Tips from Full Mouth Rehabilitation course

I observed at Lincoln Harris' Full mouth rehabilitation course recently. I'll add small tips as they come to mind:

A full mouth rehab is one of those things in dentistry that seems a lot more complicated than it is. In reality it can be broken down into smaller steps that if done well will lead to a successful and predictable outcome.

Diagnosis is key to a rehabilitation. Discovering the cause of the breakdown as well as an accurate waxup is essential. After transferring a good waxup to the teeth, the resultant dentistry is just a bunch of crown and bridge work.

Opening vertical dimension makes the patient more class 2. A class 3 patient will become less class 3 or class 1, and class 1 patient will become class 2 and a class 2 patient will worsen.

When making a putty stent for transferring a waxup or for temporary crowns and bridges, take a putty stent of the waxed up model and reline it with light body impression material.

Wax should stick well to a model. If it doesn't then the model hasn't been properly dried before the waxup.

The Mockup will assist you in determining the amount of occlusal reduction required. Prep through the mockup to the required occlusal reduction and once the mock up is removed, any deficient areas can be built up in the core buildup stage.

When transferring a waxup to the patient, have the tip of the material gun right at the occlusal surface to avoid bubble formation, cover the entire occlusal surface and go back to fill the rest of the stent. Insert the stent and always use a timer to dictate when you remove the stent. Since you want the material to stay on the tooth, you can wait longer than if you were making temporary crowns. Insert the stent firmly and apply pressure to the flanges against the gingiva to separate the flash from the crowns. Remove any excess you can while the stent is in place. When it is time to remove, lift one side of the stent off first while applying downward pressure on the other side to reduce the risk of the entire mockup being pulled off. Since the material will shrink as it sets, it will be locked onto the tooth like a "shrink wrap".

Tissue control is important during the core buildup. Teflon pack or cord can be used in the sulcus to retract the tissue and stop fluid flow. etching of enamel margins is not necessary as in most cases the core will be prepped away at the enamel margin anyway to have the prosthesis sitting on a tooth margin. Lincolns protocol is SE prime and bond, cure, flowable in a thin layer to reinforce the bond, unset flowable and pack heated bulk fill composite into the cavity, cure. If layers are required, flowable is used between layers to reduce the risk of bubble formation and improve adaptation. You rarely require a neat job of a core buildup. what you require is good isolation and bonding. Definitely overfill as the core will be prepped away right after. If adjacent teeth are to be prepared you don't even have to be careful to use matrix bands for separation.

Most waxups are additive to replace tooth structure lost from wear but in some cases e.g when an anterior tooth is too proclined or labially placed it will be subtractive. Therefore before transferring your waxup you must reduce the extra tooth back or the putty stent will not seat.

If crown lengthening is required for ferrule or aesthetics, it is important to determine where the bone is sitting. The most accurate way is with a CBCT which will show the crestal bone height. To determine the desired height of bone you need a model waxed up to the ideal positions. The bone will ideally sit 3mm from the restorative margin in a thick biotype and 2mm in a thin biotype as the thick biotype will tend to full the biologic width better. You can transfer the waxup to the mouth and use this to guide the surgery or make a clear suckdown retainer if a periodontist will be performing the surgery. You MUST guide the surgeon though or you will end up with a non prosthodontically guided result. If the bone is already 2-3 mm from the desired restorative margin, you can perform a gingivectomy only. Without bone removal, a gingivectomy into the biologic width will result in the gum regrowing to establish the biologic width. However, if bone reduction is desired, start with a gingivectomy at the restorative margin, then raise a small flap and reduce bone to the desired height. Be sure to keep the flap as small as possible in the attached gingiva as if you raise a full flap to the mucosa it will be very moveable and is likely to be sutured apically to end up as an apically repositioned flap. If there is insufficient attached gingiva, this method may become necessary.

When deciding the final position of the incisal edges, the AP position to the wet dry line can be seen with a photograph from above. the edges of the teeth should touch the wet dry line when enunciating "f" or "v" e.g fifty five.

Important things to test at the new trial VD is aesthetics, phonetics and swallowing. If the patient can't swallow then the VD has likely been increased too much.

Hemostasis takes time. Pack cord or teflon, use a hemostatic agent in cotton pellet and apply pressure with the pellet. Wait 5-10 minutes and take a break while the gingiva stops bleeding. If you check early you will upset the tissues and the gingiva will start to bleed again.

Good tissue control is not essential unless you plan on taking impressions at the prep appointment. Packing teflon will provide massive retraction and can be used during prep as it won't catch on a bur like cord would. Rather it will be prepped away as the diamond passes over. Well fitting temporaries will allow any tissue damage to heal and you will have an easier time of taking impressions at the next appointment.

Insert the teflon interproximally first as it has the most space to fit. Then hold down this point with a perio probe and don't remove it. Then use a flat plastic to pack the rest of the teflon around the tooth in the sulcus.

When making a temporary bridge in a high fracture area or where the span is very long, you can tack some everstick fibres onto the tooth with flowable without bond. Then when you place the stent with temporary material in it it will pick up the everstick fibres to have a temporary bridge with embedded everstick. The tacked area of composite must be very small as the surface contact to the tooth may cause the everstick to pull through the setting material ruining the temporary bridge.

You can't use a high speed bur to recontour acryllic temporaries as it will melt and warp the material.

When adjusting temporary crowns before insert, you should spin your disc so it polishes away from the margin as the material will melt and distort the margin.

A metal disc in a straight handpiece such as thie NTI diamond disc is useful for fine recontouring especially in the interproximal area in splinted crowns. You must provide room for the gingival papilla to grow into or you will end up with compressed papillae and a lot of bleeding at the insert appointment. A definite embrasure needs to be created in the interproximal area.