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

IJDCR 2013. All rights reserved

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PHILOSOPHIES IN FULL MOUTH REHABILITATION A SYSTEMATIC REVIEW
Bharat Raj Shetty
1
, Manoj Shetty
2
, Krishna Prasad D.
3
, S. Rajalakshmi
4
, Raghavendra Jaiman
5

1
Lecturer, Depart ment of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka,
India
2
Professor, Depart ment of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,
Karnataka, India
3
Professor & HOD, Depart ment of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,
Karnataka, India
4
P.G. Student, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,
Karnataka, India
5
P.G. Student, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore,
Karnataka, India

Address for Correspondence
Dr. Manoj Shetty
Professor
Depart ment of Prosthodontics
A.B. Shetty Memorial Institute of Dental Sciences
Mangalore, Karnataka, India
Emai l i d : drmanojshetty@gmai l .com
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 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


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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 treat ing 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 restore
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 patient.
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
missing, worn, broken down or decayed.
2. To replace improperly designed and
executed crown and bridge framework.
3. Treat ment 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
position (termed centric relat ion) 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 relat ion and
maximum intercuspation position should be analyzed
as vertical, horizontal and lateral components both at
tooth and condylar level. The occlusal vert ical
dimension should be determined by utilizing the
physiologic 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 same. A study 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 correlat ion
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 treat ment that was originally organized into a
workable concept by Dr. L.D. Pankey utilizing the
principles of occlusion espoused by Dr. Clyde
Schuyler. (5)

Schuylers 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,
Treat ment planning and Prognosis
2. PART II : Harmonizat ion 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 single tooth.
2. It is a well- organized logical procedure that
progresses smoothly with less wear and tear
on the operator, patient and technician.
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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 patients 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 vert ical
dimension to which the case will be
reconstructed.
7. All posterior occlusal contours are
programmed by and are in harmony with
both condylar border movements and a
perfected anterior guidance.
8. There is no need for t ime 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
Depart ment of Prosthodontics with a chief complaint
of discolored teeth. On clinical examination, chipping
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 attrit ion was observed with a decrease in
vertical dimension 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) art iculator using facebow
records. Anterior wax up was done to appropriate
shape, size and contour. Mandibular occlusal plane
was analysed using Broadricks 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, temporizat ion 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
temporizat ion 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 relat ion was recorded at the
proposed vertical dimension and casts were mounted
in the same relat ion. PFM crowns were cemented.
The mandibular posterior teeth preparations were
refined and impressions made. Inclines of wax
patterns were carved using fossa contour guide. The
porcelain crowns fabricated were subject to occlusal
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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 patients. Fabrication
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) Broadricks occlusal plane analysis
c) Tooth preparation of lower anteriors
completed
d) Provisionalizat ion of lower anterior teeth.



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- establishment of occlusal plane with
Broadricksocclusal plane analysis

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 different customized
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 helps 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 plastic separators behind the
condylar elements. This is termed the incisal
guidance with disclusion. The first incisal guide table
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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
Depart ment 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
Hobostwin 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 articulator (Whip mix-
Arcon). Occlusal plane was evaluated using
Broadricks 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 separators 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
movements. (Figure 4, 5, 6)

Figure 4
a) Pre operativephotograph of Case 2 to be
treated by Hobos Twin Table technique
b) Occlusal plane established using
Broadricksocclusal plane analysis
c) Maxillary full arch tooth preparation
completed.
d) Facebow transfer recording

HOBO S TWIN STAGE PHILOSOPHY (8)

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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
living 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 side)
20
Table 1: Standard values of effective cusp angle on
molars as advocated in Hobos 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 Condit ion).
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 relat ion
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 side

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
Depart ment 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
Hobos Twin stage philosophy was proposed as the
treatment of choice. Diagnostic casts were mounted
onto a Whipmix articulator using facebow t ransfer
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 movements. This would ensure
a uniform amount of posterior disclusion during
lateral and protrusive excursions when the anterior
guidance is established later.
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Figure 7
a) Pre operative photograph of Case 3, to be treated
using Hobos twin stage technique
b) Wax mock up of the diagnostic models mounted
on 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 chromium metal
ceramic alloy. The crowns were tried on the cast and
trimmed so as to achieve uniform bilateral contacts in
centric relat ion. 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: Modificat ion of articulator settings for
Hobos twin stage technique
CONCLUSION
In the tradit ional broad sense full mouth
rehabilitation implies the involvement of all
diagnostic, therapeutic, and restorative procedures at
Horizontal
condylar
guidance
Lateral
condylar
guidance
Anterior
guidance
Lateral
anterior
guidance
Modification
of art iculator
settings
(
CONDITION
1)
25 15 25 10
Modification
of art iculator
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 t imes more reliable than condylar and incisal paths.
Pankey Mann Schyulers philosophy advocates that
condylar guidance does not dictate anterior guidance.
Thus it believes in harmonizat ion 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 dentists choice of treat ment
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.
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3. Mann A W, Pankey L D: Oral Rehabilitation, J Prosth
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7. Hobo S: Twin Table technique for Occlusal
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