INTRODUCTION

Dentistry is the health science that encompasses the study and application of measures designed to prevent deterioration of the oral structures and the use of pertinent clinical procedures to improve the oral health of those treated. Among its many ramifications are the relief of pain, the treatment of oral disease, the maintenance of masticatory efficiency and the maintenance or restoration of the esthetics of the mouth and face. The word "rehabilitation" is derived from the Latin words re, meaning "again." and habilitare, meaning "suitable." Oral rehabilitation applies to all aspects of dentistry needed to make anatomy and physiology "suitable again." Oral rehabilitation implies a basic goal or objective that is achieved through examination, diagnosis, treatment planning, and treatment. Upon determining an accurate diagnosis, a sequence of coordinated multidisciplinary treatment procedures can be planned. According to the Glossary of Prosthodontic Terms-8, 2005, Mouth rehabilitation is the restoration of the form and function of the masticatory apparatus to as near normal as possible Goals.

REASONS FOR FMR The most common reason -obtain and maintain the health of periodontal tissues. Temperomandibular joint disturbance. Need for extensive dentistry(a) in case of missing teeth (b) worn down teeth and (c) old fillings that need replacement. Esthetics- in case of multiple anterior worn down teeth and missing teeth.

INDICATIONS Restoration of multiple teeth which are broken, worn, missing or decayed. Faulty dentition Discolored dentition Developmental defects Restore impaired occlusal function Preserve longevity of remaining teeth Maintain healthy periodontium

 Improve objectionable esthetics Eliminate pain and discomfort of teeth and surrounding structures. CONTRAINDICATIONS Malfunctioning mouths that do not need extensive dentistry and have no joint symptoms should be best left alone. Prescribing a full mouth rehabilitation should not be taken as a preventive measure unless there is a definite evidence of tissue breakdown. Hence it Should be conluded that NO PATHOLOGY- NO TREATMENT

GOALS FOR OCCLUSAL REHABILITATION The ultimate goal for every patient should be maintainable health for the total masticatory system. Seven specific goals should be the objective for patient care: I. Freedom from disease in all masticatory system structures 2. Maintainably healthy periodontium 3. Stable TMJs 4. Stable occlusion 5. Maintainably healthy teeth 6. Comfortable function 7. Optimum esthetics

Defined goals give purpose to treatment planning and make it possible to be highly objective. When the entire masticatory system is healthy and there is harmony of form and function, and the relationships are stable, the treatment can be said to be complete. GOALS-

Static coordinated occlusal contact of the maximum number of teeth when the condyle is in comfortable, reproducible position. An anterior guidance -in harmony with function in lateral eccentric position on the working side. Disclusion by the anterior guidance of all posterior teeth in eccentric movements Axial loading of teeth in CR, IP and Function OCCLUSAL APPROACH FOR RESTORATIVE DENTISTRY Confirmative Approach And Reorganized approach CONFIRMATIVE APPROACH Construct the restoration to conform to patients existing inter cuspal position 2 situations

1.Occlusion is untouched prior to tooth preparation although small changes can be made on restoration such as elimination of the non working contacts 2.Occlusion is modified by localized occlusal adjustmest before tooth preparation. elimination of working side interferences and removal of a deflective contact on tooth restored . Generally followed for small restoration REORGANIZED APPROACH Entire occlusal scheme in modified and restoration provided in harmony with new jaw relation so as to: 1.Provide a reproducible starting point i.e. centric relation position particularly when full mouth rehabilitation is required. 2.Provide an even, stable occlusion 3.Provide an occlusion that is in harmony with border movement 4.Ensure that pathologic deflective contacts are introduced. 5.Provide posterior stability to prevent anterior drifting. Indications for reorganizing the occlusion Existing IP is unacceptable and need to be changed.

Where a large amount of treatment is to be undertaken and operator has opportunity to optimize patients occlusion Conditions where ICP is considered unsatisfactory Repeated fractures or failures of teeth or restoration Bruxism Lack of interocclusal space for restoration Trauma from occlusion due to excessive or abruptly directed occlusal forces. Unacceptable function poor tooth to tooth contacts with tilting and over-eruption of teeth create problems with masticatory function. Unacceptible esthetics- alteration of clinical heightis necessary to improve esthetics. TMD Developmental anamolies e.g. amelogenesis imperfeta. Classification of patients requiring occlusal rehabilitation Classification by Turner and Missirlain (1984) The patients were classified into three categories

Category 1 - Excessive wear with loss of vertical dimension.

Category 2 - Excessive wear without loss of vertical dimension of occlusion but with space available. Category 3 - Excessive wear without loss of vertical dimension of occlusion but with limited space available CATEGORY -1

A typical patient in this category has few posterior teeth and unstable posterior occlusion. There is excessive wear of anterior teeth. Closest speaking space of 3mm and interocclusal distance of 6mm. there is some loss of facial contour that results in drooping of the corners of mouth. Patients with dentinogenesis imperfecta with excessive occlusal attrition, around 35 years of age and appearing prognathic in centric occlusion also belongs to this category.closest speaking space of 5mm and interocclusal distance of 9mm indicates there is loss of occlusal vertical dimension with concomitant occlusal wear. CATEGORY- 2 Patient has adequate posterior support and histoty of gradual wear. Closest speaking space of 1mm and interocclusal distance of 2-3mm. Continuous eruption has maintained occlusal vertical dimension leaving insufficient interocclusal space for restorative material. Manipulation of mandible into

centric relation will often reveal significant anterior slide from centric relation to maximum intercuspation. CATEGORY-3 Posterior teeth exhibit minimal wear but anterior teeth show excessive gradual wear over a period of 20-25 years. Centric relation and centric occlusion are coincidental with closest speaking space 1mm and interocclusal distance 2-3mm. It is most difficult to treat because vertical space must be obtained for restorative material. Classification by Breaker Group I

Class I Patients with collapse of vertical dimension of occlusion because of shifting of existing teeth caused by failure to replace missing teeth. Class II Patients with collapse of vertical dimension of occlusion because of loss of all posterior teeth in one or both jaws with remaining teeth in unsatisfactory occlusal relationship. Class III Patients with collapse of vertical dimension of occlusion because of excessive attritional wear of occlusal surfaces. Group II

Class I Patients with all or sufficient natural teeth present, with satisfactory occlusal relationship.

Class II Patients with limited teeth present but in satisfactory occlusal relationship requiring aid in the form of occlusal rims.

Group III Patients requiring maxillofacial surgery of orthodontic treatment as an aid in restoring the lost vertical dimension. Group IV Patients in whom sectional treatment is required over extended periods of time because of status of health of the patient, age or economic factor. Etiology of extremely worn dentition

Congenital abnormalities Amelogenesis imperfect and Dentinogenesis imperfecta

Parafunctional occlusal habit

Abrasion Erosion Loss of posterior support Diagnostic aids

The following aids should be used Medical history Dental history Behaviour evaluation

 Radiographs Complete mouth periapical radiographs and orthopentamograph Photographs colour of teeth and gingiva is recorded and photographs are necessary to recall to patients mind the state of his mouth prior to restorative dentistry. Clinical examination Diagnostic wax-up Computer imaging It is helpful to demonstrate the various treatment options. Computer aided image manipulation can be used to create the future appearance DIAGNOSTIC WAX UP Before diagnostic wax-up, the occlusal discrepancies in centric and eccentric occlusion should be eliminated. Diagnostic preparation of gypsum stone teeth that will require prospective crowns is carried out. This will reveal any resistance or retention form problems caused by short axial walls. Thus planning of subgingival margins or surgical crown lengthening required can be done. Then wax is used to appropriately shape all crowns and final prosthesis is planned. This diagnostic wax-up can be used to prepare an elastomeric putty mould and used for temporization or sectioned through long axis of tooth to act as reduction guide intra-orally.

TREATMENT PLAN Comprehensive treatment plan must be established prior to start of the treatment . Communication and patient education are essential in order to match the dentists and patients definition of success. Treatment plan is divided into 1) Pre- prosthetic phase 2) Prosthetic phase 3) Maintenance phase Pre-Prosthetic Phase

To develop proficiency in diagnosing the need of occlusal rehabilitation, periodontist , orthodontist , endodontist , oral surgeon and prosthodontist must all be integrated in establishing an environment conducive to oral health. PHILOSOPHIES OCCLUSAL SCHEMES GNATHOLOGICAL PHILOSOPHY

CRCP- IP coincident Canine guided lateral excursions Posterior disclusion in all excursion 1) movement of condyle in fossae determine occlusal form

 2)simutaneous contact of all posterior teeth in RCP with forces directed along long axis 3) in any excusive movement , canine should disclude the posterior teeth 4) If anterior guidance can not be provided, keep it as far forward as possible. 5) Lingual concavity of anterior teeth is determined by condylar guidance. 6) Wax up done on fully adjustble articulator. 7) Cusp fossa- tripod contact provided. Pankey- Mann Schuler Area of freedom between CRCP and IP (<0.5mm) Anterior guidance determine functionally. Anterior and lower posterior are restored FGP technique is used to assist waxing of upper posterior restoration Aim to have simultaneous contact of all posterior teeth. Absence of non working side contact Group function/ canine guidance on working side. Fully adjustable articulator is not required.

 Movement of teeth while making FGP compromised registration. Functionally generated path technique Described by Meyer 1933 It is a method of capturing in a usable way the precise border pathway that the lower posterior teeth follow. Border pathways of lower posteriors is dictated by 2 determinants Shape of occlusal surface of lower teeth has a profound influence. Advantages 1) Simple, inexpensive instrument. 2) Minimum chairside time 3) Relatively easy tech. to learn Hobo twin stage (theory of disclusion) A methodical approach two stage procedure. Occlusal morphology of posterior teeth reproduced without anterior segment- cusp angle coincident with standard value of effective cusp angle produced (conditon1). Secondly anterior morphology reproduced with anterior guidance provided which produced a standard amount of disclusion (condition 2)

TWIN STAGE PROCEDURE Condition 1: for fabrication of the cusp angulations 1. Remove anterior maxillary and mandibular segments 2. Adjust standard values of H=25, L=15, SIGA=25, FIGA=10 3. Wax up the occlusal morphology of the posterior teeth such that maxi and mandi teeth should contact each other thus creating balanced articulation and standard cuspal angulations Condition 2 for fabrication of anterior teeth 1. Reassemble the anterior segment of the cast. 2. Adjust the value of articulator as H=40,L=15, SIGA=45 and FIGA=20 3. Wax up the palatal contours of the maxillary anterior teeth such that anterior guidance should be established LONG CENTRIC The fit of the condyle into the disc is not like the fit of machine ball in bearing. Some front- back play is permitted by the disc that allows the condyles to hinge freely. So there will be a slight difference between the firm terminal hinge closure of centric relation and a light closure from rest position. LONG CENTRIC

defined as freedom to close the mandible either into centric relation or slightly anterior to it without varying the vertical dimension of occlusion.

This term is now referred to as Freedom in Centric

Area of freedom between CR, IP (0.5 +/- 0.3). All interference to terminal closure should be eliminated. If centric relation interference is present, path of closure will be dictated by the proprioceptors instead of the muscles. When interference in centric relation is eliminated by equilibration long centric will usually be provided automatically There is no relationship between the length of a slide and length of a long centric. Length of a slide is the result of interference of the teeth whereas long centric is dependant on anatomy of the condyle disc relationship and varying patterns of muscle activity in different individuals It should be clarified that : Long centric involves primarily the anterior teeth (posterior are disoccluded due to condylar guidance even with zero degree anterior guidance ) Long centric refers to freedom from centric not freedom in centric Nyman and Lindhe concept

 Used in advanced periodontal disease. Clinically hypermobility of teeth, unfavourable distribution of teeth. Bridge on such abutment teeth exhibit mobility But such bridge hypermobility can be tolrated, provided it does not exhibit increase with time or interfare with patients comfort or bridge function Such mobile bridge can further exagerrate the periodontal weaking but can be prevented by designing occlusion in such a way to obtain & maintain stability. Even and simultanuous contacts all over the dentition in ICP and excursion. If distal abutment teeth are missing in a cross arch bridge with increased mobility, balance and functional stability obtained by cantilever units. However cantilevers increased risk of failure. If increased mobility is not observed, balancing contacts on non working side should be removed. When bridge exhibit increased mobility- fulcrum identified, occlusion designed so that forces exerted by masticatory muscles meet the bridgework simultaneously with balanced load on both side of fulcrum

Youldelis concept For advanced periodontal cases. CR CP & IP concident (tripode concept) Simultaneous concept of posterior teeth in CR CP with forces through long axis of teeth. Anterior disclusion for protrusive and canine disclusion for lateral excursions. Lateral contact s are arranged such that if canine disclusion is lost through wear or tooth movement posterior teeth drop into group function. Foundation of a healthy periodontium is stressedemphasis placed on margin placement and crown contour. Useful where excursive function can not be controlled or canine compromised periodontically. Much information is gained from diagnostic temporary restoration. Both fully and semi adjustable articulators may be used. TREATMENT TECHNIQUES 1. Simultaneous restoration of both arches (Bailey, Grubb, Linkow) Advantages Disadvantages

Freedom in creating esthetic occlusal plane Freedom in occlusal scheme Freedom in intra-arch tooth spacing and interarch crown position Maximum freedom in creating and controlling porcelain esthetics

Arduous, unpredictable, patient visits Full arch anaesthesia

Increased chair time, full arch temporaries re

Multiple occlusal records, highly accurate cro impressions

Individual quadrants (Pankey, Mann, Dawson, Granger) Advantages Reduced chair time Disadvantages

Restriction for achieving ideal occlusion w altering occlusal plane

Sequential provisional restorations Quadrant anaesthesia Vertical Dimension is controlled Impression procedures are easier

Less freedom in controlling porcelain aest

PROSTHETIC PHASE Prosthetic full mouth rehabilitation is divided into1. Immediate treatment 2. Definitive treatment Immediate treatment In some cases like amelogenesis imperfecta in a child, postponing treatment until adulthood may cause adverse psychological effect and impair correct relationship between maxillary and mandibular teeth. Preformed nickel-chromium crowns are placed on first permanent molars and second deciduous molars to stabilize occlusion and halt attrition. Vertical dimension is not altered. As anterior teeth and premolars erupt, polycarbonate resin crowns are given. Second molar is fitted with nickel crown to preserve vitality. After all permanent teeth are erupted, these restorations serve as transitional treatment until adulthood. Definitive treatment Once all teeth have erupted and adulthood is reached, the size of pulp horns decreases compared to newly

erupted teeth. A definitive treatment can then be planned. Selection of instruments for full mouth rehabilitation Articulators

Awni Rihani has classified articulators as-

Fully adjustable articulator Non- adjustable articulator The two basic types if semi adjustable articulators are Arcon type Non-arcon type Semi-adjustable articulator cannot record the full range of protrusive and lateral condylar movement but mechanical equivalent of tooth movement can be recorded with much accuracy if instruments shortcomings are compensated. The instruments shortcomings are compensated with

1. Customized anterior guidance 2. Simplified fossae contour technique to relate lower fossae form to anterior guidance Functionally generated path procedures to capture the precise border movements of posterior teeth at correct vertical dimension

Facebow selection

There is a definite three dimensional relationship between the maxillary arch and the condylar motion to record this spatial relationship to the opening and closing axis of the articulator, a facebow is used. A facebow is a caliper-like device that is used to record the relationship of the jaws to the TMJ and to orient the same relationship to the opening axis of the articulator.

Vertical relation consideration for full mouth rehabilitation When fixed prosthodontic treatment is indicated for all teeth in one or both arches, the dentist must evaluate the existing vertical dimension of occlusion. There has never been a scientific, practical and accurate method by which vertical dimension of the patient could be recorded

Classic techniques have been used to determine the vertical dimension of occlusion like phonetics, interocclusal distance, facial soft tissue contour, cephalometrics,

 electromyography and patients neuromuscular perception. CAN VERTICAL DIMENSION BE ALTERED?

Sicher(1949) and Silverman(1952). They concluded that as the teeth wear or become abraded, the teeth and alveolar bone elongate through growth to maintain the original vertical dimension with the maintenance of the same closest speaking space. However, occlusal wear may occur more rapidly than continuous eruption depending upon the etiology of the wear. Harry Kazis and Albert Kazis:

stated that treatment of reduced vertical dimension is not designed to increase the vertical dimension beyond the normal, but is intended to restore the amount of vertical dimension that has been lost. A young person will tolerate a greater correction of vertical dimension and become adjusted more easily to a reduction in the interocclusal distance as necessitated by the changes.

Dawson(1974) even when the teeth have grown down to the gum line the vertical dimension is not lost because of the eruption of the teeth along with the alveolar bone. Increase in vertical dimension interferes with the

optimum length of the resting muscles which serve as a stimulus to produce hypertonicity. Closing the vertical dimension does not interfere with muscle lengths. When it is not practical to restore severely worn dentition without restoring the vertical dimension to obtain space for the restorative material, the dimension can be increased to 1-1.5 mm. The potential problems of restoring the vertical dimension are clenching, muscle fatigue, soreness of teeth, muscles and joints, headache, intrusion of teeth, fracture of porcelain , occlusal instability due to shifting of restored teeth and continual wear. In such cases, checking and periodic occlusal adjustment must be done upto a year before normal stability returns.

Methods of obtaining space for restoring worn teeth The process of eruption and alveolar development may contribute throughout life as teeth are worn because of addition of layers of cementum and vertical development of alveolar bone. Posterior teeth that interfere, deflect the mandible forward and cause excessive wear on upper anterior lingual incline. Interferences should be eliminated by selective grinding so that mandible can close at

centric relation without forward deviation to the same vertical dimension

Dahl Appliance anterior teeth.

- If wear is localized eg. Upper Possible esthetic and pulpal

Grind opposing teeth problems

Restore the lost vertical dimension _ Indicated only if majority of posterior teeth need full coverage restorations Distalize Mandible - Extensive occlusal adjustment needed to eliminate slide from RCP- ICP ( retruded axis position to intercuspal position) Only if large anterior slide present Crown Lengthening - May be required to increase axial wall height to aid in crown retention Extraction or required _ Rarely indicated but may be where gross over-eruption

Surgical Repositioning has occurred

Tests for checking the patient tolerance to the new OVD : 1. Splints 2. Temporaries SPLINTS

Permissive splint Have smooth surface on one side that allows the muscles to move the mandible in the centric relation without interference . Generally used. E.g. Stabilization appliance

Directive occlusal splint Direct the lower arch into a specific o relationship . They are mainly useful treatment of TMDs e.g. anterior repositioning split

Temporary restorations Provisional restorations generate specific information regarding functional and esthetic requirement of definitive restorations. Protect the pulp of prepared teeth from external irritants. Proper contour and adaptation maintain periodontal health. Provide positional stability of prepared teeth in elation to adjacent and opposing teeth. Evaluate esthetics and phonetics. Occlusion can be checked on the temporaries. Re-establish the vertical dimension of occlusion in extremely worn dentition. The functions of provisional restorations are

 It is a reversible treatment appliance and can be adapted to patients own neuromuscular limitation. Customized incisal guidance can be created with the help of provisional restorations. Thus horizontal and vertical overlap can be duplicated in subsequent prosthesis. Short term temporary restorations:- intraoral technique, chairside, coldcure acrylic. Long term temporary restorations:- indirect technique, heat cure acrylic resin, composite resin EQUILIBRATION PROCEDURES They can be divided into four parts Eliminating interference to terminal hinge axis closure Eliminating interference to lateral excursions Eliminating posterior tooth interferences with protrusive excursions. Harmonization of anterior guidance. Determining plane of occlusion Pankey- Mann Schuyler method accomplishes the following 1) Determine plane of occlusion 2) Determine the amount of tooth reduction

 3) Simple transfer to mouth 4) Help in laboratory wax-up to determine cusp height 5) Determine cusp height in restoration 6) Select the type of occlusal scheme ANTERIOR GUIDANCE The correct relationship of the upper and lower teeth is so critical that differences of a millimeter in the incisal edge position can feel grotesque to the patient. Along with esthetics and function of mastication, anterior teeth have a very important job of protecting the back teeth. The dynamic relationship of the lower anterior teeth against the upper anterior teeth through all the ranges of function is called anterior guidance. Steps in harmonizing anterior guidance 1. Establish coordinated centric relation stops 2. Centric stops in a postural position must have the same vertical dimension as those for centric relation 3. Refine protrusive excursions 4. Establish ideal anterior stress distribution in lateral excursions.

5. Check lateral protrusive movements 6. Smooth transition to a crossover position. Concepts of occlusion 1. Gnathological concepts of occlusion, point centric concept of occlusion.(Stuart and Stallard,1960) 2. Long centric occlusion.(Dawson, 1978) 3. Cuspid protected occlusion.(Schuyler) 4. Group function. (Schuyler) 5. Mutually protected occlusion. (Stuart and Stallard,1957) 6. Organic occlusion. (Stuart) 7. Anterior protected occlusion. (Dawson) SELECTION OF OCCLUSAL SCHEME The factors to be considered in restoring occlusal surfaces are Number of teeth contributing for occlusal support Material of occluding surface Type of occlusal scheme Parafunctional habits. Procedural steps in restoring occlusion Two best rules

1. Never begin any restorative procedure unless all the procedures that follow are outlined in advance and properly related to one another in correct sequence 2. Never begin any restorative procedure unless the result is visualized and understood. PRELIMINARY MOUTH PREPARATIONS Restorative procedures are the last step 1) Mouth hygiene instructions 2) Caries control 3) Periodontal therapy 4) Minor tooth movement 5) Necessary extractions 6) Equilibration TMJ should be comfortable before finalization of any restorative treatment. CASESRestoring all upper posterior teeth only Steps : 1. Preliminary mouth preparation 2. Selective grinding 3. Prepare all upper posterior 4. Correctness of anterior guidance should be verified and modify

5. If canine guided- set condylar path at 20degrees complete wax up 6. Or complete the restoration on fully adjustable articulator out of excursion 7. For group function- use FGP 8. Place posterior restorations and do necessary modifications

CASE-2 Restoring all upper but no lower teeth 1. Preliminary mouth preparation 2. Selective grinding of lowers 3. Prepare upper posterior 4. Correct anterior guidance 5. Do alternate tooth preparation in anteriors and make throw-away patterns 6. Centric record, articulate lower cast with first upper cast 7. Customize guide table 8. Articulate final cast 9. Duplicate anterior restorations by using throw- away patterns

10.

Replace upper posteriors as described

11. Reevaluate disclusion and guidance and do necessary corrections in patients mouth CASE- 3 Restoring all posterior but no anterior 1. Preliminary mouth preparation 2. Broadrick occlusal plane analysis 3. Prepare lower teeth accordingly 4. Harmonize anterior guidance 5. Complete lower wax patterns and restorations 6. Place lower restorations 7. Prepare upper posteriors 8. Complete upper posterior restorations (FGP) 9. Remove balancing contacts 10. Redefine working contacts

CASE-4 Restoring all lower teeth but no upper teeth 1. Preliminary mouth preparation 2. Redefine interferences in the upper arch a. correct marginal ridges b. equilibrate occlusion

c. harmonious anterior guidance 4. Every other lower anterior tooth should be prepared, through away patterns 5. CR record with ant. teeth in contact 6. Remaining teeth should be prepared 7. Articulate working cast 8. Place through away patterns 9. By using this guide prepare lower ant restorations 10. 11. 12. Prepare and place posterior restorations Remove balancing contacts Redefine working contacts

CASE-5 Preparing all upper teeth and lower posterior teeth only 1. Preliminary mouth preparation 2. Restablish anterior guidance 3. Prepare every other maxillary ant tooth 4. Place through away wax pattern 5. Prepare all anterior teeth 6. Establish predetermined anterior guidance

7. Prepare mandibular posteriors 8. By using brodrick occlusal plane analyse establish occlusal plane 9. complete lower restorations 10. 11. 12. 13. Prepare maxillary posteriors Establish desired occlusion (FGP) Place all restorations Redefine balancing and working side contacts

CASE-6 PREPARING ALL UPPER AND LOWER TEETH 1. Preliminary mouth preparation 2. Prepare lower anterior teeth 3. If the anterior relation is acceptable, prepare the lower wax patterns against unprepared maxillary ant 4. If unacceptable relation, reestablish the anterior guidance 5. Place provisional restorations in the redefined anterior guidance 6. Complete the lower restorations by exactly duplicating the incisal edge position of provisional restorations 7. Place lower restorations against upper provisionals to verify the ant guidance

8. Prepare and restore upper anterior teeth (exactly duplicate the pattern of provisionals) 9. Place upper anterior restorations 10. Refine the anterior guidance.

11. Prepare lower posterior teeth by taking guidance of Broadrick occlusal plane analyzer 12. 13. Reestablish the occlusal plane. Complete lower posterior restorations

14. Complete upper posterior restorations accordingly 15. Refine centric, working and nonworking contacts

REMOUNTING Remounting is a procedure whereby restorations are accurately related to each other and to masticatory mechanism for the purpose of minute refinement of various surfaces. It enables us to observe with accuracy just how the restorations are working. SPLINTING A splint is a rigid or flexible appliance for the fixation of displaced or movable parts. Splinting is joining of two or more teeth into a rigid unit by means of fixed or removable restoration The purpose of splints are 1) To stabilize the temperomandibular joint

 2) To improve function of masticatory system 3) To reduce abnormal muscle activity 4) Protect teeth from attrition 5) Prevent mobility due to traumatic loading 6) Alter occlusal forces Splints provide the benefits on the following rationale Redirection of stresses Redistribution of stresses Prevention of migration Prevention of supraeruption Stabilization of tilted teeth Stabilization and strengthening of abutments Maintenance phase After placement and cementation of a prosthesis the patient treatment continues with carefully structured sequence of follow-up appointments to monitor the dental health, stimulate meticulous plaque control habits, identify incipient disease and introduce any corrective measures if required. Adequate scaling is done periodically to maintain gingival health. Margins of restoration must be evaluated to detect secondary caries. Oral hygiene aids prescribed are tooth brushes,

oral floss, interdental rush, oral irrigation devices and oral rinses. Recall schedule After maintaining adequate oral hygiene, patient is recalled at 1 month, 3 months, 6 and 12 months. After 1 year patient is recalled annually for check-up and prophylaxis