by Dr. Sim Tang Eng
Full mouth rehabilitation involves the restoration of most of the teeth, if not all the teeth, in both the upper and lower jaws. If the situation allows and the treatment plan so indicates, the restoration can also involve only one jaw, either the upper or the lower jaw.
Because the extensive restoration of the teeth often positively impacts on the facial appearance of patients by restoring facial heights and giving the patients fuller lips, full mouth rehabilitation is also referred to as 'non-surgical facelift' or 'smile makeover'.
The procedures, if properly indicated and performed, do indeed make patients look younger and rejuvenated, besides restoring chewing function and enhancing smile aesthetics. However, not everybody is a candidate for this procedure. If not properly indicated, the results can be catastrophic, to say the least.
Below are the most common reasons for carrying out full mouth rehabilitation.
Extensive wear or attrition affecting almost all the teeth in the mouth due to bruxism, which is nocturnal parafuntion grinding of teeth. This wearing down of teeth can be so severe that the teeth can be shortened significantly, sometimes even causing the exposure of the pulp (tooth nerve), which may make root canal therapy necessary.
The facial height or length of face is partly determined and maintained by the presence of upper and lower teeth. Shortening of the teeth due to wear and tear causes the lower jaw to come closer to the upper jaw, thereby causing a shortening of the lower third of the face.
This can actually give rise to an aged appearance. The attrition of the upper front teeth also results in an absence of tooth display when the lips are slightly parted, as in speech or during smiling. This gives an impression or illusion that the patient is without his or her front teeth.
In fact, it is often this aesthetic concern that motivates the patient to seek consultation and treatment. In this situation, full mouth rehabilitation not only addresses the issue of restoring lost tooth structure and function, but also improves the facial profile and smile aesthetics of the patient.
Severe wear of teeth can also be caused by medical problems such as bulimia nervosa and gastroesophageal reflux disease. Both medical conditions result in chemical erosion of the teeth, particularly the palatal surfaces of the upper teeth, due to the reflux of gastric acid. The tooth wear is made worse if the patient also suffers from bruxism.
The effects of this type of tooth wear on facial profile and smile aesthetics are similar to those caused by bruxism. In order to protect the tooth structure from further destruction by gastric acid reflux, the ideal restoration involved in full mouth rehabilitation for this type of tooth wear will be full coverage ceramic crowns.
Ceramic veneers, which cover only the facial surfaces of the teeth, are not suitable as the palatal surfaces will continue to be attacked by acid erosion. The patient must also be treated medically by the appropriate medical specialists.
Loss of Teeth
Early loss of posterior teeth or molars that are not replaced often results in collapse of the bite. The occlusal loading or biting force which concentrates on the remaining front teeth often results in excessive wear or even affects mobility of these teeth.
In such cases, the patient will require full mouth rehabilitation to restore the missing posterior teeth with either bridges or implants and the front teeth will need to be restored to normal function with either crowns or veneers.
Painful conditions of the temporomandibular joint (TMJ), jaw muscles, and even headaches can result from poor occlusion (bite) due to excessive tooth wear.
Full mouth rehabilitation is sometimes carried out electively to improve the aesthetic appearance of the smile. In such cases, the procedure is usually referred to as a smile makeover, usually to address :
1. Dark tetracycline-stained teeth that are resistant to tooth bleaching or whitening.
2. Slight spacing or gaps between teeth due to hypodontia (congenital absence of several teeth) or early loss of some teeth, resulting in shifting or movement of the adjacent teeth.
3. Mild crowding or mal-position of the teeth
4. An uneven smile line due to a slanting or canted occlusal plane (horizontal plane of teeth arrangement when patients are viewed face on).
It must be pointed out that full mouth rehabilitation involves multiple phases. First of all, a thorough examination of the mouth is carried out. Your dentist will take note of the condition of existing teeth, especially the wear patterns, in order to ascertain the cause of the wear.
Your gum will also be evaluated and assessed for the presence of any gum disease. Any tooth decay and gum disease must be treated first before embarking on full mouth rehabilitation.
Radiographs are an integral part of the examination to assess the health of the roots of teeth, the supporting alveolar bone, and also the TMJ. Any hidden pathology of the jaw bone and hidden decay in between the teeth can easily be detected on radiographs as well.
A thorough analysis of your occlusion (the way your upper and lower teeth bite together while at rest and during function) has to be done. Impressions of your teeth will be made to produce models of your jaws. Your bite pattern and jaw relationships will also be recorded using a specialised instrument called a face-bow.
These records will then be used to mount your jaw models in the correct spatial position relative to your face on a special device called an articulator, which is a mechanical instrument used to simulate jaw movements.
With this done, we have your jaw models that move in almost the same manner on the articulator as your jaws do in your mouth. This way, a very detailed analysis of your occlusion and problems can be done, and an appropriate comprehensive treatment plan can be formulated.
A diagnostic mock-up of the final ideal occlusion and teeth arrangement will also be done on the mounted models on the articulator. That will form the blueprint of the entire treatment, much like an architectural drawing for a proposed building.
Photographs, both intra-oral and extra-oral, also aid in the treatment plan. Proper diagnosis and treatment planning is key to the eventual success of the treatment. The treatment plan may call for an inter-disciplinary approach with referrals to an orthodontist, oral surgeon, and endodontist.
As such, full mouth rehabilitation may involve multiple treatment stages and may take from a few months up to even a year or more in complicated cases. In cases that involve painful TMJ and jaw muscles, the patient may need to undergo bite readjustment by wearing a plastic bite splint to reposition the jaws to the optimal position before commencing on the actual treatment.
If your request is for a smile makeover, your dentist will need to address your specific concerns and expectations, besides carrying out the detailed examination and bite pattern analysis described above.
A proper interview is vital to assess whether the patient's expectations are realistic and achievable. You have to bear in mind that a smile makeover is an elective procedure which, unfortunately, involves invasive preparation of most, if not all, teeth in the mouth. Therefore, unless it can achieve the objectives you expect, you have to consider this option very carefully.
Since full mouth rehabilitation involves the preparation of all the teeth in the mouth, the patient's original bite pattern or occlusion will be lost with the removal of the biting surfaces of the teeth. A new occlusal scheme as determined by the diagnostic mock-up will be incorporated into the treatment to ensure that the patient will end up with a proper bite when they receive their new ceramic restorations.
A very common problem faced by patients who have undergone such extensive treatment is the inability to bite and eat properly for many months. While some patients with better adaptive ability and robust TMJ eventually overcome the problem, there are also a few who need to have the whole treatment redone.
Therefore, behind the facade of the perceived nice set of new teeth, the central issue in full mouth rehabilitation and smile makeover is proper management of occlusion and biology of teeth and gums.
Not only should you look good immediately after the new white crowns and veneers are cemented, but the results must be long-term and the treatment should not adversely affect the health of your teeth, gums, and TMJ.
It is very easy to get excited and carried away when your dentist promises you a 'winning smile' because it is such an emotional thing, but it would be wiser for you to seek a second or even third opinion as to whether you should proceed with the treatment.
The last thing you want is to have your 'winning smile” turn into 'waning smile' because of a wrong diagnosis, improper treatment plan, and lack of the required clinical skills to carry out such a demanding treatment.
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