A Segmented Approach to Full-Mouth

Rehabilitation

Written by Christopher J. Stevens, DDS
Wednesday, 14 November 2012 14:29
INTRODUCTION The ability to change lives through comprehensive care is
truly a wonderful part of dentistry. But along with the advantage to the patient,
there is a challenge to the providers to understand and address the chief
concerns and desires of the patient, as well as to understand all the medical
and dental implications related to treatment.

Two other considerations need to be made with regard to full-arch or full-
mouth comprehensive care: Will the care being considered be tolerated and
accepted physiologically? Can the desired treatment be provided within the
FINANCIAL constraints that many patients are presenting with in the
current economic times?

There can be many issues regarding the patients ability to tolerate and
accept the intended care. What will be the restorative material choice? What
is the health of the stomatognathic system? Is this a case that requires a
change in the patients existing vertical dimension of occlusion (VDO)? If the
bite needs to be opened, how much is enough? How does one know if it is too
much or too little? Can a trial bite position be done? How can a trial bite
position be transferred to the final bite records? Not answering these
questions can result in providing hope dentistry, a situation when the
clinician simply hopes that everything turns out for the best.

Further complicating the case is the increasing desire by patients to spread
their care out over time, sometimes a year or more. Of course, when providing
full-arch or full-mouth care in a case requiring that we open the bite, traditional
quadrant dentistry is not applicable. Therefore, new methods must be devised
to create holding patterns until the next phase of care can be started.

The case presented here will illustrate a method to satisfy both concerns
discussed above. By using these techniques, providers can eliminate hope
dentistry and be sensitive to their patients FINANCIAL situation.
CASE REPORT A 56-year-old male was referred to my practice by a good
friend and colleague who had been diagnosed with cancer. The patients
restorative work had been planned for some time, but due to scheduling
issues on the part of the patient and the health of his doctor, his care had
been delayed. By the time the patient was completely ready, the doctors
health had declined to a point where he was no longer practicing.
Dental History The patients dental history consisted of traditional dentistry
with several large amalgam restorations and PFM crowns. He was concerned
about wearing his teeth away, and also about crowns that had broken due to
bruxism (Figures 1 to 4). Because of discussions with his previous dentist, the
patient was very knowledgeable about his condition. He asked that he have
his teeth rebuilt to give him more vertical support, which he hoped would
help him reduce his grinding. In fact, he wore a maxillary and mandibular
appliance simultaneously at night. He said that if he wore just one appliance
his jaw would hurt in the morning. If he wore both, not only did he not have
jaw pain, he slept better. However, he had broken the maxillary appliance into
2 pieces.

Figure 1. Preoperative view;
unretracted frontal smile.
Figure 2. Preoperative view;
retracted frontal smile.

Figure 3. Preoperative view;
maxillary arch.
Figure 4. Preoperative view;
mandibular arch.
Comprehensive Evaluation The patient was asked to complete a
symptomatic history fashioned after the Kinnie-Funt-Stack Visual Index.
Symptoms reported included tension headaches, pain in the cheek and neck
MUSCLES , and shoulder stiffness. He attributed these symptoms to his
nocturnal bruxism. The existing occlusal disease raised my level of concern
for the health of his temporomandibular joint (TMJ) complex. In order to
evaluate the TMJ complex, bioelectric instrumentation (BioRESEARCH) was
utilized. Analysis of joint vibration recordings demonstrated low-level
vibrations near maximum opening that were indicative of eminence vibrations
(Figure 5). Corrected bilateral multipositional parasagittal tomograms (Figures
6a and 6b) were also obtained. The information from these diagnostic tests
demonstrated the patients resistance to systemic breakdown, and the
decision was made that the TMJ complex did not need to be treated prior to
restoration. The information also helped to establish a prognosis: due to the
patients high resistance to systemic breakdown, even withstanding his
occlusal disease, his acceptance of a new occlusal environment should be
favorable.

Figure 5. Joint vibration sweep display (BioRESEARCH). Low-level
vibrations on the right side are evident at the wide opening position. This
is indicative of an eminence vibration, considered nonpathologic. Opening
occurs without deviation or deflection.

Figures 6a and 6b. Bilateral temporomandibular joint (TMJ) tomograms,
closed view.
Case Planning In order to increase the VDO, the 3-dimensional (3-D)
relationship of the mandible to the maxilla had to be modified. That
relationship was determined via progressive appliance therapy. The
appliances used allowed an unimpeded trajectory of closure or a path to
develop. A vertical point along that path was then chosen. This position was
recorded with a rigid bite registration material (Luxa-Bite [DMG America])
(Figure 7). To determine a preliminary incisal length, a mock-up with flowable
composite resin (Revolution Formula 2 [Kerr] was done. Using the phonetic
determination of the F- and V-point (Figure 8), the incisal edge length, relative
to the lower lip position, was modified until the length satisfied both aesthetic
and phonetic considerations.

In addition to the bite registration and incisal edge determination, other
records were obtained. These records included the intended modifications to
gingival tissue zenith heights and position, midline, shape, and the shade to
be used for the provisional restorations.

Figure 7. Rigid bite registration
(Luxa-Bite [DMG America])
recording of the intended occlusal
relationship.
Figure 8. Unretracted view of the
incisal mock-up. (Note the incisal
edge position relative to the lower
lip.)

Figure 9. Frontal view of mounted
pretreatment maxillary cast for
comparison of the stick bite to the
articulator stage.
Figure 10. Frontal view of the
completed diagnostic wax-up.

Figure 11. The pretreatment bite
registration is seated fully against
the unprepared teeth and relined to
maintain the integrity of the
registration throughout the
preparation appointment.
Figure 12. Maxillary preparations
completed. Tissue retraction was
completed with the CO
2
laser.

Quality maxillary and mandibular study impressions were obtained with vinyl
polysiloxane (Aquasil Ultra [DENTSPLY Caulk]) and accurate dental casts
were then fabricated. The casts, along with the occlusal bite registration, were
sent to the dental laboratory team for mounting on an articulator (Accu-Liner
[Accu-Liner Products]). The maxillary cast was mounted to the upper member
of the articulator using the hamular notchincisive papilla (HIP) plane. This
HIP plane was introduced to dentistry by Dr. Harry Cooperman in 1960 and
has been shown to be a very reliable horizontal reference plane of the skull.
1,2

The mandibular cast was mounted relative to the maxillary cast utilizing the
rigid occlusal bite registration provided. The mandibular cast was then
removed from the articulator and the provided stage set in place.

Analysis of the maxillary cast against the stage demonstrated a pitch concern
(the anterior region pitched up). This concern would be addressed by
increasing the length of the anterior teeth as demonstrated in the mock-up.

A stick-bite reference was taken. It should be noted the stick bite is not a
representation of level but rather a representation of perpendicular to plumb.
In this way, the smile-line is perpendicular to the long axis of the face, even
when the head is tilted. The stick bite is then placed on the mounted maxillary
cast and compared to the stage. Note in this case, the stick bite is parallel to
the stage of the articulator indicating no presence of an unwanted frontal roll
to the smile and/or the maxillary arch (Figure 9).

The central incisor length, as determined by the F- and V-point, was
duplicated on the central incisors of the cast and the maxillary cast was
lowered so that the intended incisal edge of the centrals contact the stage of
the articulator. Next, the maxillary wax-up was completed by the laboratory
team to the ideal plane against the stage. Once the maxillary wax-up was
completed, the mandibular cast was re-mounted. Then, the wax-up on the
lower arch was completed (Figure 10). Finally, temporary stents and reduction
guides could be made by the laboratory team for use during the preparation
appointment.

At the consultation appointment with the patient, the decision was made to
complete the full-mouth restorative work in segments: the maxillary arch first,
followed by the mandibular arch at a later date. The primary reason for this
was driven by patient FINANCIAL constraints. However, a significant
benefit to segmenting care is that the patient can test the new maxillary-
mandibular relationship prior to placement of the final restorations. Our
intention was to complete the maxillary arch with final restorations and to
provide some form of long-term provisionalization on the lower arch to
maintain the intended maxillomandibular relationship. Then, when the patient
was ready to proceed with the lower arch segment, the new occlusal position
would be verified and accepted. As an additional benefit, this second segment
would be much simplified because the care would be provided in centric
occlusion (CO). Laser Contouring of the Gingival Tissues and
Preparations The case was now ready for the preparation visit. Laser-
assisted tissue recontouring should be performed first. In this case, the
contouring was done to place gingival zeniths in the appropriate position for
each tooth independently as well as relation to one another. Symmetry is
always the ultimate goal. My intention was to have the zenith height of the
central incisors level with the zenith height of the canines. The lateral incisors
should be 0.5 to 1.0 mm lower. Further, the zenith position of the lateral
incisors is in the middle of the long axis of the tooth while the zenith position
of the central incisors and canines is slightly distal to the long axis.

Figure 13. The maxillary
provisionals do not interdigitate with
the unprepared lower teeth
requiring provisionalization of the
unprepared lower arch.
Figure 14. Frontal retracted view of
the upper and lower provisionals.


Figure 15. Maxillary final
restorations articulating with the
Radica overlays.
Figure 16. Occlusal view of the
temporary overlays (Radica
[DENTSPLY Ceramco]).

Figure 17. Radica segments make
placement easier.
Figure 18. Tooth Slooth II crown
seaters (Professional Results)
securing the position of the veneer
for tacking.

Figure 19. Securing the Radica
segment via light-tacking.
Figure 20. Flowable composite
resin can be added to the facial to
mask the darker (natural) tooth
color.

The laser that I used here was the Smart US-20D CO
2
laser by DEKA Laser
Technologies. This laser emits a wavelength of 10,600 nm, thus providing
extremely high water absorption characteristics, the major component of soft
tissue. The peak power of the laser is as high as 320 W. The UltraSpeed
technology allows for shorter emission time and increased tissue relaxation
time. This allows one to incise tissue with the speed of a scalpel while sealing
blood vessels for a bloodless field, resulting in virtually no trauma to the
surrounding tissues. Using the repeat setting at 1.5 W and 50 Hz, along with
the perio tip insert on the laser handpiece, an outline of the intended position
could be drawn with guidance from the horizontal stick reference. Once the
outline was confirmed, a 2.0 W and 80 Hz setting with the perio tip insert was
used to make the gingival changes, again confirming zenith heights and
positions were at the pretreatment intention.

Actual tooth preparation could now begin. Teeth Nos. 3 to 6 and 11 to 14
were fully prepared. The previously taken occlusal bite registration was
reintroduced, and once complete seating of the unprepared teeth was
confirmed, the registration was relined (Luxa-Bite) to maintain the integrity of
the occlusal registration (Figure 11). Preparation of the remaining maxillary
teeth was then completed. All preparations were prepared with shoulder
margins (Figure 12). The posterior teeth would be restored with lithium
disilicate restorations (IPS e.max [Ivoclar Vivadent]), and the anterior teeth
with leucite-reinforced porcelain restorations (IPS Empress [Ivoclar Vivadent]).

The color mapping, smile selection, and natural core preparation shades (also
referred to as dentin-stump shades) with necessary photographs were
obtained. A stick-bite reference (perpendicular to plumb) was made. This
allowed the dental laboratory team to compare horizontal to the stage of the
Accu-Liner articulator, removing the potential for canting in the final
restorations.

Provisionals were fabricated by loading a bis-acryl temporary material
(Integrity [DENTSPLY Caulk]) into silicone stents (Sil-Tech (Ivoclar Vivadent])
fabricated from a model of the diagnostic wax-up. The maxillary stent was
loaded and seated against the maxillary preparations. An attempt was made
to place even pressure throughout the stent using the palate and tuberosities
as positive stops. Rubbing the anterior portion of the stent with a finger helped
to thin excess, making it easier to remove. The silicone stent was removed 2
minutes after placement, then the excess bis-acryl material was removed with
a No. 15 scalpel and fine carbide burs.

The maxillary provisionals do not interdigitate with the unprepared lower teeth
(Figure 13); therefore, even though the lower arch was unprepared at this
time, provisionalization was required. To accomplish this, soft periphery wax
was placed in all gingival embrasures. This was done to reduce the amount of
interproximal cleanup needed due to potential excess of the bis-acryl
temporary material. The lower silicone stent was then seated over the
unprepared teeth in similar fashion as the upper arch. The mechanically
retained provisionals over the lower teeth were then trimmed and polished
(Figure 14).

A next-day, follow-up appointment was made to evaluate incisal edge
position, shape, and color. Occlusal adjustments were performed as
necessary. Any modifications made at this time were related to the laboratory
team. Photographs and/or casts of the provisionals can be included with
instructions to the lab team.

Maintaining tissue health, to minimize gingival bleeding at the seat
appointment, is vital to the bonding process. Carefully opening gingival
embrasures will allow for daily flossing (I recommend Super Floss [Oral-B]). In
addition, daily water irrigation (Waterpik [Waterpik]) with a solution of water,
LISTERINE (Johnson & Johnson), and antibacterial hand soap promote
healing and reduce bacterial activity.
3

Laboratory Fabrication The case was sent to the lab team with all the
gathered records. In order to maintain an engineered occlusion, the maxillary
arch restorations were fabricated to a level occlusal plane aided by the stage
of the Accu-Liner articulator.

Modifications to the lower arch needed to be made even though those teeth
were not prepared. This process required the teeth be overlayed with a
transitional material strong enough to resist fracture, but one that could also
be engineered for occlusal maintenance of the intended maxilla-mandibular
relationship. The material of choice in this case was a glass-filled composite
provisional and diagnostic material (Radica [DENTSPLY Ceramco]).

Radica is a UDMA-based visible light-cured composite with an MMA-free
resin matrix. This material is dimensionally stable, providing a good long-term
option for provisionals.

The Radica overlays were fabricated against the maxillary final restorations
(Figure 15). My preference is to fabricate these in 3 segments because this
simplifies the adhesive process; this includes the right and left posterior
segments and the anterior segment (Figures 16 and 17).
Cementation At the cementation appointment, following the administration
of lingual local anesthesia, the maxillary provisionals were sectioned and then
removed. The preparations were cleaned with Consepsis Scrub (Ultradent
Products) and an intracoronal brush (ICB [Ultradent Products]) followed by
Consepsis (Ultradent Products) liquid. Each unit was tried independently for fit
and, as a group, for proximal contact determination. Once confirmation of
each unit was accomplished, the anterior segment was placed and reviewed
for midline position, canting, shape, and shade. Incisal edge length can be
evaluated by comparing it to the length of a remnant of the adjacent central
provisional restoration.

Once the patient had accepted the restorations, they were removed and
thoroughly rinsed. The lithium disilicate restorations were to be seated using a
universal composite resin cement (Multilink Automix [Ivoclar Vivadent]). The
anterior leucite-reinforced porcelain restorations were to be cemented into
place with a light-cured resin cement (Rely X Veneer [3M ESPE]). Both the
anterior leucite-reinforced porcelain restorations and posterior lithium disilicate
restorations had been previously etched with hydrofluoric acid in the dental
laboratory. Silane primer (Kerr) was to be applied at the chair to the
restorations before cementation. For the anterior teeth, after light-cured resin
cement was applied to the internal aspects, they were placed in a crown and
bridge light-protected organizer (C & B Organizer [Patterson Dental]) to
maintain a light free environment and to log their respective position in the
arch.

The rubber dam (Derma Dam [Ultradent Products]) was placed in a trough
format and the palate was sealed with bite registration material to prevent
saliva contamination. The 6 anterior teeth were etched for 15 seconds and
washed. Excess water was removed and Ultracid (Ultradent Products) was
placed as a wetting agent. A bonding adhesive (OptiBond Solo Plus [Kerr])
was applied per manufacturer instructions. The units were the placed short of
final position starting with the 2 central incisors. The remaining restorations
were placed front to back. Final positioning was done with 2 Tooth Slooth II
crown seaters (Professional Results); one positioned incisally, pushing
apically; and one positioned facially, pushing lingually. When completely
placed, the units were tacked midfacially (Figure 18). Once tacked, complete
seating of the restorations was confirmed. Final curing was performed with
multiple light units to expedite the curing process. Remaining bonding resin
was removed with a scalpel (No. 12 blade), fine carbide finishing burs, and
diamond impregnated finishing strips. The rubber dam was removed.

To seat the Radica on the lower arch, the rubber dam was again employed. A
total-etch technique with dual-cure resin cement was used to ensure a
complete seal. The Radica segment was loaded with resin cement and held to
place while initial cleanup was done with a rubber tip stimulator (Sunstar
Americas). The segment was then tacked to place (Figure 19). Final cleanup
was accomplished with finishing diamonds. Flowable resin can be added to
create color blending and mask the facial aspect of darker natural teeth
(Figure 20).

Some authors prefer to prepare all the teeth and use long-term provisionals
over prepared teeth to discover a final restorative position. The Radica
overlay method allows use of an engineered occlusion, a fracture resistant
and durable material and a complete adhesive protocol to prevent leakage,
especially in the prepared dentin.

Once the mandibular arch was seated, preliminary occlusal adjustments were
performed. Since the patients occlusal awareness was reduced by the effects
of the anesthesia, adjustments were done only to remove obvious CO
prematurities. Final adjustments were done the next day.
LOWER FINAL RESTORATIONS About one year later, the patient returned
to the office ready to proceed with the final restorations on the lower arch.
Joint vibration analysis was again performed to evaluate the TMJs
acceptance of the new occlusal position. Recordings demonstrated no
evidence of joint noise. Normal mandibular range of motion without deviation
or deflection was also noted (Figure 21). Tomograms at CO were also
favorable (Figures 22a and 22b). The patient also reported he no longer had
jaw pain.

Figure 21. Joint vibration sweep display, demonstrating the absence of
any joint vibration and opening without deviation/deflection.

Figures 22a and 22b. Bilateral TMJ tomograms at new centric occlusion.

A CO registration was used with the same rigid bite registration material as
described above. Preparations on teeth Nos. 19 to 22 and 27 to 30 were
completed. It was noted that the retention of the Radica to the occlusal portion
of the teeth during preparation was an indicator of the adhesive nature of the
overlay (Figure 23). Once the initial teeth were prepared, the bite registration
was reseated and relined in the prepared areas maintaining the occlusal
registration. The remaining 6 teeth were prepared, and the bite registration
was relined again in those areas.

Impressions were obtained using digital impression technology (iTero
[Cadent]). Provisionals were fabricated using the technique described earlier.
All records and instructions were sent to the dental laboratory team.

Once the final restorations were completed, the patient was appointed for
placement in the same manner as described earlier. Again, only preliminary
occlusal adjustments were performed. Since the patients occlusal awareness
was reduced by the effects of the anesthesia, final adjustments were done the
next day.
Final Adjustments The patient returned to the office for the removal of any
residual bonding resin and the initiation of occlusal balancing. Balancing was
accomplished by utilizing the T-Scan III System (TekScan). This system
accurately records the timing of occlusal contacts and the forces generated by
them.

The T-Scan III occlusal analysis system measures occlusal contact in real
time and has the ability to disclose time and force data. Occlusal data is
recorded by instructing the patient to occlude on an intraoral sensor that is
connected to a computer. This time and force measurement capability allows
the clinician to optimize occlusal contact patterns precisely, thereby attaining
measurable verification of what has been theorized as ideal occlusal
parameters in many classical occlusal principles.
4-7
The data displayed on the
monitor represents the maxillary arch. Data can be displayed in various
formats including the 2-dimensional (2-D) contour view and the 3-D columnar
view. The 2-D view resembles articulation paper marks and the 3-D view
makes force viewing easy when compared to the color-coded force legend.
The force versus time graph allows the clinician to view time between initial
tooth contact and last tooth contact; ideally less than 0.2 seconds.
8


Figure 23. Note the adhesive
retention of the Radica material
even during preparation for the final
restorations.
Figure 24. Right to left force
balancing noted as 52.9% right and
47.1% left on T-Scan III occlusal
management system.

Figure 25. Frontal view of the final restorations.
The display generated by the T-Scan demonstrated a force balancing right to
left of 52.9% to 47.1% (Figure 24). Our ultimate goal is 50 to 50 with an
acceptable range 45 to 55. The time between initial tooth contact and static
intercuspation was 0.162 seconds, again within the acceptable range.
Follow-up Follow-up appointments were made for final touch-ups and
fabrication of a nocturnal parafunctional appliance (bite splint). The patient
was extremely pleased with the final results (Figure 25). Thus far, the 2-year
postoperative appointment demonstrated excellent stability of the restorations
and no evidence of jaw discomfort.
CLOSING COMMENTS Discretionary income of our patients has been
reduced in recent years. Comprehensive care, although still a needed option,
is often being delayed. A segmental approach to care, in a manner that allows
the patient and practitioner to achieve goals over time, can be very valuable.
Not only can it help a patient achieve a desired outcome; this approach allows
the doctor to know the care provided will be accepted and well-tolerated by
the patient.F
ACKNOWLEDGEMENT The author wishes to thank Kent Garrick of
Arrowhead Dental Laboratory (Sandy, Utah) for his help in development of
this protocol. His ability to listen to my thoughts and ideas and then apply
laboratory solutions to them was critical to the success of this technique. The
author also wishes to thank Arrowhead Dental Laboratory for these fine
restorations. Dr. Michael Forgette, first my student, then my friend, and finally
my inspiration, lost his battle with cancer. I truly wish that he was able to know
how many people have been helped with this approach to care.

References
1. Cooperman HN, Willard SB. Studies of the Louchheim Collection of Skulls.
New York, NY: American Museum of Natural History; 1960.
2. Cooperman HN. HIP plane of occlusion in oral diagnosis. Dent Surv.
1975;51:60-62.
3. Venneri AJ. A new approach to at-home oral irrigation. J Am Dent Assoc.
1997;128:755.
4. Kerstein RB. Current applications of computerized occlusal analysis in
dental medicine. Gen Dent. 2001;49:521-530.
5. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems.
2nd ed. St. Louis, MO: Mosby; 1988.
6. Schuyler CL. Fundamental principles in the correction of occlusal
disharmony, natural and artificial. J Am Dent Assoc. 1935;22:1193-
1202.
7. Glickman I. Clinical Periodontology. 4th ed. Philadelphia, PA: W.B.
Saunders; 1972.
8. Kerstein RB, Grundset K. Obtaining measurable bilateral simultaneous
occlusal contacts with computer-analyzed and guided occlusal
adjustments. Quintessence Int. 2001;32:7-18.

Dr. Stevens is a graduate of Marquette University School of Dentistry in
Milwaukee, Wis. He is a Fellow of the International College of
Craniomandibular Orthopedics, a Diplomate of the American Academy of Pain
Management, and cofounded the Multi-Disciplinary Pain Clinic at the Medical
College of Wisconsin. Dr. Stevens maintains the Center for Advanced Studies
of Functional and Restorative Esthetics where he teaches occlusion, full-
mouth reconstruction for both symptomatic and nonsymptomatic patients, and
over-the-shoulder cosmetic courses. An active international lecturer for more
than 2 decades, he has spoken to thousands of care providers including
dentists, physicians, chiropractors, and physical therapists on the subjects of
smile enhancement, principles of occlusion, full-mouth restoration and
diagnosis and treatment of temporomandibular disorders. He also has
published numerous articles. He can be reached at (608) 837-4880,
cjs@drchrisstevens.com, or by visiting the Web site drchrisstevens.com.
Disclosure: Dr. Stevens lectures for TekScan, Inc, BioResearch, Inc, and
DEKA Laser Technologies, Inc.