FULL MOUTH REHABILITATION Part 2

Occlusal concepts in FMR

• Gnathological concept – McCollum, stuart, Stallard
• Freedom in centric concept – Schyuler
• Simplified occlusal design – Wiskott and Besler
• Youdelis scheme
• Nyman and Lindhe scheme
• Pankey, Mann and schyuler philosophy – 1960
• Twin table – Hobo – 1991
• Twin stage – Hobo and Takayama
2
Gnathological concept – McCollum, stuart, Stallard
• This is the earliest concept.
• Their observations led to the development of mandibular movements, transverse hinge
axis, maxillomandibular relations and acron adjustable articulator.
• They initially supported balanced occlusion but later adapted the concept of canine
guided and mutually protected occlusion.
• Point centric concept
• Cusp-fossa relationship with tripodism

Tiwari B,Ladha K ,Lalit A,Naik B. Occlusal Concepts in Full Mouth Rehabilitation: An Overview. J Indian Prosthodont Soc.2014;14:344-51
 Freedom in centric concept (Schuyler) (1959)
• Schuyler first introduced the Concept Of ‘Freedom in
Centric’’ and supported the theory that centric relation was
rather a biological area of the TMJ than a point.
• In this concept, ‘‘there is a flat area in the central fossae
upon which opposing cusps contact which permits degree of
freedom (0.5–1 mm) in eccentric movements uninfluenced
by tooth inclines’’.
• It relies on cusp-to-surface mechanics.
• Incisal guidance without freedom of movement from a
centric relation occlusion will ‘‘lock-in’’ the posterior
occlusion. 4

Dawson PE. Functional occlusion. Elsevier Health Sciences; 2006.

• Balancing contacts are deleterious and must be avoided in natural dentition.
• Incisal guidance is a predominating factor for selection of posterior guiding tooth
inclines than condylar guidance so it should be the first step of occlusal rehabilitation.
• Antero-posterior freedom of movement must be incorporated in the restoration.

Dawson PE. Functional occlusion. Elsevier Health Sciences; 2006

Contact in centric relation: All posterior interferences to centric

relation must be completely eliminated so anterior contact in centric

relation can be verified.

Postural closure: With the patient in an upright, relaxed, postural

position, gentle tapping of the teeth together should not result in striking

the upper lingual incline before complete closure to the most closed

position.

Dawson PE. Functional occlusion. Elsevier Health Sciences; 2006.

4 possibilities arise-

• When each red mark is covered by the blue centric mark- no long centric is needed

• When red marks extend forward from blue centric marks- shows a need for long centric

• When red marks extend backward from blue centric marks- not manipulated correctly into centric closure

• When blue centric marks are missing from red marks- equilibration for centric is incomplete .

Dawson PE. Functional occlusion. Elsevier Health Sciences.

 Wiskott and Belser - Simplified occlusal design (1973)

• Cusp-fossa relation with only one occlusal contact per tooth

• Anterior disocclusion during all eccentric movements

• Freedom in centric occlusion

• Can be adapted to most anterior guidances and varying degrees of

group function.

Tiwari B,Ladha K ,Lalit A,Naik B. Occlusal Concepts in Full Mouth Rehabilitation: An Overview. J Indian Prosthodont Soc.2014;14:344-51
 Youdelis Scheme (1971)

• Features :-
• Used in periodontitis cases
• Aim is to coincide centric occlusion with maximum intercuspation so that forces are
directed axially
• Cuspal anatomy is so arranged that if the canine disocclusion is lost through wear or tooth
movement, the posterior teeth drop into group function
Nyman and Lindhe Scheme (1977)

• Used in extremely advanced periodontitis case

• When there are long tooth-borne cantilevered restorations, balanced occlusion must be
achieved
• When distal support is present, anterior disocclusion is provided.
• For extremely advanced periodontitis cases
• Type of contacts not specified
 PANKEY MANN
SCHUYLER CONCEPT
● This concept is based on spherical theory of occlusion and functional chew-in
technique given by Meyer and Brenner.
● As a modification of canine guided occlusion, group function occlusion is followed.
● Traditionally PM device was used to determine the occlusal plane of mandibular
posterior teeth.

Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and in restoring lower
posterior teeth. J Prosthet Dent 10:135–150
 PM INSTRUMENT

Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and in restoring lower
posterior teeth. J Prosthet Dent 10:135–150
 Sequence of restoring teeth

1. The lower posterior teeth rehabilitation

2. Followed by establishing anterior guidance with the help of upper cuspids

3. Upper posterior teeth rehabilitation

 15
Protocol for Pankey-Mann-Schuyler philosophy of occlusal rehabilitation(PMS)

• Step 1 : occlusal plane should be determined using Broadrick occlusal plane analyzer.
• Step 2 : lower posteriors are restored according to the established occlusal plane.
• Step 3 : Meyer’s functionally generated path technique should be used establish the occlusal pattern
of the upper posterior teeth.
• Step 4 : the upper posteriors are adjusted such that group function occlusion is established during

lateral excursions.
Determining an acceptable occlusal plane for restorative cases

Using Broadrick's flag (Broadrick's occlusal plane analyser) for occlusal plane analysis-

The technique was adapted for restorative dentistry by Pankey from original anthropological research by

Monson. The technique consists of the following steps-

1.After the upper and lower mounting is complete with a face bow registration and centric bite record, the

upper model is removed and set aside for later use.

2. The flag is secured to the upper bow of the articulator and the plastic sheet is snapped onto one side.

3. The pencil lead is inserted into one end of the caliper and is set at a radius of 4 inches from the needle

point to the lead point.

Dawson PE. Functional occlusion. Elsevier Health Sciences.

4. Anterior survey line is drawn by keeping the needle point at the cuspid

tip/distoincisal line angle and the lead pencil tip on the flag to scribe an arc.

5. Condylar survey line is drawn on the flag (without altering the radius=4

inches) by keeping the needle point at the center of the condyle ball

6. The intersect obtained is the SURVEY CENTER.

Dawson PE. Functional occlusion. Elsevier Health Sciences.

• Now keeping the needle point at this survey point-draw an arc on the model and determine if an acceptable

plane of occlusion would result from using the survey point.

• When an acceptable height is established for the most distal lower tooth, a line is scribed on the model till

the cuspid. This line represents the height of the buccal cusp tips.

• To determine the buccal preparation line, the calipers are opened an amount equivalent to the desired

occlusal thickness of the proposed restoration and a second line is scribed.

Dawson PE. Functional occlusion. Elsevier Health Sciences.

• This established occlusal plane is transferred intraorally by fabricating an index with the
help of autopolymerising resin or PVS impression material .
• After tooth preparation, master casts are remounted in the articulator, wax patterns
fabricated and castings are done.
• The castings are reseated on the dies and any occlusal discrepancies are reduced.

Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and in restoring lower
posterior teeth. J Prosthet Dent 10:135–150
 REHABILITAION OF MAXILLARY TEETH
1.FABRICATING BILATERAL INCISAL GUIDES

• The cuspids are waxed up by creating freedom from centric to relieve the
lock-in occlusion.
• These wax patterns are casted and adjusted in the centric and eccentric
movements in the articulator as ideal as possible.
• These are called guide castings and ready to be tried in before making the
functional chew in record.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
• The cuspids have been corrected to the exact vertical dimension
and centric and eccentric occlusions.
• Even more important, nothing is touching in the back of cuspids.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
 22

Functionally generated path technique

● Method of rehabilitating the upper posterior teeth using ‘functionally generated path ’
record based on a modification of the principles outlined by Meyer and Brenner in
1933.
● Mann and Pankey used this procedure for complete occlusal rehabilitation.
 2. FUNCTIONALLY GENERATED PATH TABLES
• The path tables are fabricated one on each side to support
the wax generated path records.
• Wax patterns are made on the dies of most mesial and distal
prepared teeth.
• Thin sheet of casting wax is attached on the wax patterns so
that it only contacts the occlusal surfaces of the other
prepares teeth, with 0.5mm clearance in all excursions.
• It is then luted to the wax patterns of terminal abutments and
casting is done.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
• There must be no contact behind the cuspids so the contacts are not pulled
out of position or displaced.
• Now, the bite registration wax is added on the guide table and patient is
instructed to make
1. Power bite in centric relation
2. Then open and contact the opposing tips of cuspids and glide teeth back to
the centric relation.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
 LABORATORY PROCEDURE

Guide castings returned to master cast

Incisor teeth on upper cast shortened 1 to 2 mm and

flattened for done index to be poured

FGP table is placed on master cast and sealed with

sticky wax

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
 LABORATORY PROCEDURE

Flattened incisal edges of maxillary inciors are boxed

Dental stone is poured from the wax generated path

record and onto the flattened incisal surfaces of
anterior teeth for half inch.

Now, the stone is poured over the lower mounting

plate to within half inch of the FGP record

And then they are united with hydrocal.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
 Fabricating wax patterns and castings

• Lower anatomic cast is substituted with the FGP mounting jig

which provides the mandibular occlusal surfaces.
• Wax patterns are fabricated and then FGP jig is replaced with
anatomic cast and then, the wax patterns are corrected
• After casting, intraorally the occlusion is corrected in both
centric and eccentric conditions.

Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated path
technique. J Prosthet Dent 10:151–162
Twin table procedure
 TWIN TABLE CONCEPT

Terminologies used mainly in this concept include

• Condylar guidance
• Anterior guidance
• Angle of hinge rotation
• Cuspal shape factor
• Disocclusion
• Incisal guide table without disocclusion and with disocclusion
• Previously, incisal and condylar guidance are considered two separate
entities.
• Hobo proposed that both are codependent factors and condylar
guidance is not a fixed entity in an adult
• The deviation in the condylar path during eccentric movements was
attributed to the shock-absorbing nature of the articular disk. This
study refers to this deviation in condylar path as a "buffer space”.

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I:

mechanism of anterior guidance. J Prosthet Dent 66:299–303
• The average buffer spaces -0.3 mm in laterotrusion, and 0.8 mm along
the protrusive and nonworking sagittal condylar path.
• Molar disclusion should be greater than the buffer space to avoid
occlusal interferences during eccentric movements.

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I:

mechanism of anterior guidance. J Prosthet Dent 66:299–303
 Cusp shape factor

• Cusp Angle (ἀ) is "The angle made by the average slope of a cusp with the cusp plane
measured mesiodistally or buccolingually”
• The angle formed by the average cusp slope and the horizontal reference plane is called
the Effective Cusp Angle(ß)

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I:

mechanism of anterior guidance. J Prosthet Dent 66:299–303
 • The posterior teeth disocclude only when the
cusp inclination of the molar is parallel to the
condylar path and anterior guidance is steeper
than the condylar path.
• The cusp inclination (A) also becomes more
shallow with a semicircular shape (B).
• The shape of the cusp has great influence on the
disclusion of posterior teeth.
• To produce fully balanced occlusion, it is then
necessary to make the cusp with a straight edge,
whereas for disclusion the cusp requires a convex
semicircular shape
Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303
 Angle of Hinge rotation

• When anterior guidance is steeper than the condylar path, mandible

translates and rotates causing posterior disocclusion.
• This rotation of the condyle compensates for the difference in the
steepness of the anterior and the condylar path

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I:

mechanism of anterior guidance. J Prosthet Dent 66:299–303
 TECHNIQUE
● Record the condylar path by using a pantograph or
interocclusal records.
● Make the maxillary cast with a removable anterior segment.
● Remove the maxillary anterior segment and move the
articulator through eccentric movements to eliminate
interferences that impede an even, gliding motion .
● This procedure results in a cusp shape factor that harmonizes
with the condylar path.

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I:

mechanism of anterior guidance. J Prosthet Dent 66:299–303
● Insert a flat incisal table and mold chemical cure resin by moving the incisal pin
through eccentric movements.
● Repeat the procedure on second table to complete two incisal tables without
disoclusion.

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
● Use one of the incisal tables without disclusion on the articulator.
● Place two 3mm plastic spacers behind the condyle to simulate a protrusive position.
● Place a 1.1 mm thick spacer on the mesio buccal cusp tip of the mandibular first molar,
then close the articulator

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
● The lateral movement can be simulated by placing a 3 mm thick plastic spacer behind
one of the condyles on the articulator.
● A 1 mm thick vinyl sheet is positioned on the tip of the mesiobuccal cusp of the
mandibular first molar on the nonworking side and a sheet 0.5 mm thick can be also
positioned on the working side. When the articulator is closed, the incisal pin is
directed laterally and upward.
● This creates the angle of hinge rotation to ensure the average disclusion during lateral
movement.

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
 Incisal guidance with disclusion

● The tip of the incisal pin is directed backward and upward

from the incisal table. A brush is used to build chemical-
cure acrylic resin into a cone between the incisal pin and
incisal table.
● The cone marks the three-dimensional position of the tip
of the incisal pin at a 3 mm protrusive movement with 1.1
mm molar disclusion.
● This creates the angle of hinge rotation required to
produce the average disclusion during protrusive
movement.
Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
 Fabrication of restorations
● After final impression, master casts mounted on the articulator with the help of
facebow transfer
● The anterior maxillary segment is removed and posterior wax patterns are fabricated
first by using incisal guide table without disclusion
● After posterior teeth waxup is completed now incisal guide table with disocclusion is
placed in the articulator
● After that the maxillary anterior segment is reinserted and wax is melted on maxillary
anterior lingual surfaces
● All the border movements are made

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
● The wax is contoured by the incisal edges of the mandibular anterior teeth so that they
contact evenly.
● This procedure establishes the angle of hinge rotation and develops anterior guidance
in harmony with the condylar path. Since the anterior guidance programmed in this
manner is steeper than the condylar path and the molar cuspal inclinations, the
posterior restorations provide a predetermined disclusion during eccentric movement

Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent 66:471–477
Twin stage procedure
Twin table vs twin stage
1. in the Twin-Stage procedure, a standard cusp angle is created on a restoration and
2. the incisal path (anterior guidance) for obtaining the standard amount of disocclusion
is then computed based on the mathematical model of mandibular movement.

Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a new method to reproduce precise eccentric occlusal
relations. Int J Periodontic Restor Dent 17:113–123
Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a new method to reproduce precise eccentric occlusal
relations. Int J Periodontic Restor Dent 17:113–123
● The Adjustment values used to obtain standard cusp angle was called "Condition 1- 25°"
● The Adjustment values used to create anterior guidance was called "Condition 2-1mm"
 49

• Master casts are mounted on the articulator,

• The anterior segment is made removable.
• Posterior teeth are waxed to meet to Condition 1.

Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a new method to reproduce precise eccentric occlusal
relations. Int J Periodontic Restor Dent 17:113–123
• Maxillary and Mandibular molars under even tooth in contact condition 1.

• The sagittal condylar path and anterior guide table adjusted to Condition 2 to

create anterior guidance.

• The anterior segment at the maxillary working cast and wax is replaced. Anterior

guidance was created.

Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a new method to reproduce precise eccentric occlusal
relations. Int J Periodontic Restor Dent 17:113–123
SUMMARY AND CONCLUSION
 REFERENCES
● Dawson PE. Evaluation, diagnosis and treatment of occlusal problems. Saint Louis: The CV Mosby Co; 1974. p. 48-

293.

● Rosenstiel FS, Land FM, Fujimoto J: Contemporary fixed prosthodontics, 4 th ed. St. Louis, Elsevier,2011, pp.42-74.

● Broderson SP. Anterior guidance- The key to successful occlusal treatment. J Prosthet Dent 1978;39(4):396-400.

● Ladha K ,Lalit A,Naik B. Occlusal Concepts in Full Mouth Rehabilitation: An Overview. J Indian Prosthodont

Soc.2014;14:344-51

● Mann AW, Pankey LD Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and in restoring

lower posterior teeth. J Prosthet Dent 1960; 10:135–50

● Pankey LD, Mann AW Oral rehabilitation: part II. Reconstruction of the upper teeth using a functionally generated

path technique. J Prosthet Dent 1960; 10:151–62

● Hobo S. Twin-tables technique for occlusal rehabilitation. Part I: mechanism of anterior guidance. J Prosthet Dent

1991; 66:299–303.

● Hobo S . Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet Dent .1991;

66:471–77

● Hobo S, Takayama H. Twin-stage procedure. Part 1: a new method to reproduce precise eccentric occlusal relations.

Int J Periodontic Restor Dent 1997; 17:113–23

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