeth
and a loss of the critical disclusive effect on posterior teeth.

Identify the cause of the wear
Types of Wear:
i. Attritional wear
ii. Wear from erosion
iii. Abrasive wear
iv. Toothpaste abuse

Treatment planning for wear
problems
Should be designed to accomplish six things:
Equal-intensity contacts on all teeth in a verifiable
centric relation.
An anterior guidance that is in harmony with the
patient‘s normal functional jaw movements.
Immediate disclusion of all posterior contacts the
moment the mandible moves in any direction from
centric relation.www.indiandentalacademy.com

Restoration of any tooth surfaces that have problem
wear through the enamel.
Counseling, so that the patient understands that
normal jaw posture keeps the teeth apart except
during swallowing. Advice: "Lips together, teeth apart“
Nighttime occlusal splint if habitual nocturnal
bruxism persists after occlusal correction.

Diagnostic wax-up
Four primary questions should be answered in the
following order:
1. Can the lower incisal edges be correctly contoured?
2. Can a definite holding stop be provided for each lower
incisal edge against its upper lingual surface?
3. Can the upper incisal edges be corrected or maintained
without interference to the existing neutral zone or lip-
closure path?
4. Can an anterior guidance be worked out between the
established centric stops and the upper incisal edges?www.indiandentalacademy.com

Analyzed first at the most closed VDO of the
equilibrated casts. If the anterior relationships can be
worked out without increasing VDO, that is ideal.
Or it should be increased only as much as necessary.
Can the anterior guidance (as waxed) disclude all
posterior teeth in all excursions?
If the anterior guidance cannot disclude the posterior
teeth, can the problem be resolved by changes in the
posterior segments?

Procedure
Step 1: Casts mounted in
centric relation make the
starting point obvious.
The lower anterior teeth
are waxed up to establish
definite labio-incisal line
angles

Step 2: The lower teeth
are prepared, and the
provisional restorations
are placed.
Step 3: Minor changes can
be made this stage, and
the upper arch can be
equilibrated to allow
complete closure in
centric relation.www.indiandentalacademy.com

Step 4: A, New impressions
are taken of the upper arch
and the provisionals in
place. Refine the upper wax-
up for copying in the upper
provisional restorations
after teeth are prepared.
Step 5: Both upper and
lower arches can be refined
for best anterior guide
function and esthetics.

Step 6: An index made
on a cast of the lower
anterior provisional
restorations.
Step 7: Lower
restorations are placed
and cemented.

Step 8: After verification of
the correct anterior
guidance, a centric relation
bite record is made at the
correct VDO with anterior
teeth in contact.
Step 9: The cast of the
approved provisional
restorations is mounted in
centric relation.

Step 10: A customized
anterior guide is made to
communicate precise
details of the anterior
guidance to the technician.
Step 11: This is then copied
into the final restorations.
Ceramic contouring is
related to the matrix.

Restoring severely worn
posterior teeth
A. Pin-retained all-gold restorations.
B. Increase in the VDO
C. Crown-lengthening procedures
D. Pulp extirpation and endodontic post and coping
construction

Conservative correction
of lower incisal wear
When incisal wear
penetrates through the
enamel, the softer dentin
begins to cup, leaving an
elevated ring of unsupported
enamel rods. This leads to
chipping away of the enamel
and makes the incisal edges
unsightly and rough.www.indiandentalacademy.com

When should occlusal wear be
restored?
Will treatment be complicated by delay in restoring
the wear?
Is restoration necessary to control sensitivity?
Is restoration required to satisfy esthetic desires?
Is it relatively certain that restorations will eventually
be required?

For more details please visit

full mouth rehabilitation/ academy general dentistry

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