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Int J Dent Case Reports 2013; 3(3): 30-39

© IJDCR 2013. A ll rights reserved m

Bharat Raj Shetty 1 , Manoj Shetty2 , Krishna Prasad D.3 , S. Rajalaksh mi4 , Raghavendra Jaiman 5

Lecturer, Depart ment of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka,


Professor, Depart ment of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,

Karnataka, India

Professor & HOD, Depart ment of Prosthodontics, A.B. Shetty Memo rial Institute of Dental Sciences, Mangalore,

Karnataka, India

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

Karnataka, India

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

Karnataka, India

Address for Correspondence
Dr. Manoj Shetty
Depart ment of Prosthodontics
A.B. Shetty Memorial Institute of Dental Sciences
Mangalore, Karnataka, India
Email id :
Contact: 09845267087

Co mplete mouth rehabilitation is a dynamic functional endeavour and it embodies the correlation and integration of
all co mponent parts into one functioning unit. Over time have evolved various concepts and philosophies to attain
reconstruction and rehabilitation of the entire dentit ion, satisfying all the related factors. This case series describes
cases requiring full mouth rehabilitation t reated 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

horizontal and lateral co mponents both at M OUTH tooth and condylar level. the goals to be attained are: rehabilitation. The discrepancies between centric relat ion and maximu m intercuspation position should be analyzed INDICATIONS FOR FULL as vertical. combination of many aspects of dental treatment such Affected as patient education. Painful therapy.Shetty. As the goal of medicine is to increase the life span of The restoration of mu ltiple teeth which are missing. Unacceptable esthetics. resources at its command in both maintenance work Treat ment of temporo mandibular d isorders is also advised. worn. all o f which enhance the oral health and welfare of the patient. The aim is to restore the tooth to its natural form. Rajalakshmi. Stable TMJs 4. skill and all the 3. though caution is advised. Severe attritional Successfully treat ing patients requires a thoughtful wear. endodontic dentition. function and esthetics while maintaining the physiologic integrity in BIOLOGICA L harmonious relationship with the adjacent hard and CONSIDERATIONS DURING OCCLUSAL REHA BILITATION (9. 3 . Prasad. The occlusal vert ical REHABILITATION dimension should be determined by utilizing the The primary indications for rehabilitation of the physiologic rest position of the mandible as a guide entire dentition are: and noting the existing freeway space. Shetty. or fracture of teeth or restorations. operative skills. the functioning individual. (1) Occlusal Reorganization of the occlusion can be considered if rehabilitation is defined as the restoration of the existing intercuspal position can be considered functional integrity of dental arch by the use of inlays. Optimu m esthetics new occlusal scheme around a stable condylar position (termed ‘centric relat ion‘) should be considered. Co mfortab le function 7. musculature due to disharmony between occlusion harmony and TMJs. Stable occlusion 5. bro ken down or decayed. sound diagnosis. 11) soft tissues. To To summarize. increase the life span of the functioning dentition. Vo l. Maintainable healthy periodontium 3. attain the various goals of fu ll mouth necessary along with the indicated conditions. the goal of dentistry is to 2. Sensitive teeth. bridges and partial unsatisfactory for various reasons . 10. between the TMJ and occlusion. and rehabilitation to achieve its goal. occlusal considerations. The effects of occlusal pattern on the periodontal structures should 31 Int J Dent Case Reports Nov-Dec 2013. periodontal treatment and achieving Unacceptable function. crowns. Freedom fro m d isease in all masticatory Adoption of an alternative strategy by establishing a system structures 2. certain bio logical considerations are 1. Lack of interocclusal space for restoration. To replace imp roperly designed and executed crown and bridge framework. Jaiman Full Mouth Rehabilitation INTRODUCTION 1. No. Maintainable healthy teeth 6. Dentistry uses its knowledge.3. 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.Repeated failure dentures.

3) One of the most practical philosophies is the rationale of treat ment that was orig inally organized into a Advantages of the Pankey Mann Schuyler technique: workab le concept by Dr. No. (5) treatment fo r entire rehabilitation before Schuyler’s principles were : (4) preparing a single tooth. dentition. patient and technician. 1. 4. on the operator. FUNCTIONA L ASPECTS OF FULL M OUTH Group function of the wo rking side inclines in lateral excursions.organized logical procedure that maximu m number of teeth when the progresses smoothly with less wear and tear mandib le is in centric relation. the following Co mplete mouth rehabilitation is a dynamic sequence is advocated by the PMS philosophy: functional endeavour and it embodies the correlat ion 1.D. Diagnosis. temporo mandibular disorders is necessary. therefo re. reconstruction and rehabilitation of the entire PART II : Harmonizat ion of the anterior guidance for best possible esthetics . An anterior guidance that is in harmony with health is also an objective o f the same. The aim. (2. three proved and accepted fundamentals: PART III: Selection of an acceptable occlusal plane and restoration of the lo wer The existence of a physiologic rest position posterior occlusion in harmony with the of the mandib le. and integration of all co mponent parts into one PART I : Examination. PART IV: Restoration of the upper posterior occlusion in harmony with the anterior centric occlusion guidance and condylar guidance. 3. REHABILITATION (10) In order to accomp lish these goals. anterior guidance in a manner that will not 2. Treat ment planning and Prognosis functioning unit. Pankey utilizing the (5) 1. satisfying all the related factors. Shetty. evaluation and the effects of materials used on occlusal stability control of parafunction Disclusion by the anterior guidance of all posterior teeth in protrusion. principles of occlusion espoused by Dr. occlusal pattern by means of roentgen graphic 3. Clyde It is possible to diagnose and plan the Schuyler.3. A study of the function in lateral eccentric position on the temporo mandibular joint positions relative to the working side. 3 . Vo l. L. Rajalakshmi.Shetty. and 4. The acceptance of a dynamic. The recognition of a vert ical dimension interfere with condylar guidance. Prasad. The PHILOSOPHIES FOLLOWED IN FULL M OUTH functionally generated path technique is so RECONSTRUCTION closely allied with this part of the reconstruction. 32 Int J Dent Case Reports Nov-Dec 2013. The function and comfort science of comp lete mouth rehabilitation rests upon 3. Jaiman Full Mouth Rehabilitation also be assessed as attaining optimal periodontal 2. must be 2. Disclusion of all non-working inclines in lateral excursions. functional 1. which is a constant. A static co-ordinated occlusal contact of the It is a well. 2. 5.

It was diagnosed series neither to be a case of Amelogenisis imperfecta where necessary nor desirable to do the entire case generalized attrit ion was observed with a decrease in at one time. This was followed by maxillary occlusal reconstructed. Rajalakshmi.Maxillary operator always has an idea where he is at and man dibu lar d iagnostic casts were mounted onto all times. size and contour. Vo l. temporizat ion of the prepared Laboratory procedures are simp le first. fused to metal crowns for the mandibular anteriors. Prasad. In controlled to an extremely fine degree by the order to maintain the increase in VD. Mandibular occlusal plane the teeth to be rebuilt at the exact vert ical was analysed using Broadrick’s occlusal plane dimension to which the case will be analysis. On clin ical examination. patterns were carved using fossa contour guide. 4. wax up to maximu m intercuspation. The Utilizing phonetics and esthetics as a guide. The There is no need fo r t ime consuming mandibular anterior teeth were prepared techniques and complicated equip ment. This was followed by fabrication of porcelain understands the goals of optimu m occlusion. 7. An impression was made and rehabilitation can fu lfill the mos t exacting temporizat ion of the mandibular posterior teeth was and sophisticated demands if the operator done. The maxillary anterior teeth were A healthy 18 year old female patient reported to the prepared next. Inclines of wax observed with respect to all the occlusal surfaces. Shetty. The Mann Schuyler philosophy was planned. No. Full Mouth Rehabilitation There is never a need for preparing or decrease in vertical dimension building more than 8 teeth at a time.3. Jaiman 3. Generalized attrition was refined and impressions made. posterior also had to be prepared in order to prevent 10. 5. mm to be worn by the patient for 6 weeks. The PMS philosophy of occlusal posterior open bite. Centric relat ion was recorded at the Depart ment of Prosthodontics with a chief co mplaint proposed vertical dimension and casts were mounted of discolored teeth. Cementation of the crowns was done using glass CASE REPORT ionomer cement. Anterior wax up was done to appropriate relation are taken on the occlusal surface of shape. a Whip mix (Arcon) art iculator using facebow The functionally generated path and centric records. of enamel was seen with respect to most teeth with The mandibular posterior teeth preparations were exposure of dentine. Radiographic examination revealed no requirement It divides the rehabilitation into separate of endodontic therapy for any teeth. 2 mm porcelain crowns fabricated were subject to occlusal 33 Int J Dent Case Reports Nov-Dec 2013. Anterior wax up All of appointments. vertical d imension of 2 mm. are was checked for proper anterior guidance to achieve programmed by and are in harmony with disclusion in eccentric movements. 9. Full mouth rehabilitation There is no danger of getting at sea and pertaining to the principles and goals of Pankey losing patient’s vertical dimension. 8. 6. the mandibular dentist. 3 .Shetty. A splint was both condylar border movements and a fabricated with an increase in vertical dimension of 2 perfected anterior guidance. PFM crowns were cemented. posterior occlusal It is contours was observed. ch ipping in the same relat ion. Following imp ression. and teeth was done at a raised vertical dimension.

It is fabricated by preparing die systems with removable anterio r and posterior segments. The first incisal table is termed incisal table without disclusion. The technique utilizes 2 d ifferent customized incisal guide tables.3. developed anterior guidance to create a predetermined.Shetty. Th is is followed by preparation of maxillary posteriors. This is termed the incisal guidance with disclusion. Shetty. The first incisal guide table 34 Int J Dent Case Reports Nov-Dec 2013. Rajalakshmi. Su miya Hobo anteriors which is followed in rehabilitation of dentate completed patients. The other incisal table is made when the articu lator can simu late border movements by placing 3 mm plastic separators behind the condylar elements. Vo l.7) treated by Pankey Mann Schuyler technique b) Broadrick’s occlusal plane analysis c) Tooth preparation of lower Another philosophy was given by Dr.establishment of occlusal plane with Broadrick’socclusal plane analysis Figure 1: a) Pre operative photograph of Case – 1 to be HOBO ‘S TW IN TABLE PHILOSOPHY (6. 3) Figure 2: a) Transfer of cusp to fossa relationship b) Fabrication of fossa guide c) Wax preparation of the mandibular posteriors using fossa guide d) Re.( Figure 1. Fabrication and cementation of the crowns are done. This table helps us achieve uniform contacts in the posterior restorations during eccentric movements. 2. Jaiman Full Mouth Rehabilitation plane verification and then cemented. Prasad. Wax patterns are fabricated for the same. And posterior disclusion is checked by keeping the condylar guidance shallower than the patient’s. harmonious disclusion with the condylar path. He proposed Twin table concept which d) Provisionalizat ion of lower anterior teeth. No. 3 .

Shetty. Disclusion of 0. The incisal table with d isclusion was fabricated next by using 3 mm acry lic separators behind the condylar elements. Once the Disocclusion of posterior teeth on lateral incisal table is refined. which was treated. Jaiman Full Mouth Rehabilitation is used to fabricate restorations for posterior teeth. (Figure 4. No. movements. The need to increase the vertical c) dimension by 4 mm was seen and an overlay splint at Maxillary full arch tooth preparation completed. using Pre-operative indicated endodontic treatment fo r certain teeth. 3 . Prasad. Th is was d) Facebow transfer recording followed by preparation of maxillary and mandibular teeth. The casts are mounted onto the articulator HOBO’ S TW IN STA GE PHILOSOPHY (8) using facebow transfer. This is b) Post operative photograph of full mouth followed by ceramic build-up of the copings and rehabilitation using Pankey Mann Schuyler cementation after analysis of the eccentric and centric technique. the raised vertical dimension was cemented. the metal copings are excursive movements fabricated and try in of the same is done.3. an incisal table without disclusion was made without The second guide table is used to achieve incisal anterior guidance.5 mm was achieved on the working side and 1 mm is achieved on the non working side. the vertical dimension p lane established using Broadrick’socclusal plane analysis was evaluated. 6) CASE REPORT: A 44 year o ld healthy male reported to the Depart ment of Prosthodontics with a co mplaint of worn out. Vo l. for the posterior teeth to achieve uniform contacts. Diagnostic casts were mounted using facebow Figure 4 records onto a semi adjustable articu lator (Whip mixArcon). Rajalakshmi. Shetty. The wax patterns were fabricated guidance with disclusion. 5. 35 Int J Dent Case Reports Nov-Dec 2013. As explained in the concept. Using phonetics b) Occlusal and freeway space as a guide. This is done for each condylar element one at a time and protrusive movement by placing Figure 3 a) separators behind both condylar elements. It was diagnosed to be a case of severe generalized attrition and abrasion and a treatment plan was formulated to rehabilitate Hobo’stwin table radiographic evaluation the dentition technique. sensitive teeth and difficu lty in chewing. Occlusal plane was evaluated a) using Pre operativephotograph of Case 2 to be treated by Hobo’s Twin Table technique Broadrick’s occlusal plane analysis.

it is necessary changed by the dentist. Shetty. Rajalakshmi. Jaiman Full Mouth Rehabilitation Dentists have tried for years to prevent harmful Table 1: Standard values of effective cusp angle on horizontal occlusal forces on teeth caused by mo lars mandibular eccentric movements. Vo l. the concept that focuses on the condylar path as the reference of occlusion Basic concept of twin stage procedure: was utilized. Though fabricating the anterior teeth to produce disocclusion. the incisal path would not be a reliable shallower cusp angle. But the condylar path has to wax the occlusal morphology to produce balanced been shown to have deviation and minimal influence articulation so the cusp angle becomes parallel to the on disocclusion arising questions on the validity of cusp path of opposing teeth during eccentric the concept. Reproduce the occlusal morphology of the posterior STANDA RD VA LUES OF EFFECTIVE CUSP teeth without the anterior segment and produce a ANGLE ON M OLARS cusp angle coincident with the standard values of CUSP ANGLE CUSP A NGLE protrusive cusp angle segment is produce fabricated. some guidance should be incorporated. ON MOLARS Sagittal removable anterior teeth (Referred to as ‘Condition 2’). However. 3 . Thus the cusp angle was working cast becomes an obstacle. when considered as a new reference for occlusion. Du ring develop ment. Secondly. Prasad. No. when individual disocclusion. The pantograph philosophy: as advocated in Hobo’s Twin Stage and fully adjustable articulators are results of their efforts. the anterior portion of the reference fo r occlusion. reproduce the anterior morphology with the anterior segment and provide anterior guidance 25 which produces a standard amount of disocclusion effective cusp angle Frontal lateral effective anterior help effective cusp angle (Referred to as ‘Condit ion’). The deviation of the incisal path is less movement. 15 (working side) Frontal lateral effective cusp angle 20 (non working side) 36 Int J Dent Case Reports Nov-Dec 2013. In this a standard value for cusp angle was determined such methodical approach described by Hobo. Also.3. when a dental technician waxes the variation and the occurrence rate of malocclusion is occlusal morphology and tries to reproduce a incorporated. Th is concept was derived from the In order to provide disocclusion. independent of condylar path as well as incisal path. a cast with that it may co mpensate for wear of natural dentition a due to caries.Shetty. the cusp angle belief that condylar path was unchangeable in the should be shallower than the condylar path. Since than that of condylar path. To make liv ing body whereas anterior guidance could be freely a shallower cusp angle in a restoration. abrasion and restorative works.

Vo l.Shetty. Abnormal curve of Wilson impression was made using addition silicone. Condition 1: Case report: Posterior wax patterns are fabricated such that there A healthy 38 year o ld patient reported to the are smooth glid ing contacts fro m centric relation to Depart ment of Prosthodontics with a chief co mplaint protrusive and lateral movements. Full mouth rehabilitation following 37 Int J Dent Case Reports Nov-Dec 2013. Panoramic radiograph a uniform amount of posterior disclusion during indicated endodontic treatment and restoration with lateral and protrusive excursions when the anterior post and core for few teeth. Diagnostic wax up was done increasing the vertical dimension by 4 mm. Diagnostic casts were mounted onto a Whipmix articulator using facebow t ransfer and interocclusal records. Abnormally rotated teeth patterns were fabricated at an increased vertical 4. 3 . was completed. Rajalakshmi. Figure 5 a) Recording of interocclusal centric relat ion using Aluwax b) Mounting of the prepared models using Figure 6 facebow transfer and interocclusal record c) a) Condylar insert of 3 mm placed behind the Condylar inserts inserted behind condylar elements condylar elements to achieve disclusion of b) Preparation of wax patterns posterior teeth. Prasad. Jaiman Full Mouth Rehabilitation Hobo’s Twin stage philosophy was proposed as the treatment of choice.3. No. Once endodontic therapy guidance is established later. Abnormally inclined teeth dimension of 4mm and the prepared teeth were temporized using heat cure acrylic resin. c) d) Disclusion of 1 mm achieved on the non- Disclusion achieved in lateral excursive movement working side d) Post operative photograph of the co mpleted full mouth rehabilitation Contraindications: 1. This would ensure of excessive tooth wear. Shetty. Abnormal curve of Spee Teeth preparation was completed and final 2.Wax 3.

After cutback to create space for porcelain. Jaiman 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.3. The crowns were tried on the cast and Wax mock up of the diagnostic models mounted trimmed so as to achieve uniform b ilateral contacts in on semi adjustable articulator c) centric relat ion. Ceramic working cast d) layering was subsequently carried out and prosthesis Fabrication of wax pattern on the mandibular was cemented using Glass ionomer luting cement. therapeutic. Shetty. Prasad. working cast (Figure 7. to be treated patterns were cast with a nickel chro miu m metal using Hobo’s twin stage technique ceramic alloy. Metal try in was subsequently done Fabrication of wax pattern on the maxillary intraorally and verified for fit and contacts. and restorative procedures at 38 Int J Dent Case Reports Nov-Dec 2013. Vo l. No. 8) Modification of art iculator settings ( CONDITION 1) Modification of art iculator settings (CONDITION 2) Figure 8 a) Co mpleted Posterior restorations in centric Horizontal condylar guidance 25 Lateral condylar guidance 15 Anterior guidance 25 Lateral anterior guidance 10 40 15 45 20 Table 2: Modificat ion of articu lator settings for relation Hobo’s twin stage technique b) Unifo rm g lid ing contants from centric c) relation to lateral excursive movements CONCLUS ION Post operative photograph of full mouth In rehabilitation rehabilitation the tradit ional imp lies broad the sense full involvement mouth of all diagnostic. Anterior dies are replaced onto the casts and wax up is co mpleted to achieve adequate aesthetics. Rajalakshmi. The palatal contours are adjusted according to the anterior guidance to provide immed iate disclusion away fro m centric relation.Shetty. 3 . the wax Figure 7 a) b) Pre operative photograph of Case 3.

function and dental disease. Pankey L D: Oral Rehabilitation. S. J Prosth Dent 66 (4) : 471. derived fro m the condylar path. St. J Prosth Dent 10: 135-62 .3. Schyuler C H : Factors in Occlusion applicable to restorative dentistry . Vo l. These factors contribute to the determination of an ideal anterior 9. J Prosth Dent 3 : 722. 5. the cusp angle was considered as the most reliable 10. Louis . 1963 rehabilitation have different approaches and concepts regarding the relationship of the factors that govern disocclusion. Hobo S : Twin Table technique for occlusal rehabilitation : Part I – M echanism of Anterior guidance . in the Twin Stage procedure. M osby . Anterior guidance was 4. Rajalakshmi.A 37 : 19. Clinical determination of Occlusion. J. Dent Clin North Am 7: 621-38 . 7.1960 primarily on condylar path as it was theorized to be a constant through adulthood. Early gnathological concepts focused 3. REFERENCES 1. In the narro wer. 1948. J Prosth Dent 4 (6): 833-842.Shetty. 1991 According to the Twin table technique by Hobo.82 . 1960. No. 4 t imes mo re reliable than condylar and incisal paths. This was in accordance with the proven data fro m studies that cusp angle was 11. J Prosth Dent 10 (2): 296-303 . amount of d isocclusion during eccentric movement. (6. Joseph. M ann A W. mo re recently comfo rt and the determination of an occlusal p lane acquired sense. 2007 McCollu m and Stuart concluded fro m a study conducted on 10 patients that condylar guidance is 6. the cusp shape factor and angle of hinge rotation is 8. Kazis Harry: Functional aspects of complete mouth rehabilitation. Harry Kazis.D. 7) In Prosthodontics. However. restoration and maintenance of the path. followed and clin ical skills. London. Occlusal rehabilitation is intensive restorative procedures in which the occlusal a radical p rocedure and should be carried out in plane is modified in many aspects to accomplish accordance with the dentist’s choice of treat ment equilibrat ion. J Prosth Dent 5(4):527-37. Quintessence publication. (12) These modifications are motivated based on his knowledge of various philosophies by various in esthetics. Dawson P: Functional occlusion from TM J to smile design. the condylar path has been considered the main determinant of occlusion. Hobo S: Twin Table technique for Occlusal rehabilitation: Part II – Clinical procedure . relieving and practical approach must be directed towards tempero mandibular joint dysfunction. Shetty. Jaiman Full Mouth Rehabilitation our command for the treatment and prevention of guidance for best possible esthetics.A. Pankey L D: The Pankey M ann philosophy of occlusal rehabilitation. Prasad. Kazis Harry: Complete M outh Rehabilitation through restoration of lost vertical dimension . the term refers to the extensive and based on anterior guidance.77 . 3 . A comprehensive study function. Albert Kazis : Complete M outh Rehabilitation through fixed partial denture Prosthodontics. The condylar reconstruction. 1954 determinant of occlusion. Hobo S: Oral rehabilitation . J Prosth Dent 66 (3) : 299-303 . M ann A W. Pankey Mann Schyuler’s philosophy advocates that 12. 1953 considered to be at the discretion of the dentist. Thus it believes in harmon izat ion of the anterior 39 Int J Dent Case Reports Nov-Dec 2013. guidance. Irving Goldman: The goal of full mouth rehabilitation . 1991 dependent on the anterior guidance. incisal path and cusp angle determine the health of the entire oral mechanis m. J restoration factors: improvement of occlusal The three philosophies followed in fu ll mouth Prosth Dent 2(2) : 246 -51. 1952 2. 1955 condylar guidance does not dictate anterior guidance. Landa: An analysis of current practices in mouth rehabilitation.