Whole mouth rehabilitation – A quick guide By Dr. Vasanth

I understand a lot of dentists want to take up whole mouth rehabilitation, but do not know how, and others who are doing it already but want to improve their work.

This article is for their benefit. It is about whole mouth rehabilitation, how it should be approached, and how to achieve predictable success.

There are various definitions of what whole mouth rehabilitation is.

My personal definition is as follows:

Any procedure that involves the whole stomatognathic system and not teeth alone, that brings harmony to its various components, namely TMJ, muscles and teeth, should be called whole mouth rehabilitation. It has to be a centric relation based approach, where teeth surfaces are modified with equilibration, or fillings or crowns, and missing teeth replaced with bridges or implants or cast partial dentures, so that teeth can achieve maximum intercuspation with the joints seated in centric relation. The occlusal scheme should be anterior guidance, or in rare cases group function.

So according to me whole mouth rehab does not necessarily mean 14 or 28 crown and bridges. Just equilibration, or 28 crowns, or anything in between can be called whole mouth rehabilitation if it satisfies the above said criteria.

Now let us go through the step by step process of whole mouth rehabilation.

Examination –data collection

The whole process starts with a complete examination – what is called a COMPREHENSIVE EXAMINATION. Examination should cover the TMJ, the muscles of mastication and other head and neck muscles, teeth and periodontium.

A good set of die stone models, face bow record, centric relation record and a protrusive bite record should be made.

A discussion appointment, after a week, is scheduled where the diagnosis and treatment plan will be presented with a diagnostic mock up.

Treatment planning

Treatment planning should be done on mounted casts in a semi-adjustable articulator with face bow and CR record. Incorporating all treatment goals, a wax up is made, which I call “A treatment blue-print”. Cut and move teeth requiring orthodontic treatment, grind teeth requiring equilibration, build up with wax teeth requiring filling and crown and bridge, or teeth to be restored with implant or cast partial.

Treatment execution

The basic essential treatment like periodontal / endodontic management and extractions should be completed first. All crown & bridges should then be done, but with only provisional. Occlusion is tested in the mouth. Finally when you and the patient are completely satisfied, final impressions and final ceramic crowns should be cemented and equilibration done.

Let me explain the various aspects of whole mouth rehabilitation

    1.     Clinic set up and Doctor’s skill

1. Doctor’s skill. 

2. Good lab support. 

3. Four or six handed dentistry.

4. Good impression technique. 

5. Semi-adjustable articulator.

6. Provisionalisation.

      1. Doctor’s skill

A dentist must hone up his skill in various fields of dentistry, through self study and various continuing education courses. At the end of the article, I will outline the hands on programs that I conduct at Chennai and at Dentcare lab, Muvattupuzha. These are tailor-made for whole mouth rehab aspirants. You definitely need extra skill beyond dental school training to successfully tackle full mouth rehab cases.

2. Good lab support

You cannot undertake whole mouth rehab cases unless you have a good dental laboratory support. Both the lab and the dentist must be in good rapport, and must work with the common goal of delivering EXCELLENCE.

  

3. Four or Six - handed dentistry

Any dentist who wants to go beyond just “extraction, acrylic dentures and amalgam filling practice” must realize that the first step in that direction is working with assistance.

Two handed dentistry is no longer acceptable. Minimum is four handed dentistry (dentist and one assistant). Ideal will be six handed dentistry (dentist and two assistants).

4. Good impression technique

In the last ten years that I have been conducting workshops and hands on programs, I realized that taking impression is the most neglected procedure in most clinics. My discussion with dental labs also confirmed that. Getting an excellent (good is not enough!) impression is a basic requirement for whole mouth rehabilitation cases. 

5. Semi-adjustable articulator

Possession and knowledge of handling a semi-adjustable articulator, is another mandatory requirement for doing any meaningful diagnosis or treatment plan.

 6. Provisionalisation

All crowns and bridges planned on the casts should be tested with acrylic provisional in the patient’s mouth before committing on permanent ceramic. A provisional should resemble the final in shape and shade. So making a good provisional, is one more skill needed in whole mouth rehab cases.

2. Diagnosis and treatment planning

If building a house requires a plan and a detailed blue-print before we start, how can you start building occlusion without a pre-plan – what we can call as treatment blue-print or treatment wax up?

The following aspects are important in planning treatment:

1. Centric relation 

2. Face bow transfer 

3. Occlusal scheme

4. Treatment wax up 

5. Clinical photographs 

6. Patient education

1. Centric relation

Centric relation is the key for predictable success. Dentists must develop a good understanding about the temporo-mandibular joint and its relationship to teeth and muscle harmony. Recording centric relation is a very learnable skill that every dentist should master.

     2. Face bow transfer 

It is a simple 3- minute procedure, which transfers patient’s hinge axis relationship to the articulator. It is a mandatory procedure, without which the articulation will not represent patient’s occlusion.

3.Occlusal scheme

 To me, the only acceptable occlusal scheme is Anterior guidance. In rare cases, group function occlusion will become necessary. 

4.     Treatment wax up 

Treatment wax up is like a preview of the final treatment. It convinces the dentist that his treatment plan will work. It allows the patient to visualize the treatment outcome. Patients will be more convinced to accept your treatment plan.

     

     5.Clinical photographs 

Clinical photography is an important component in whole mouth rehabilitation. Right from convincing patients for treatment acceptance to showing off your excellent work to the patient and others, good photo records go a long way to make your practice different.

    6.Patient education 

A patient who understands the nature of his problems, and who understands the effort you have put to plan an ideal treatment plan for him, will appreciate your work and pay with gratitude, and will also refer patients. Your reputation as a “Different Dentist” will be a great practice builder.

           3. Execution of treatment

1. Periodontics 

2. Surgery 

3. Endodontics 

4. Restorative 

5. Orthodontics

6. Crown & Bridge 

7. Implant 

8. Cast partials 

9. Equilibration

 1. Periodontics 2. Surgery 3. Endodontics 4. Restorative 

Periodontal management, surgical procedures, endodontics and caries management are normally carried out first. These are baseline treatment protocols that form the starting point for any serious whole mouth planning.

Plaque control, improving patient’s hygiene management and caries control have to be in place for any long term success.

     5. Orthodontics

It is unfortunate that orthodontic treatment has never been projected as a strong tool in whole mouth rehab armamentarium. Also since the average dentists’ (other than orthodontists) knowledge on orthodontics is very limited it is natural that they will not be in a position to incorporate it in their treatment plan. Some basic orthodontic training, especially in straight wire, is essential for any dentist who wants to do whole mouth rehab cases.

     6. Crown & Bridge

In most whole mouth rehab cases, crown & bridge play a great role. Extra training in crown preparation and impression taking is essential. Developing this skill will decide your success in managing whole mouth rehab cases.

           7.Implant

Implants are another way of replacing missing teeth like crown and bridge. Where ever possible it is the best way to replace missing teeth, because it avoids unnecessary preparation of abutment teeth, and also preserves bone in the edentulous areas. But good implant training is mandatory. Unless the implants are placed in the exact planned three-dimensional location, restoration according to prosthetic plan might not be possible.

     8. Cast partials 

It is unfortunate that cast partials are hardly used as routine treatment. If implant option is not possible due to financial or other reasons, cast partial becomes a good option. But unfortunately undergraduate dental training hardly stresses on cast partials. Most dentists require cast partial training. Even if you do not do full mouth rehabs, learning to do cast partial dentures is a great help to normal practice.

 9.  Equilibration

Equilibration is reductive reshaping of occlusal and incisal surfaces to achieve occlusal goals. This is an essential skill every dentist must develop.

Added benefits of this centric relation based approach

I have been following this centric relation based approach to whole mouth rehab for about 5 years now – I call it comprehensive CR based dentistry. It is based on the Pankey – Dawson philosophy. As centric relation based dentistry restores harmony between TMJ, muscle and teeth, it helps us to tackle TMD and myo-facial pain.

As your client base will include patients with migraine, intractable headache, vertigo, neck and shoulder pain, your practice will become exclusive. You will elevate yourself into a physician of the stomatognathic system.

Whole mouth rehabilitation is not an "anybody can do it procedure". But at the same time, if a dentist takes time and effort to implement the main requirements I have listed above, success will be predictable.