Int J Dent Case Reports 2013; 3(3): 30-39© IJDCR 2013. A ll rights reserved www.ijdcr.co m 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 :
[email protected] 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 Repeated failure dentures. operative skills. Co mfortab le function 7. bro ken down or decayed. the goal of dentistry is to 2.Shetty. Lack of interocclusal space for restoration. skill and all the 3.3. sound diagnosis. To To summarize. Sensitive teeth. Prasad. Dentistry uses its knowledge. 10. Vo l. resources at its command in both maintenance work Treat ment of temporo mandibular d isorders is also advised. Stable occlusion 5. Jaiman Full Mouth Rehabilitation INTRODUCTION 1. As the goal of medicine is to increase the life span of The restoration of mu ltiple teeth which are missing. Painful therapy. The discrepancies between centric relat ion and maximu m intercuspation position should be analyzed INDICATIONS FOR FULL as vertical. 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. 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 . Stable TMJs 4. combination of many aspects of dental treatment such Affected as patient education. crowns. Severe attritional Successfully treat ing patients requires a thoughtful wear. To replace imp roperly designed and executed crown and bridge framework. between the TMJ and occlusion. Rajalakshmi. bridges and partial unsatisfactory for various reasons . horizontal and lateral co mponents both at M OUTH tooth and condylar level. 11) soft tissues. periodontal treatment and achieving Unacceptable function. all o f which enhance the oral health and welfare of the patient. musculature due to disharmony between occlusion harmony and TMJs. The effects of occlusal pattern on the periodontal structures should 31 Int J Dent Case Reports Nov-Dec 2013. the functioning individual. No. or fracture of teeth or restorations. Unacceptable esthetics. Shetty. Freedom fro m d isease in all masticatory Adoption of an alternative strategy by establishing a system structures 2. worn. (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. occlusal considerations. Optimu m esthetics new occlusal scheme around a stable condylar position (termed ‘centric relat ion‘) should be considered. The aim is to restore the tooth to its natural form. Maintainable healthy teeth 6. certain bio logical considerations are 1. and rehabilitation to achieve its goal. the goals to be attained are: rehabilitation. Maintainable healthy periodontium 3. attain the various goals of fu ll mouth necessary along with the indicated conditions. 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. increase the life span of the functioning dentition. endodontic dentition. though caution is advised. The recognition of a vert ical dimension interfere with condylar guidance. Jaiman Full Mouth Rehabilitation also be assessed as attaining optimal periodontal 2. functional 1. 3 . 2. Prasad. on the operator.D. 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. and integration of all co mponent parts into one PART I : Examination. 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. Rajalakshmi. evaluation and the effects of materials used on occlusal stability control of parafunction Disclusion by the anterior guidance of all posterior teeth in protrusion. occlusal pattern by means of roentgen graphic 3. The PHILOSOPHIES FOLLOWED IN FULL M OUTH functionally generated path technique is so RECONSTRUCTION closely allied with this part of the reconstruction. FUNCTIONA L ASPECTS OF FULL M OUTH Group function of the wo rking side inclines in lateral excursions. anterior guidance in a manner that will not 2. which is a constant. patient and technician. 4. (2. dentition. must be 2. Pankey utilizing the (5) 1. 1. principles of occlusion espoused by Dr. 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. Shetty. Clyde It is possible to diagnose and plan the Schuyler. Treat ment planning and Prognosis functioning unit.organized logical procedure that maximu m number of teeth when the progresses smoothly with less wear and tear mandib le is in centric relation. (5) treatment fo r entire rehabilitation before Schuyler’s principles were : (4) preparing a single tooth. 5.Shetty. A static co-ordinated occlusal contact of the It is a well. No. PART IV: Restoration of the upper posterior occlusion in harmony with the anterior centric occlusion guidance and condylar guidance. 3. 32 Int J Dent Case Reports Nov-Dec 2013. satisfying all the related factors. REHABILITATION (10) In order to accomp lish these goals. Diagnosis. L. 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. Vo l. The aim. temporo mandibular disorders is necessary. Disclusion of all non-working inclines in lateral excursions. and 4. The function and comfort science of comp lete mouth rehabilitation rests upon 3. A study of the function in lateral eccentric position on the temporo mandibular joint positions relative to the working side.3. therefo re. The acceptance of a dynamic. 4. 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. posterior occlusal It is contours was observed. PFM crowns were cemented. Rajalakshmi. 9. A splint was both condylar border movements and a fabricated with an increase in vertical dimension of 2 perfected anterior guidance. 8. Vo l. 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. This was followed by maxillary occlusal reconstructed. The Utilizing phonetics and esthetics as a guide.3. fused to metal crowns for the mandibular anteriors. 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. temporizat ion of the prepared Laboratory procedures are simp le first. Cementation of the crowns was done using glass CASE REPORT ionomer cement. 2 mm porcelain crowns fabricated were subject to occlusal 33 Int J Dent Case Reports Nov-Dec 2013. Anterior wax up was done to appropriate relation are taken on the occlusal surface of shape. and teeth was done at a raised vertical dimension. 3 . ch ipping in the same relat ion. Prasad. vertical d imension of 2 mm. Radiographic examination revealed no requirement It divides the rehabilitation into separate of endodontic therapy for any teeth. the mandibular dentist. On clin ical examination. are was checked for proper anterior guidance to achieve programmed by and are in harmony with disclusion in eccentric movements. The There is no need fo r t ime consuming mandibular anterior teeth were prepared techniques and complicated equip ment. 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. 6. 7. Shetty. This was followed by fabrication of porcelain understands the goals of optimu m occlusion. Anterior wax up All of appointments. 5. size and contour.Maxillary operator always has an idea where he is at and man dibu lar d iagnostic casts were mounted onto all times. patterns were carved using fossa contour guide. The maxillary anterior teeth were A healthy 18 year old female patient reported to the prepared next. The Mann Schuyler philosophy was planned. wax up to maximu m intercuspation. Following imp ression. mm to be worn by the patient for 6 weeks.Shetty. In controlled to an extremely fine degree by the order to maintain the increase in VD. a Whip mix (Arcon) art iculator using facebow The functionally generated path and centric records. Jaiman 3. Generalized attrition was refined and impressions made. of enamel was seen with respect to most teeth with The mandibular posterior teeth preparations were exposure of dentine. posterior also had to be prepared in order to prevent 10. 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. No. Inclines of wax observed with respect to all the occlusal surfaces. Full Mouth Rehabilitation There is never a need for preparing or decrease in vertical dimension building more than 8 teeth at a time. The PMS philosophy of occlusal posterior open bite. 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. 2. developed anterior guidance to create a predetermined. He proposed Twin table concept which d) Provisionalizat ion of lower anterior teeth. And posterior disclusion is checked by keeping the condylar guidance shallower than the patient’s. It is fabricated by preparing die systems with removable anterio r and posterior segments. No.( Figure 1. Rajalakshmi. 3 . Wax patterns are fabricated for the same. Vo l.Shetty.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. This is termed the incisal guidance with disclusion. The technique utilizes 2 d ifferent customized incisal guide tables. harmonious disclusion with the condylar path.7) treated by Pankey Mann Schuyler technique b) Broadrick’s occlusal plane analysis c) Tooth preparation of lower Another philosophy was given by Dr. Su miya Hobo anteriors which is followed in rehabilitation of dentate completed patients. The first incisal guide table 34 Int J Dent Case Reports Nov-Dec 2013. This table helps us achieve uniform contacts in the posterior restorations during eccentric movements. Fabrication and cementation of the crowns are done.3. 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. The first incisal table is termed incisal table without disclusion. Th is is followed by preparation of maxillary posteriors. Jaiman Full Mouth Rehabilitation plane verification and then cemented. Prasad. Shetty. Th is was d) Facebow transfer recording followed by preparation of maxillary and mandibular teeth. the metal copings are excursive movements fabricated and try in of the same is done. Rajalakshmi. 3 . 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. Shetty. As explained in the concept. The incisal table with d isclusion was fabricated next by using 3 mm acry lic separators behind the condylar elements. The casts are mounted onto the articulator HOBO’ S TW IN STA GE PHILOSOPHY (8) using facebow transfer. for the posterior teeth to achieve uniform contacts. No. The wax patterns were fabricated guidance with disclusion.Shetty. Vo l. the raised vertical dimension was cemented. Using phonetics b) Occlusal and freeway space as a guide. an incisal table without disclusion was made without The second guide table is used to achieve incisal anterior guidance. movements. 5.3. Once the Disocclusion of posterior teeth on lateral incisal table is refined. using Pre-operative indicated endodontic treatment fo r certain teeth. Diagnostic casts were mounted using facebow Figure 4 records onto a semi adjustable articu lator (Whip mixArcon). This is done for each condylar element one at a time and protrusive movement by placing Figure 3 a) separators behind both condylar elements. 6) CASE REPORT: A 44 year o ld healthy male reported to the Depart ment of Prosthodontics with a co mplaint of worn out.5 mm was achieved on the working side and 1 mm is achieved on the non working side. Jaiman Full Mouth Rehabilitation is used to fabricate restorations for posterior teeth. 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. the vertical dimension p lane established using Broadrick’socclusal plane analysis was evaluated. 35 Int J Dent Case Reports Nov-Dec 2013. which was treated. 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. sensitive teeth and difficu lty in chewing. Disclusion of 0. (Figure 4. Prasad. The need to increase the vertical c) dimension by 4 mm was seen and an overlay splint at Maxillary full arch tooth preparation completed. 3. it is necessary changed by the dentist. 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’). Vo l. a cast with that it may co mpensate for wear of natural dentition a due to caries. The pantograph philosophy: as advocated in Hobo’s Twin Stage and fully adjustable articulators are results of their efforts. Th is concept was derived from the In order to provide disocclusion. ON MOLARS Sagittal removable anterior teeth (Referred to as ‘Condition 2’). 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.Shetty. Since than that of condylar path. 3 . No. the anterior portion of the reference fo r occlusion. when considered as a new reference for occlusion. 15 (working side) Frontal lateral effective cusp angle 20 (non working side) 36 Int J Dent Case Reports Nov-Dec 2013. when a dental technician waxes the variation and the occurrence rate of malocclusion is occlusal morphology and tries to reproduce a incorporated. the concept that focuses on the condylar path as the reference of occlusion Basic concept of twin stage procedure: was utilized. independent of condylar path as well as incisal path. some guidance should be incorporated. Though fabricating the anterior teeth to produce disocclusion. Thus the cusp angle was working cast becomes an obstacle. Secondly. abrasion and restorative works. when individual disocclusion. the cusp angle belief that condylar path was unchangeable in the should be shallower than the condylar path. 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. 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. However. the incisal path would not be a reliable shallower cusp angle. In this a standard value for cusp angle was determined such methodical approach described by Hobo. Also. The deviation of the incisal path is less movement. To make liv ing body whereas anterior guidance could be freely a shallower cusp angle in a restoration. Du ring develop ment. Prasad. Shetty. Rajalakshmi. Vo l. Shetty. Abnormal curve of Spee Teeth preparation was completed and final 2.3. Jaiman Full Mouth Rehabilitation Hobo’s Twin stage philosophy was proposed as the treatment of choice. 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. Full mouth rehabilitation following 37 Int J Dent Case Reports Nov-Dec 2013. Once endodontic therapy guidance is established later. This would ensure of excessive tooth wear. Abnormally rotated teeth patterns were fabricated at an increased vertical 4. No. 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.Wax 3. Rajalakshmi. Abnormally inclined teeth dimension of 4mm and the prepared teeth were temporized using heat cure acrylic resin. Diagnostic casts were mounted onto a Whipmix articulator using facebow t ransfer and interocclusal records. was completed. Diagnostic wax up was done increasing the vertical dimension by 4 mm. Prasad. 3 . 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.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. After cutback to create space for porcelain. the wax Figure 7 a) b) Pre operative photograph of Case 3. 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. 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. The palatal contours are adjusted according to the anterior guidance to provide immed iate disclusion away fro m centric relation. and restorative procedures at 38 Int J Dent Case Reports Nov-Dec 2013. 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. Vo l. Metal try in was subsequently done Fabrication of wax pattern on the maxillary intraorally and verified for fit and contacts.Shetty. Shetty. therapeutic. Rajalakshmi. 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. 3 . working cast (Figure 7.3. to be treated patterns were cast with a nickel chro miu m metal using Hobo’s twin stage technique ceramic alloy. Anterior dies are replaced onto the casts and wax up is co mpleted to achieve adequate aesthetics. Prasad. No. guidance. 4 t imes mo re reliable than condylar and incisal paths. 1955 condylar guidance does not dictate anterior guidance.82 . Kazis Harry: Functional aspects of complete mouth rehabilitation. Thus it believes in harmon izat ion of the anterior 39 Int J Dent Case Reports Nov-Dec 2013. Harry Kazis. 1991 dependent on the anterior guidance. J Prosth Dent 3 : 722. Vo l. Dent Clin North Am 7: 621-38 . Rajalakshmi. Jaiman Full Mouth Rehabilitation our command for the treatment and prevention of guidance for best possible esthetics. London. 3 . followed and clin ical skills. J Prosth Dent 10: 135-62 . J Prosth Dent 4 (6): 833-842. Joseph. M osby . Landa: An analysis of current practices in mouth rehabilitation. Hobo S : Twin Table technique for occlusal rehabilitation : Part I – M echanism of Anterior guidance . the cusp angle was considered as the most reliable 10. function and dental disease. These factors contribute to the determination of an ideal anterior 9. Kazis Harry: Complete M outh Rehabilitation through restoration of lost vertical dimension . S. Louis . J Prosth Dent 5(4):527-37. 5. 1991 According to the Twin table technique by Hobo. Albert Kazis : Complete M outh Rehabilitation through fixed partial denture Prosthodontics. Irving Goldman: The goal of full mouth rehabilitation . 1953 considered to be at the discretion of the dentist. incisal path and cusp angle determine the health of the entire oral mechanis m. mo re recently comfo rt and the determination of an occlusal p lane acquired sense. Pankey Mann Schyuler’s philosophy advocates that 12. Early gnathological concepts focused 3. 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. 1963 rehabilitation have different approaches and concepts regarding the relationship of the factors that govern disocclusion. 1952 2. M ann A W. the term refers to the extensive and based on anterior guidance. Quintessence publication. 7) In Prosthodontics. 2007 McCollu m and Stuart concluded fro m a study conducted on 10 patients that condylar guidance is 6. A comprehensive study function. Pankey L D: The Pankey M ann philosophy of occlusal rehabilitation.77 . This was in accordance with the proven data fro m studies that cusp angle was 11.Shetty. REFERENCES 1. However. Shetty. St.D. Hobo S: Oral rehabilitation . Anterior guidance was 4.1960 primarily on condylar path as it was theorized to be a constant through adulthood. Hobo S: Twin Table technique for Occlusal rehabilitation: Part II – Clinical procedure . 1954 determinant of occlusion. (6. J. Schyuler C H : Factors in Occlusion applicable to restorative dentistry . J Prosth Dent 10 (2): 296-303 . J restoration factors: improvement of occlusal The three philosophies followed in fu ll mouth Prosth Dent 2(2) : 246 -51. relieving and practical approach must be directed towards tempero mandibular joint dysfunction. Pankey L D: Oral Rehabilitation. 1960. Prasad. derived fro m the condylar path.3. amount of d isocclusion during eccentric movement. 1948.A. M ann A W. No. in the Twin Stage procedure. Clinical determination of Occlusion. 7. J Prosth Dent 66 (3) : 299-303 . the cusp shape factor and angle of hinge rotation is 8. The condylar reconstruction.A 37 : 19. In the narro wer. (12) These modifications are motivated based on his knowledge of various philosophies by various in esthetics. J Prosth Dent 66 (4) : 471. restoration and maintenance of the path. Dawson P: Functional occlusion from TM J to smile design. the condylar path has been considered the main determinant of occlusion.