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Case Report

Full‑mouth rehabilitation using twin‑stage technique

Ashish Kalra, Harbir Singh Sandhu1, Nanda Kishore Sahoo2, AK Nandi3, Shilpa Kalra4
Graded Specialist (Prosthodontics), 3Commandant, Command Military Dental Center, 4Orthodontist, Lucknow, Uttar Pradesh,
1
Classified Specialist (Prosthodontics), 2Commandant, Command Military Dental Center, Pune, Maharashtra, India

Abstract The wear and tear of the occlusal surfaces of teeth keeps on happening throughout life. However, excessive
occlusal wear may lead to occlusal disharmony, pulpal trauma, esthetic disfigurement, and impaired
function. Tooth wear can be classified as attrition, abrasion, and erosion depending on the cause. Therefore,
it is important to identify the factors which contribute to excessive wear and reduce the vertical dimension
of occlusion. This case report presents the rehabilitation of complete maxillary and mandibular arch in
a 45‑year‑old male patient with severe attrition. The patient was treated using the Hobo’s twin‑stage
approach with porcelain‑fused‑to‑metal crowns on all maxillary and mandibular teeth.

Keywords: Full mouth, porcelain fused to metal (PFM), vertical dimension

Address for correspondence: Dr. Ashish Kalra, CMDC, Lucknow, Uttar Pradesh, India.
E‑mail: doc_ashish47@rediffmail.com

INTRODUCTION more challenging when insufficient space for restoration

The gradual wear of the occlusal surfaces of teeth
is a continuous phenomenon which kee ps on
happening throughout the life of a patient. However,
excessive occlusal wear may result in pulpal trauma,
occlusal disharmony, impaired function, and esthetic
disfigurement. [1] Tooth wear can be in the form of
attrition, abrasion, and erosion. Therefore, it is important
to identify the factors which contribute to excessive wear
and reduce the vertical dimension of occlusion (VDO).[2]
Mostly, the VDO is maintained by continuous tooth
eruption and alveolar bone growth. The alveolar bone
undergoes an adaptive process and compensates for the
loss of tooth structure to maintain the VDO as the teeth
are worn.[3,4]
Esthetic and functional rehabilitation of the worn out
dentition is always a significant clinical challenge. However,
the rehabilitation of the severely worn dentition becomes
is present. Proper diagnosis and careful comprehensive
treatment plan are required in managing such patients.
Full‑mouth rehabilitation enhances the patient’s self‑esteem,
confidence, and quality of life. Full‑mouth rehabilitation
is the procedure when restoration of the missing teeth
involves the complete rehabilitation of the oral cavity, in
terms of function and esthetics.
This case report describes the full‑mouth rehabilitation of
worn out dentition by twin‑stage procedure to produce
definite esthetic and occlusal scheme favorable to the
patient.
CASE REPORT
A 45‑year‑old male patient reported with the chief
complaints of difficulty in eating and unesthetic appearance
of his face because of excessive wear of the upper teeth.
Intraoral examination revealed a generalized loss of dental

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DOI: How to cite this article: Kalra A, Sandhu HS, Sahoo NK, Nandi AK,
10.4103/ijohs.ijohs_62_18 Kalra S. Full-mouth rehabilitation using twin-stage technique. Int J Oral
Health Sci 2019;9:40-4.

40 © 2019 International Journal of Oral Health Sciences | Published by Wolters Kluwer - Medknow
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Kalra, et al.: Full-mouth rehabilitation

substance that was greater in the maxillary teeth [Figure 1].

The patient did not have temporomandibular joint disorder
history and soreness of the masticatory muscles. Loss
of 5  mm of vertical dimension  (VD) was evident, and
his phonetics was also altered. Periodontal charting was
carried out, and based on the findings, the treatment plan
was formulated involving oral prophylaxis, extraction
of 36 and 16, followed by full‑mouth rehabilitation
with porcelain‑fused‑to‑metal full‑coverage fixed partial
dentures and crowns at an increased VD of 4 mm with
canine‑guided occlusion to improve esthetic and functional
value of the patient.

The case was taken for the following objectives of

treatment to: Figure 1: Showing the pre op intraoral frontal view
• Attain functional harmony
• Reestablish form, function, and esthetics
• Establish a canine‑guided occlusal scheme.

A splint made up of hard sheet was given to the patient for

6 weeks. The adaptation of the patient to the increased VDO
was evaluated during 2‑month trial period. Muscle tenderness
and temporomandibular discomfort were not found.

Occlusal equilibration was done in the patient’s mouth by

removing the occlusal interferences, so that centric relation
coincided with the maximum intercuspal position. A Lucia
jig was fabricated at an established increased VDO at 4 mm.
Interocclusal and protrusive records were made using
polyvinyl siloxane occlusal registration material  (Jet Bite).
The diagnostic impressions were made using irreversible Figure 2: Showing the Broadrick’s occlusal plane analyzer
hydrocolloid. The patient’s casts were mounted on a
semiadjustable articulator (Hanau H2) using a facebow record
at increased VD. Mandibular occlusal plane was analyzed
using the Broadrick’s occlusal plane analyzer  [Figure  2].
Divider of Broadrick occlusal plane analyzer was opened at
4 inches and a mark was obtained on the flag by keeping one
end at the distal end of the canine and the second end of the
divider at the distobuccal cusp of the last molar and another
mark crossing the first one was obtained. Now, another end
of the divider was kept on this intersection of the marks,
and occlusal plane was marked on wax occlusal rim made
on mandibular cast. The semiadjustable Hanau articulator
was programmed to Condition 1 of Hobo’s twin‑stage
procedure [Table 1], wherein after removal of the maxillary
anterior segment [Figure 3], posterior segment diagnostic
wax‑up was done in bilaterally balanced occlusion. The Figure 3: Showing the separate anterior segment
settings were changed to Condition 2 where the maxillary
anterior segment was replaced and the anterior wax‑up Provisional crowns were fabricated with autopolymerizing
was completed and checked for proper anterior guidance resin using a vacuum‑formed matrix produced from the
to achieve disocclusion in eccentric movements due to diagnostic wax‑up. Adjusted occlusion was transferred
canine‑guided occlusion [Figure 4]. to a customized anterior guide table, which was made
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Kalra, et al.: Full-mouth rehabilitation
with acrylic resin  (PATTERN RESIN; GC Corp.,
Tokyo, Japan). Tooth preparation of all maxillary
and mandibular teeth was prepared [Figure 5], and
definitive two‑stage double‑mix putty light‑body
impression was made with polyvinyl siloxane impression
material (Aquasil, Dentsply) [Figure 6]. The interocclusal
record was made with interocclusal recording material
at established VD, and facebow was used for recording
of orientation jaw relation. Provisional crowns were
cemented with soft zinc polycarboxylate temporary
cement  (Hybond). After die cutting, the casts were
mounted on semiadjustable ar ticulator (Hanau
H2) [Figure  7]. The wax patterns were fabricated,
invested, and casted. The metal copings were retrieved,
and metal try‑in was done after finishing  [Figure  8].
After the metal try‑in, the ceramic was applied and
bisque try‑in was completed. Porcelain‑fused‑to‑metal
restorations were made using Condition 1 and 2 of
Hobo’s technique. The canine‑guided occlusion was
checked in the mouth, and after verification, the crowns
were cemented with temporary polycarboxylate cement.
After 2 weeks, once the patient was comfortable,
all the crowns were cemented with resin‑modified
glass ionomer cement  (FujiCEM; GC America, Alsip,
USA) [Figures 9 and 10]. Postoperative orthopantogram
was taken [Figure 11], and oral hygiene instructions and
regular checkup were administered.
Figure 4: Diagnostic wax up
Figure 6: Showing the final impression
42 International Journal of Oral Health Sciences | Volume 9 | Issue 1| January-June 2019
DISCUSSION
Treatment of reduced VD is not designed to increase it,
but is intended to restore the amount of VD lost. Such
cases require the development of sufficient restorative
space, which may lead to fulfilling the esthetics, functional,
and occlusal parameters essential to long‑term success.
All our efforts for full‑mouth rehabilitation are directed
toward reestablishing a state of functional efficiency,
in which the hard and soft tissues of the stomognathic
system function in synchronous harmony. Dawson stated
that interocclusal space is never lost and any loss is
compensated by tooth eruption, alveolar bone expansion,
and muscle action. Success in maintaining severe wear
cases depends on the development of proper incisal
guidance to allow for proper disocclusion within patient’s
envelop of motion.[5]
The etiology of tooth wear is multifactorial, and clinical
controlled trials of restorative and prosthodontic
approaches are limited in quantity and quality. The VD
should be raised with occlusal splints before starting the
treatment, and the overlay prostheses should be tried
between 3 weeks and 5 months for deprogramming of
temporomandibular joint.[6]
In this case, 4 mm of VD was raised as moderate amount
of increase in VD is not harmful for temporomandibular
apparatus. The patient was carefully monitored for
2 months to evaluate the adaptation to the removable
Table 1: Showing values for hobo's twin stage technique
Condition Condylar Guidance Anterior Guidance
Sagittal Lateral Sagittal Lateral
1 25° 15° 25° 10°
2 40° 15° 45° 20°
Figure 5: Showing the maxillary and mandibular teeth preparation
Figure 7: Showing the Die cutting
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Kalra, et al.: Full-mouth rehabilitation

Figure 8: Metal Try in

Figure 10: Canine guided occlusion

occlusal overlay splints. No discomfort, wear, and muscle

fatigue were observed during that period. The increase of
VDO was determined by the patient’s physiologic factors
such as interocclusal rest space and speech. Arbitrary Figure 9: Final Prosthesis in situ
increase of VDO would lead to multiple complications.

Stuart and Stallard in 1957 said that the cuspid‑protected

occlusion concept had many advantages over the group
function. Hobo and Takayama said that amount of
disocclusion depends on the condylar path, incisal
path, and the cusp angle.[7] Posterior disocclusion is
very important in controlling harmful lateral forces.
This case has demonstrated that if the condyles are
seated in centric relation, additional restorative‑required
space may be obtained. Proper anterior guidance not
only is essential for preventing the interferences in the
condylar envelop of movement but also prevents the
excessive wear. Figure 11: Post op Orthopentogram

CONCLUSION
not be published and due efforts will be made to conceal
Multidisciplinary approach and proper treatment planning their identity, but anonymity cannot be guaranteed.
with adequate manual dexterity are required for creating
Financial support and sponsorship
the perfect esthetic with health. For doing the full‑mouth
rehabilitation treatment, all the imperfections in bite Nil.
position should be removed, and the mandible should
Conflicts of interest
be seated in centric relation. Following this principle,
There are no conflicts of interest
it creates a smile that is esthetic, comfortable, and
functional. REFERENCES

Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
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