6 Philosophies in Full Mouth Rehabilitation a Systematic Review

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Int J Dent Case Reports 2013; 3(3): 30-39© IJDCR 2013. All rights reserved

www.ijdcr.com

PHILOSOPHIES IN FULL MOUTH REHABILITATION – A S YSTEMATIC REVIEW

Bharat Raj Shetty1, Manoj Shetty

2, Krishna Prasad D.

3, S. Rajalakshmi

4, Raghavendra Jaiman

5

1Lecturer, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka,

India

2Professor, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,

Karnataka, India

3Professor & HOD, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,

Karnataka, India

4P.G. Student, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,

Karnataka, India

5P.G. Student, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,

Karnataka, India

Address for Correspondence

Dr. Manoj Shetty

Professor

Department of Prosthodontics

A.B. Shetty Memorial Institute of Dental Sciences

Mangalore, Karnataka, India

Email i d : [email protected]

Contact: 09845267087

ABSTRACT

Complete mouth rehabilitation is a dynamic functional endeavour and it embodies the correlation and integration of

all component parts into one functioning unit. Over time have evolved various concepts and philosophies to attain

reconstruction and rehabilitation of the entire dentition, satisfying all the related factors. This case series describes

cases requiring full mouth rehabilitation treated following Twin Table Philosophy and Twin Stage Philosophy by

Sumiya Hobo and Pankey Mann Schuyler Philosophy considering the requirements of the rehabilitation. It also

describes briefly the principle behind each philosophy as well as the various pros and cons of each and its

application in various scenarios.

Keywords: hobo; full mouth rehabilitation; pankey- mann

mailto:[email protected]






Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation

31

Int J Dent Case Reports Nov-Dec 2013, Vol.3, No. 3

INTRODUCTION

As the goal of medicine is to increase the life span of

the functioning individual, the goal of dentistry is to

increase the life span of the functioning dentition.

Dentistry uses its knowledge, skill and all the

resources at its command in both maintenance work

and rehabilitation to achieve its goal. (1) Occlusal

rehabilitation is defined as the restoration of

functional integrity of dental arch by the use of

inlays, crowns, bridges and partial dentures.

Successfully treating patients requires a thoughtful

combination of many aspects of dental treatment such

as patient education, sound diagnosis, periodontal

therapy, operative skills, occlusal considerations,

endodontic treatment and achieving harmony

between the TMJ and occlusion. The aim is to res tore

the tooth to its natural form, function and esthetics

while maintaining the physiologic integrity in

harmonious relationship with the adjacent hard and

soft tissues, all of which enhance the oral health and

welfare of the pat ient.

To summarize, the goals to be attained are:

1.

Freedom from disease in all masticatory

system structures

2. Maintainable healthy periodontium

3. Stable TMJs

4. Stable occlusion

5. Maintainable healthy teeth

6. Comfortable function

7. Optimum esthetics

INDICATIONS FOR FULL MOUTH

REHABILITATION

The primary indications for rehabilitation of the

entire dentition are:

1. The restoration of multiple teeth which are

miss ing, worn, broken down or decayed.

2. To replace improperly designed and

executed crown and bridge framework.

3.

Treatment of temporomandibular disorders

is also advised, though caution is advised.

Reorganization of the occlusion can be considered if

the existing intercuspal position can be considered

unsatisfactory for various reasons - Repeated failure

or fracture of teeth or restorations, Severe attritional

wear, Lack of interocclusal space for restoration,

Affected dentition, Unacceptable function,

Unacceptable esthetics, Sensitive teeth, Painful

musculature due to disharmony between occlusion

and TMJs .

BIOLOGICAL CONSIDERATIONS DURING

OCCLUSAL REHABILITATION (9, 10, 11)

To attain the various goals of full mouth

rehabilitation, certain biological considerations are

necessary along with the indicated conditions.

Adoption of an alternative strategy by establishing a

new occlusal scheme around a stable condylar

pos ition (termed ‘centric relation‘) should be

considered. The decision to reorganize the occlusion

in a patient is done only after a detailed and careful

examination of the occlusion using study models etc.

The discrepancies between centric relation and

maximum intercuspation position should be analyzed

as vertical, horizontal and lateral components both at

tooth and condylar level. The occlusal vertical

dimension should be determined by utilizing the

phys iologic rest position of the mandible as a guide

and noting the existing freeway space. The effects of

occlusal pattern on the periodontal structures should




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also be assessed as attaining optimal periodontal

health is also an objective of the s ame. A s tudy of the

temporomandibular joint positions relative to the

occlusal pattern by means of roentgen graphic

evaluation and the effects of materials used on

occlusal stability control of parafunction and

temporomandibular disorders is necessary.

FUNCTIONAL ASPECTS OF FULL MOUTH

REHABILITATION (10)

Complete mouth rehabilitation is a dynamic

functional endeavour and it embodies the correlation

and integration of all component parts into one

functioning unit. The aim, therefore, must be

reconstruction and rehabilitation of the entire

dentition, satisfying all the related factors. The

science of complete mouth rehabilitation rests upon

three proved and accepted fundamentals:

1.

The existence of a physiologic rest position

of the mandible, which is a constant.

2. The recognition of a vert ical dimension

3.

The acceptance of a dynamic, functional

centric occlusion

PHILOSOPHIES FOLLOWED IN FULL MOUTH

RECONSTRUCTION

One of the most practical philosophies is the rationale

of treatment that was originally organized into a

workable concept by Dr. L.D. Pankey utilizing the

principles of occ lusion espoused by Dr. Clyde

Schuyler. (5)

Schuyler’s principles were : (4)

1. A static co-ordinated occlusal contact of the

maximum number of teeth when the

mandible is in centric relation.

2. An anterior guidance that is in harmony with

function in lateral eccentric position on the

working side.

3. Disclusion by the anterior guidance of all

posterior teeth in protrusion.

4. Disclusion of all non-working inclines in

lateral excursions .

5.

Group function of the working side inclines

in lateral excursions.

In order to accomplish these goals, the following

sequence is advocated by the PMS philosophy:

1. PART I : Examination, Diagnosis,

Treatment planning and Prognosis

2. PART II : Harmonization of the anterior

guidance for best possible esthetics ,

function and comfort

3. PART III: Selection of an acceptable

occlusal plane and restoration of the lower

posterior occlusion in harmony with the

anterior guidance in a manner that will not

interfere with condylar guidance.

4.

PART IV: Restoration of the upper posterior

occlusion in harmony with the anterior

guidance and condylar guidance. The

functionally generated path technique is so

closely allied with this part of the

reconstruction. (2, 3)

Advantages of the Pankey Mann Schuyler technique:

(5)

1.

It is possible to diagnose and plan the

treatment for entire rehabilitation before

preparing a s ingle tooth.

2. It is a well- organized logical procedure that

progresses smoothly with less wear and tear

on the operator, patient and technician.




33


3. There is never a need for preparing or

building more than 8 teeth at a time.

4. It divides the rehabilitation into separate

series of appointments. It is neither

necessary nor desirable to do the entire case

at one time.

5. There is no danger of getting at sea and

losing patient’s vertical dimension. The

operator always has an idea where he is at

all times.

6. The functionally generated path and centric

relation are taken on the occlusal surface of

the teeth to be rebuilt at the exact vertical

dimension to which the case will be

reconstructed.

7. All posterior occlusal contours are

programmed by and are in harmony with

both condylar border move ments and a

perfected anterior guidance.

8. There is no need for time consuming

techniques and complicated equipment.

9. Laboratory procedures are simple and

controlled to an extremely fine degree by the

dentist.

10. The PMS philosophy of occlusal

rehabilitation can fulfill the most exacting

and sophisticated demands if the operator

understands the goals of optimum occlusion.

CASE REPORT

A healthy 18 year old female patient reported to the

Department of Prosthodontics with a chief complaint

of discolored teeth. On clin ical examination, ch ipping

of enamel was seen with respect to most teeth with

exposure of dentine. Generalized attrition was

observed with respect to all the occlusal surfaces.

Utilizing phonetics and esthetics as a guide, 2 mm

decrease in vertical dimension was observed.

Radiographic examination revealed no requirement

of endodontic therapy for any teeth. It was diagnosed

to be a case of Amelogenisis imperfecta where

generalized attrition was observed with a decrease in

vertical d imension of 2 mm. Full mouth rehabilitation

pertaining to the principles and goals of Pankey

Mann Schuyler philosophy was planned.Maxillary

and man dibular diagnostic casts were mounted onto

a Whip mix (Arcon) articulator using facebow

records. Anterior wax up was done to appropriate

shape, size and contour. Mandibular occlusal plane

was analysed using Broadrick’s occlusal plane

analysis. This was followed by maxillary occlusal

wax up to maximum intercuspation. Anterior wax up

was checked for proper anterior guidance to achieve

disclusion in eccentric movements. A splint was

fabricated with an increase in vertical dimension of 2

mm to be worn by the patient for 6 weeks. The

mandibular anterior teeth were prepared first.

Following impression, temporization of the prepared

teeth was done at a raised vertical dimension. In

order to maintain the increase in VD, the mandibular

posterior also had to be prepared in order to prevent

posterior open bite. An impression was made and

temporization of the mandibular posterior teeth was

done. This was followed by fabrication of porcelain

fused to metal crowns for the mandibular anteriors.

Cementation of the crowns was done using glass

ionomer cement. The maxillary anterior teeth were

prepared next. Centric relation was recorded at the

proposed vertical dimension and casts were mounted

in the same relation. PFM crowns were cemented.

The mandibular posterior teeth preparations were

refined and impressions made. Inclines of wax

patterns were carved us ing foss a contour guide. The

porcelain crowns fabricated were subject to occlusal




34


plane verification and then cemented. This is

followed by preparation of maxillary posteriors. Wax

patterns are fabricated for the same. And posterior

disclusion is checked by keeping the condylar

guidance shallower than the patient’s. Fab rication

and cementation of the crowns are done.( Figure 1, 2,

3)

Figure 1:

a)

Pre operative photograph of Case – 1 to be

treated by Pankey Mann Schuyler technique

b) Broadrick’s occlusal plane analysis

c)

Tooth preparation of lower anteriors

completed

d) Provisionalization of lower anterior teeth.

Figure 2:

a) Transfer of cusp to fossa relationship

b) Fabrication of fos sa guide

c) Wax preparation of the mandibular

posteriors us ing fossa guide

d)

Re- establishment of occlusal plane with

Broadrick’socclusal plane analys is

HOBO ‘S TWIN TABLE PHILOSOPHY (6,7)

Another philosophy was given by Dr. Sumiya Hobo

which is followed in rehabilitation of dentate

patients. He proposed Twin table concept which

developed anterior guidance to create a pre-

determined, harmonious disclusion with the condylar

path. The technique utilizes 2 d ifferent cus tomized

incisal guide tables. The first incisal table is termed

incisal table without disclusion. It is fabricated by

preparing die systems with removable anterior and

posterior segments . This table he lps us achieve

uniform contacts in the posterior restorations during

eccentric movements. The other incisal table is made

when the articulator can simulate border movements

by placing 3 mm plast ic separators behind the

condylar elements. This is termed the incisal

guidance with disclusion. The first incisal guide table




35


is used to fabricate restorations for posterior teeth.

The second guide table is used to achieve incisal

guidance with disclusion.

Figure 3

a) Disocclusion of posterior teeth on lateral

excursive movements

b) Post operative photograph of full mouth

rehabilitation using Pankey Mann Schuyler

technique.

CASE REPORT:

A 44 year old healthy male reported to the

Department of Prosthodontics with a complaint of

worn out, sensitive teeth and difficulty in chewing. It

was diagnosed to be a case of severe generalized

attrition and abrasion and a treatment plan was

formulated to rehabilitate the dentition using

Hobo’stwin table technique. Pre-operative

radiographic evaluation indicated endodontic

treatment for certain teeth, which was treated.

Diagnostic casts were mounted using facebow

records onto a semi adjustable articu lator (Whip mix-

Arcon). Occlusal plane was evaluated using

Broadrick’s occlusal plane analysis. Using phonetics

and freeway space as a guide, the vertical dimension

was evaluated. The need to increase the vertical

dimension by 4 mm was seen and an overlay splint at

the raised vertical dimension was cemented. This was

followed by preparation of maxillary and mandibular

teeth. The casts are mounted onto the articulator

using facebow transfer. As explained in the concept,

an incisal table without disclusion was made without

anterior guidance. The wax patterns were fabricated

for the posterior teeth to achieve uniform contacts.

The incisal table with disclusion was fabricated next

by using 3 mm acrylic s eparators behind the condylar

elements. Disclusion of 0.5 mm was achieved on the

working side and 1 mm is achieved on the non-

working side. This is done for each condylar element

one at a time and protrusive movement by placing

separators behind both condylar elements. Once the

incisal table is refined, the metal copings are

fabricated and try in of the same is done. This is

followed by ceramic build-up of the copings and

cementation after analysis of the eccentric and centric

move ments . (Figure 4, 5, 6)

Figure 4

a) Pre operativephotograph of Case 2 to be

treated by Hobo’s Twin Table technique

b) Occlusal plane established using

Broadrick’socclusal plane analysis

c) Maxillary full arch tooth preparation

completed.

d) Facebow transfer recording

HOBO’ S TWIN STAGE PHILOSOPHY (8)




36


Dentists have tried for years to prevent harmful

horizontal occlusal forces on teeth caused by

mandibular eccentric movements. The pantograph

and fully adjustable articulators are results of their

efforts. During development, the concept that focuses

on the condylar path as the reference of occlusion

was utilized. This concept was derived from the

belief that condylar path was unchangeable in the

liv ing body whereas anterior guidance could be freely

changed by the dentist. But the condylar path has

been shown to have deviation and minimal influence

on disocclusion arising questions on the validity of

the concept. The deviation of the incisal path is less

than that of condylar path. However, when individual

variation and the occurrence rate of malocclusion is

incorporated, the incisal path would not be a reliable

reference for occlusion. Thus the cusp angle was

considered as a new reference for occlusion. Though

independent of condylar path as well as incisal path,

a standard value for cusp angle was determined such

that it may compensate for wear of natural dentition

due to caries, abrasion and restorative works.

STANDARD VALUES OF EFFECTIVE CUSP

ANGLE ON MOLARS

CUSP ANGLE CUSP ANGLE ON

MOLARS

Sagittal protrusive

effective cusp angle

25

Frontal lateral effective

cusp angle (working

side)

15

Frontal lateral effective

cusp angle (non

working s ide)

20

Table 1: Standard values of effective cusp angle on

molars as advocated in Hobo’s Twin Stage

philosophy:

Basic concept of twin stage procedure:

In order to provide disocclusion, the cusp angle

should be shallower than the condylar path. To make

a shallower cusp angle in a restoration, it is necessary

to wax the occlusal morphology to produce balanced

articulation so the cusp angle becomes parallel to the

cusp path of opposing teeth during eccentric

movement. Since anterior teeth help produce

disocclusion, when a dental technician waxes the

occlusal morphology and tries to reproduce a

shallower cusp angle, the anterior portion of the

working cast becomes an obstacle. Also, when

fabricating the anterior teeth to produce disocclusion,

some guidance should be incorporated. In this

methodical approach described by Hobo, a cast with

a removable anterior segment is fabricated.

Reproduce the occlusal morphology of the posterior

teeth without the anterior segment and produce a

cusp angle coincident with the standard values of

effective cusp angle (Referred to as ‘Condition’).

Secondly, reproduce the anterior morphology with

the anterior segment and provide anterior guidance

which produces a standard amount of disocclusion

(Referred to as ‘Condition 2’) .




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Figure 5

a) Recording of interocclusal centric relation

using Aluwax

b) Mounting of the prepared models using

facebow transfer and interocclusal record

c) Condylar insert of 3 mm placed behind the

condylar elements to achieve disclusion of

posterior teeth.

d) Disclusion of 1 mm achieved on the non-

working s ide

Contraindications:

1. Abnormal curve of Spee

2. Abnormal curve of Wilson

3. Abnormally rotated teeth

4. Abnormally inclined teeth

Case report:

A healthy 38 year old patient reported to the

Department of Prosthodontics with a chief complaint

of excessive tooth wear. Panoramic radiograph

indicated endodontic treatment and restoration with

post and core for few teeth. Once endodontic therapy

was completed, Full mouth rehabilitation following

Hobo’s Twin stage philosophy was proposed as the

treatment of choice. Diagnostic casts were mounted

onto a Whipmix articulator using facebow transfer

and interocclusal records. Diagnostic wax up was

done increasing the vertical dimension by 4 mm.

Figure 6

a) Condylar inserts inserted behind condylar

elements

b) Preparation of wax patterns

c)

Disclusion achieved in lateral excursive

movement

d) Post operative photograph of the completed

full mouth rehabilitation

Teeth preparation was completed and final

impression was made using addition silicone.Wax

patterns were fabricated at an increased vertical

dimension of 4mm and the prepared teeth were

temporized using heat cure acrylic resin.

Condition 1:

Posterior wax patterns are fabricated such that there

are smooth gliding contacts from centric relation to

protrusive and lateral move ments. This would ensure

a uniform amount of posterior disclusion during

lateral and protrusive excursions when the anterior

guidance is es tablished later.




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Figure 7

a) Pre operative photograph of Case 3, to be treated

using Hobo’s twin stage technique

b)

Wax mock up of the diagnostic models mountedon semi adjustable articulator

c) Fabrication of wax pattern on the maxillary

working cast

d) Fabrication of wax pattern on the mandibular

working cast

Figure 8

a) Completed Posterior restorations in centric

relation

b) Uniform gliding contants from centric

relation to lateral excursive movements

c) Post operative photograph of full mouth

rehabilitation

d) Posterior disclusion during Lateral excursive

movements

Condition 2:

The anterior segment of the removable die system is

replaced onto the cast and wax patterns are fabricated

with the articulator settings. Anterior dies are

replaced onto the casts and wax up is completed to

achieve adequate aesthetics. The palatal contours are

adjusted according to the anterior guidance to provide

immediate disclusion away from centric relation.

After cutback to create space for porcelain, the wax

patterns were cast with a nickel chro mium metal

ceramic alloy. The crowns were tried on the cast and

trimmed so as to achieve uniform bilateral contacts in

centric relation. Metal try in was subsequently done

intraorally and verified for fit and contacts. Ceramic

layering was subsequently carried out and prosthesis

was cemented using Glass ionomer luting cement.

(Figure 7, 8)

Table 2: Modification of articulator settings for

Hobo’s twin stage technique

CONCLUS ION

In the traditional broad sense full mouth

rehabilitation implies the involvement of all

diagnostic, therapeutic, and restorative procedures at

Horizontal

condylar

guidance

Lateral

condylar

guidance

Anterior

guidance

Later

anteri

guida

Modificationof articulator

settings

(

CONDITION

1)

25 15 25 10

Modification

of articulator

settings

(CONDITION

2)

40 15 45 20




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our command for the treatment and prevention of

dental disease. In the narrower, more recently

acquired sense, the term refers to the extensive and

intensive restorative procedures in which the occlusal

plane is modified in many aspects to accomplish

equilibrat ion. (12) These modifications are motivated

by various factors: improvement in esthetics,

restoration of occlusal function, relieving

temperomandibular joint dysfunction. The condylar

path, incisal path and cusp angle determine the

amount of disocclusion during eccentric movement.

The three philosophies followed in full mouth

rehabilitation have different approaches and concepts

regarding the relationship of the factors that govern

disocclusion. Early gnathological concepts focused

primarily on condylar path as it was theorized to be a

constant through adulthood. Anterior guidance was

considered to be at the discretion of the dentist.

McCollum and Stuart concluded from a study

conducted on 10 patients that condylar guidance is

dependent on the anterior guidance. (6, 7) In

Prosthodontics, the condylar path has been

considered the main determinant of occlusion.

According to the Twin table technique by Hobo, the

cusp shape factor and angle of hinge rotation is

derived from the condylar path. These factors

contribute to the determination of an ideal anterior

guidance. However, in the Twin Stage procedure, the

cusp angle was considered as the most reliable

determinant of occlusion. This was in accordance

with the proven data from studies that cusp angle was

4 times more reliable than condylar and incisal paths.

Pankey Mann Schyuler’s philosophy advocates that

condylar guidance does not dictate anterior guidance.

Thus it believes in harmonization of the anterior

guidance for best possible esthetics, function and

comfort and the determination of an occlusal plane

based on anterior guidance. Occlusal rehabilitation is

a radical procedure and should be carried out in

accordance with the dentist’s choice of treatment

based on his knowledge of various philosophies

followed and clinical skills. A comprehensive study

and practical approach must be directed towards

reconstruction, restoration and maintenance of the

health of the entire oral mechanis m.

REFERENCES

1. Irving Goldman: The goal of fu ll mouth rehabilitation , JProsth Dent 2(2) : 246 -51, 1952

2. Mann A W, Pankey L D: The Pankey Mann philosophy

of occlusal rehabilitation, Dent Clin North Am 7: 621-38 ,

1963

3. Mann A W, Pankey L D: Oral Rehabilitation, J Prosth

Dent 10: 135-62 ,1960

4. Schyuler C H : Factors in Occlusion applicable to

restorative dentistry , J Prosth Dent 3 : 722- 82 , 1953

5. Dawson P: Functional occlusion from TMJ to smile

design, Mosby , St. Louis , 2007

6. Hobo S : Twin Table technique for occlusalrehabilitation : Part I – Mechanism of Anterior guidance , J

Prosth Dent 66 (3) : 299-303 , 1991

7. Hobo S: Twin Table technique for Occlusal

rehabilitation: Part II – Clinical procedure , J Prosth Dent

66 (4) : 471- 77 , 1991

8. Hobo S: Oral rehabilitation . Clinical determination of

Occlusion. Quintessence publication, London.

9. Kazis Harry: Complete Mouth Rehabilitation through

restoration of lost vertical dimension , J.A.D.A 37 : 19,

1948.

10. Kazis Harry: Functional aspects of complete mouth

rehabilitation. J Prosth Dent 4 (6): 833-842, 1954

11. Harry Kazis, Albert Kazis : Complete MouthRehabilitation through fixed partial denture Prosthodontics.

J Prosth Dent 10 (2): 296-303 , 1960.

12. Joseph. S. Landa: An analysis of current practices in

mouth rehabilitation. J Prosth Dent 5(4):527-37, 1955

6 Philosophies in Full Mouth Rehabilitation a Systematic Review

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