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

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PHILOSOPHIES IN FULL MOUTH REHAB ILITATION – A S YSTEMATIC REVIEW

Bharat Raj Shetty 1 , Manoj Shetty2 , Krishna Prasad D.3 , S. Rajalaksh mi4 , 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 Memo rial 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
Email id : drmanojshetty@gmail.com
Contact: 09845267087

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

INTRODUCTION 1. The restoration of mu ltiple teeth which are

As the goal of medicine is to increase the life span of missing, worn, bro ken down or decayed.
the functioning individual, the goal of dentistry is to 2. To replace imp roperly designed and
increase the life span of the functioning dentition. executed crown and bridge framework.
Dentistry uses its knowledge, skill and all the 3. Treat ment of temporo mandibular d isorders
resources at its command in both maintenance work is also advised, though caution is advised.
and rehabilitation to achieve its goal. (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
unsatisfactory for various reasons - Repeated failure
inlays, crowns, bridges and partial dentures.
or fracture of teeth or restorations, Severe attritional
Successfully treat ing patients requires a thoughtful
wear, Lack of interocclusal space for restoration,
combination of many aspects of dental treatment such
Affected dentition, Unacceptable function,
as patient education, sound diagnosis, periodontal
Unacceptable esthetics, Sensitive teeth, Painful
therapy, operative skills, occlusal considerations,
musculature due to disharmony between occlusion
endodontic treatment and achieving harmony
and TMJs.
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 BIOLOGICA L CONSIDERATIONS DURING
harmonious relationship with the adjacent hard and OCCLUSAL REHA BILITATION (9, 10, 11)
soft tissues, all o f which enhance the oral health and
welfare of the patient. To attain the various goals of fu ll mouth
To summarize, the goals to be attained are: rehabilitation, certain bio logical considerations are
necessary along with the indicated conditions.
1. Freedom fro m d isease in all masticatory
Adoption of an alternative strategy by establishing a
system structures
new occlusal scheme around a stable condylar
2. Maintainable healthy periodontium
position (termed ‘centric relat ion‘) should be
3. Stable TMJs
considered. The decision to reorganize the occlusion
4. Stable occlusion
in a patient is done only after a detailed and careful
5. Maintainable healthy teeth
examination of the occlusion using study models etc.
6. Co mfortab le function
The discrepancies between centric relat ion and
7. Optimu m esthetics
maximu m intercuspation position should be analyzed
as vertical, horizontal and lateral co mponents both at
INDICATIONS FOR FULL M OUTH
tooth and condylar level. 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. The effects of
occlusal pattern on the periodontal structures should
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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation

also be assessed as attaining optimal periodontal 2. An anterior guidance that is in harmony with
health is also an objective o f the same. A study of the function in lateral eccentric position on the
temporo mandibular joint positions relative to the working side.
occlusal pattern by means of roentgen graphic 3. Disclusion by the anterior guidance of all
evaluation and the effects of materials used on posterior teeth in protrusion.
occlusal stability control of parafunction and 4. Disclusion of all non-working inclines in
temporo mandibular disorders is necessary. lateral excursions.
5. Group function of the wo rking side inclines
FUNCTIONA L ASPECTS OF FULL M OUTH in lateral excursions.
REHABILITATION (10)
In order to accomp lish these goals, 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. PART I : Examination, Diagnosis,
and integration of all co mponent parts into one
Treat ment planning and Prognosis
functioning unit. The aim, therefo re, must be
2. PART II : Harmonizat ion of the anterior
reconstruction and rehabilitation of the entire
guidance for best possible esthetics ,
dentition, satisfying all the related factors. The
function and comfort
science of comp lete mouth rehabilitation rests upon
3. PART III: Selection of an acceptable
three proved and accepted fundamentals:
occlusal plane and restoration of the lo wer

1. The existence of a physiologic rest position posterior occlusion in harmony with the

of the mandib le, which is a constant. anterior guidance in a manner that will not

2. The recognition of a vert ical dimension interfere with condylar guidance.

3. The acceptance of a dynamic, functional 4. PART IV: Restoration of the upper posterior

centric occlusion occlusion in harmony with the anterior

guidance and condylar guidance. The

PHILOSOPHIES FOLLOWED IN FULL M OUTH functionally generated path technique is so

RECONSTRUCTION closely allied with this part of the

reconstruction. (2, 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. L.D. Pankey utilizing the (5)

principles of occlusion espoused by Dr. Clyde 1. It is possible to diagnose and plan the

Schuyler. (5) treatment fo r entire rehabilitation before

Schuyler’s principles were : (4) preparing a single tooth.

1. A static co-ordinated occlusal contact of the 2. It is a well- organized logical procedure that

maximu m number of teeth when the progresses smoothly with less wear and tear

mandib le is in centric relation. on the operator, patient and technician.

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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman
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 vert ical
dimension to which the case will be
reconstructed.
7. All posterior occlusal contours
programmed by and are in harmony with
both condylar border movements and a
perfected anterior guidance.
8. There is no need fo r t ime consuming
techniques and complicated equip ment.
9. Laboratory procedures are simp le
controlled to an extremely fine degree by the
dentist.
10. The PMS philosophy of occlusal
rehabilitation can fu lfill the mos t exacting
and sophisticated demands if the operator
understands the goals of optimu m occlusion.
CASE REPORT
A healthy 18 year old female patient reported to the
Depart ment of Prosthodontics with a chief co mplaint
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
Int J Dent Case Reports
Full Mouth Rehabilitation
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 d imension of 2 mm. Full mouth rehabilitation
pertaining to the principles and goals of Pankey
Mann Schuyler philosophy was planned.Maxillary
and man dibu lar d iagnostic 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 Broadrick’s occlusal plane
analysis. This was followed by maxillary occlusal
wax up to maximu m intercuspation. Anterior wax up
are 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 imp ression, temporizat ion of the prepared
and 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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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation

plane verification and then cemented. Th is 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. Fabrication
and cementation of the crowns are done.( Figure 1, 2,
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- 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 (6,7)
treated by Pankey Mann Schuyler technique
b) Broadrick’s occlusal plane analysis Another philosophy was given by Dr. Su miya Hobo
c) Tooth preparation of lower anteriors which is followed in rehabilitation of dentate
completed patients. He proposed Twin table concept which
d) Provisionalizat ion of lower anterior teeth. developed anterior guidance to create a pre-
determined, harmonious disclusion with the condylar
path. The technique utilizes 2 d ifferent customized
incisal guide tables. The first incisal table is termed
incisal table without disclusion. It is fabricated by
preparing die systems with removable anterio r 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 articu lator can simu late 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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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation

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.
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 d isclusion was fabricated next
by using 3 mm acry lic 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)

CASE REPORT:
A 44 year o ld healthy male reported to the
Depart ment of Prosthodontics with a co mplaint of
worn out, sensitive teeth and difficu lty 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 fo r certain teeth, which was treated.
Diagnostic casts were mounted using facebow
Figure 4
records onto a semi adjustable articu lator (Whip mix-
a) Pre operativephotograph of Case 2 to be
Arcon). Occlusal plane was evaluated using
treated by Hobo’s Twin Table technique
Broadrick’s occlusal plane analysis. Using phonetics
b) Occlusal p lane established using
and freeway space as a guide, the vertical dimension
Broadrick’socclusal plane analysis
was evaluated. The need to increase the vertical
c) Maxillary full arch tooth preparation
dimension by 4 mm was seen and an overlay splint at
completed.
the raised vertical dimension was cemented. 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. As explained in the concept,

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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. Du ring develop ment, the concept that focuses
on the condylar path as the reference of occlusion
was utilized. Th is 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 fo r 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 co mpensate for wear of natural dentition
due to caries, abrasion and restorative works.
STANDA RD VA LUES OF EFFECTIVE CUSP
ANGLE ON M OLARS
CUSP ANGLE CUSP A NGLE ON
MOLARS
Sagittal protrusive 25
effective cusp angle
Frontal lateral effective 15
cusp angle (working
side)
Frontal lateral effective 20
cusp angle (non
working side)
Table 1: Standard values of effective cusp angle on
mo lars 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 ‘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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Hobo’s 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 5
a) Recording of interocclusal centric relat ion
using Aluwax
b) Mounting of the prepared models using
Figure 6
facebow transfer and interocclusal record
a) Condylar inserts inserted behind condylar
c) Condylar insert of 3 mm placed behind the
elements
condylar elements to achieve disclusion of
b) Preparation of wax patterns
posterior teeth.
c) Disclusion achieved in lateral excursive
d) Disclusion of 1 mm achieved on the non-
movement
working side
d) Post operative photograph of the co mpleted
full mouth rehabilitation
Contraindications:

1. Abnormal curve of Spee Teeth preparation was completed and final

2. Abnormal curve of Wilson impression was made using addition silicone.Wax
3. Abnormally rotated teeth patterns were fabricated at an increased vertical
4. Abnormally inclined teeth dimension of 4mm and the prepared teeth were
temporized using heat cure acrylic resin.
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. This would ensure
of excessive tooth wear. 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. Once endodontic therapy guidance is established later.
was completed, Full mouth rehabilitation following

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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 co mpleted to
achieve adequate aesthetics. The palatal contours are
adjusted according to the anterior guidance to provide
immed iate disclusion away fro m centric relation.
Figure 7 After cutback to create space for porcelain, the wax
a) Pre operative photograph of Case 3, to be treated patterns were cast with a nickel chro miu m metal
using Hobo’s twin stage technique ceramic alloy. The crowns were tried on the cast and
b) Wax mock up of the diagnostic models mounted
trimmed so as to achieve uniform b ilateral contacts in
on semi adjustable articulator
centric relat ion. Metal try in was subsequently done
c) Fabrication of wax pattern on the maxillary
intraorally and verified for fit and contacts. Ceramic
working cast
layering was subsequently carried out and prosthesis
d) Fabrication of wax pattern on the mandibular
working cast was cemented using Glass ionomer luting cement.
(Figure 7, 8)

Horizontal Lateral Anterior Lateral

condylar condylar guidance anterior
guidance guidance guidance
Modification 25 15 25 10
of art iculator
settings
(
CONDITION
1)
Modification 40 15 45 20
of art iculator
settings
(CONDITION
2)
Figure 8
a) Co mpleted Posterior restorations in centric
Table 2: Modificat ion of articu lator settings for
relation
Hobo’s twin stage technique
b) Unifo rm g lid ing contants from centric
relation to lateral excursive movements CONCLUS ION
c) Post operative photograph of full mouth In the tradit ional broad sense full mouth
rehabilitation rehabilitation imp lies the involvement of all
diagnostic, therapeutic, and restorative procedures at

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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman
our command for the treatment and prevention of
dental disease. In the narro wer, mo re 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
tempero mandibular joint dysfunction. The condylar
path, incisal path and cusp angle determine the
amount of d isocclusion during eccentric movement.
The three philosophies followed in fu ll 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.
McCollu m and Stuart concluded fro m 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 fro m 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 fro m studies that cusp angle was
4 t imes mo re reliable than condylar and incisal paths.
Pankey Mann Schyuler’s philosophy advocates that
condylar guidance does not dictate anterior guidance.
Thus it believes in harmon izat ion of the anterior
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Int J Dent Case Reports
Full Mouth Rehabilitation
guidance for best possible esthetics, function and
comfo rt and the determination of an occlusal p lane
based on anterior guidance. Occlusal rehabilitation is
a radical p rocedure and should be carried out in
accordance with the dentist’s choice of treat ment
based on his knowledge of various philosophies
followed and clin ical 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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1. Irving Goldman: The goal of full mouth rehabilitation , J
Prosth Dent 2(2) : 246 -51, 1952
2. M ann A W, Pankey L D: The Pankey M ann philosophy
of occlusal rehabilitation, Dent Clin North Am 7: 621-38 ,
1963
3. M ann 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 TM J to smile
design, M osby , St. Louis , 2007
6. Hobo S : Twin Table technique for occlusal
rehabilitation : Part I – M echanism 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 M outh Rehabilitation through
restoration of lost vertical dimension , J.A.D.A 37 : 19,
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10. Kazis Harry: Functional aspects of complete mouth
rehabilitation. J Prosth Dent 4 (6): 833-842, 1954
11. Harry Kazis, Albert Kazis : Complete M outh
Rehabilitation through fixed partial denture Prosthodontics.
J Prosth Dent 10 (2): 296-303 , 1960.
12. Joseph. S. Landa: An analysis of current practices in
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