A Simplified and Stress Free Approach to Full Mouth Rehabilitation

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Posted on By Gerald Benjamin In Full Arch & Dentures

Nothing is more daunting to the general dentist than starting a full mouth rehabilitation. Fear of performing complete mouth reconstruction was created in dental school when we were warned about the challenge of changing vertical dimension and creating a permanent TMD problem. "Better leave FMR to the prosthodontists" was the watchword of faculty members.
Having been rejected virtually every dental school in the country at least once, three years in a row, I understood that full mouth rehab was beyond my level of understanding despite having taken all of Frank Spears courses when he was in Seattle and studying under the great Fred McIntyre, Board Cert Pros. That said, I was quite good at dentures and recognized that if I could treat a fixed case like a removable case, I too could perform FMR. My technique is simple, easy and stress free and relies on two numbers: Maxillary central incisors need to be 10.5 mm (although it can be 11 or 12 mm) and mandibular incisors need to be 9 mm in length. In the case under discussion, the patient had 10 maxillary veneers placed 4-5 years ago and now wanted her mandibular teeth restore. Prior to having cosmetic dentistry, the patient had Invisilign treatment because the maxillary centrals were in lingual version and trapped behind the lateral incisors. The mandibular anterior teeth were 6.75 mm in length meaning that we needed to add approximately 2.25 mm to these teeth. The most straight forward technique is to place 2.25 mm of resin onto the incisal edges of the 6 mandibular teeth and cure (no etching.) Once cured, the patient is asked to count from 60-70 to test the sibilant sound. Esthetics were excellent as was speech. The sibilant sound (ie 66 ) was perfect with the space between the maxillary anterior teeth and the resin enhanced teeth was less than a mm.

Centric Relation or the seating of the condyles in the fossa will occur as long as there are no posterior teeth present. With the 2.25 mm of resin on the mandibular teeth, the patient is asked to gently close as if biting on their back teeth. (Note: This is similar to using a leaf gauge.)With the patient gently closing on the resin sitting on their anterior teeth there is an opening in the posterior region of the mouth. This space is registered using PVS bite registration material. The Centric Relation Recording and the correct Vertical Dimension of Occlusion has been established with little effort. Impressions and a Facebow are taken and mounted on a semi-adjustable articulator. A wax up is then done for 10 mandibular teeth ignoring the posterior teeth for now. When the patient presents for the preparation appointment, the 2.25 mm of resin is placed onto the mandibular anterior teeth. Two patties of GC Resin Pattern are mixed and placed onto the occlusal surface of the posterior teeth (lubricated with a thin layer of Vaseline) and the patient is again instructed to close as if biting on the posterior teeth. A rigid bite registration has been made and can remain in the mouth while prepping teeth 20-29).After the anterior teeth are prepared, another patty of GC Resin Pattern is placed on the mandibular 4 anterior teeth and the patient is instructed to close into the POSTERIOR bite registrations. The CR and VDO have been perfectly recorded and final impressions and temporaries are fabricated. After the temps are placed and adjusted for uniform contacts, resin was added to the buccal cusps of non restored posterior teeth only after the usual adhesive protocol was initiated. The buccal resins may be retained for up to 10 years when indirect restorations are placed.

Pre Op and Before Invisilign therapy.
Pre Restorative treatment but after Invisilign therapy

Maxillary Arch previously restored with 10 maxillary Emax veneers
Full face Restored Maxillary anterior teeth


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15 Comments

Steps for establishing Centric Relation and the VDO

The incisal resin matrix was placed back onto the mandibular anterior teeth and the patient was asked to gently close on their posterior teeth. PVS bite registration material was placed into the open posterior space. The Centric Relation Recording and the
The PVS material is replaced by GC Resin Pattern to now establish a RIGID bite registration. This is done because when the patient is anesthetized bilaterally the PVS can be unknowingly compressed, decreasing the VDO


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Obtaining a full bite registration at the correct VDO and CR after teeth are prepared.

I wax my own cases in Filtek Supreme Ultra so that I learn how the teeth will be prepared
The mandibular 10 anterior teeth were prepared WITH the GC Resin Pattern matrixes in the mouth while preparing the teeth. After the teeth are prepared, an anterior bite registration using GC Resin Pattern is taken.


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The completed restorations at the correct CR and VDO. There were virtually no occlusal adjustments. There are no stressful moments during this case because all the determinants of the case were established in the mouth using a technique similar to fabricating dentures.

To review the four determinants of occlusion:
1. The maxillary incisal edge position including the buccal-palatal position as well as the correct incisal length ~10.5. This is responsible for establishing esthetics and the "F" sound.
2. The mandibular incisal edge position aka anterior guidance is responsible for esthetics and the correct sibilant or 'S' sound.
3. The ideal occlusal plane with the Curve of Spee
4. The correct condylar seating known as Centric Relation, a braced position.

The completed mandibular Emax restorations


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Great post Dr Benjamin.

This is as predictable a protocol as it gets. Couple of questions/comments;

1- Were you able to prep the lowers in enamel only?

2- How do you cement the lower provisional?

3- Were the molars restored with direct resin or indirect?

4- Concerning the lower occlusal plane, I try to get as flat a plane as possible. This allows for minimal posterior interferences.

5- Since opening the bite is basically a 1:3 ratio from 2 nd molar to incisor, how did you get 2-2.5mm opening in the back from 2.5 mm added resin to the lower incised edges?

Truly enjoy reading your posts.


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Thank you so much, David. 1.Yes the preps were kept in enamel. There was no incisal reduction. When you open the bite, there is plenty of room on the labial surface. 2. Sometimes I lute the temps with my permanent luting cement no bonding and sometimes I shrink fit the temps. 3. The buccal cusps were temporarily 'restored' in resin. Since both molars had existing crowns, I air abraded, HF, silaine, optibond solo plus and Filtek Supreme Ultra. I place the resin on the buccal cusp and part way down the buccal wall and buccal aspect of incline plane. I shape with a brush and have the patient quickly close and cure from the buccal and then the occlusal. The bite is always perfect. I went back and measured the GC Resin Pattern and the opening was 1.3 mm.


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Dear Dr Benjamin
Great Post and mind this is what Academics is
You are clincal professor and giving us clinical tips how to manage patients clinically
What ever is learned academically should be implemented clinically otherwise such knowledge and research has no use
You doing great job

Regards
Prof Dr Neeraj Mahajan


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Dr Benjamin,
Had the lower anteriors been aligned, would you have considered prepless veneers since you had 2.25mm of interarch anterior space ? What’s your opinion on prepless emax veneers if teeth aren’t crowded and underlying color is acceptable ?


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Hi Dr. Olknine;
The answer is: It depends. If the teeth are naturally light and the patient wants a bleach shade, I think that you can go prepless. If the patient has C3 or C4 natural teeth and they want a bleach shade, we probably would have to prep something away.
Great question.
Regards,
gerald


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Simple, stress free and repeatable approach..
Thank you for sharing your great work Dr.Benjamin..


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Thank you Omar! This should be the way young dentists learn how to perform what is perceived as complex treatment. I hope that you noted that there was not one word in the technique about which muscles are doing what. That is pure intellectual obfuscation to discourage dentists from learning full mouth rehab. I have an extremely successful patient who does not appreciate explanations even when they are beneficial. He is fond of say, " I asked you about the time and you are telling me about your watch." Too much of dental learning has an eye on selling another course.


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Hi Benjamin. Beautiful concept and result! Always a pleasure to se you’re cases. Best regards. Chuck


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Hi Chuck; Thanks so much! I fear that the old guys will not be able to leave an enduring legacy of excellence. I am on many forums and our young (American) colleagues are not enamored by excellence.


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Dear Dr Benjamin
Great Post and mind this is what Academics is
You are clincal professor and giving us clinical tips how to manage patients clinically
What ever is learned academically should be implemented clinically otherwise such knowledge and research has no use
You doing great job

Regards
Prof Dr Neeraj Mahajan


Reply

Dr. Majajan; I am honored by your comments. I could not agree more with your thoughts. Sometimes I think that Dental School is a sadistic event, frustrating at every turn. Learning should be a joy. Thank you, Regards, Gerald


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For FMR , Is there any technique which is simple than this ? I don't think so. If you make this technique so simple probably you cant sell it , lol!! ( and i know that you will not do that )Because majority of the dentists wants more complex procedures . And how many clinicians can teach like this!!, probably very less. Dr. Gerald, thanks for posting.


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