philosophies of full mouth

1. Philosophies of full Mouth
rehablitation
Dr. Vikram Kumar

2. Content
• Introduction
• Classification
• Occlusal approach
• Choices of occlusal concept and philosphy
• Basic concept of philosphy
• Schulyer principle
• Brief case report of PMS
• Case report using Hobo twin table
• Case report using Hobo twin stage
• Disscusion
• Conclusion

3. Introduction
• The objective of full mouth rehabilitation is not only the reconstruction
and restoration of the worn out dentition, but also maintenance of the
health of the entire stomatognathic system.
• Full mouth rehabilitation should re-establish a state of functional as well
as biological efficiency where teeth and their periodontal structures, the
muscles of mastication, and the temporomandibular joint (TMJ)
mechanisms all function together in synchronous harmony
• Occlusal Concepts in Full Mouth Rehabilitation: An Overview Bhawana
Tiwari • Komal Ladha • Aaruti Lalit

4. classification
• Various classifications have been proposed to classify patients
requiring full mouth rehabilitation, however, the classification most
widely adopted is the one given by Turner and Missirlian.
• According to them, patients with occlusal wear can be broadly
classified as follows:
• Category-1: Excessive wear with loss of vertical dimension of
occlusion (VDO)
• The patient closest speaking space is more than 1 mm and the
interocclusal space is more than 4 mm and has some loss of facial
contour and drooping of the corners of the mouth.
• All teeth of one arch must be prepared in a single sitting once the
final decision is made.

5. • Category-2: Excessive wear without loss of VDO
but with space available
• Patients typically have a long history of gradual wear caused
by bruxism, oral habits, or environmental factors but the
occlusal vertical dimension (OVD) is maintained by continuous
eruption.
• It might be difficult to achieve retention and resistance form
because of shorter crown length and gingivoplasty may be
needed.
.

6. • Category-3: Excessive wear without loss of
VDO but with limited space
• There is excessive wear of anterior teeth over
a long period, and there is minimal wear of
the posterior teeth.
• Centric relation and centric occlusion are
coincidental

7. Occlusal Approach
• Occlusal approach for restorative therapy can be either
conformative approach (often advisable) or a reorganised
approach.
• In conformative approach , occlusion is reconstructed
according to the patient’s existing intercuspal position
• In reorganised approach, new occlusal scheme is established
around a suitable condylar position which is the centric
relation position.
• Occlusal Concepts in Full Mouth Rehabilitation: An Overview Bhawana Tiwari •
Komal Ladha • Aaruti Lalit

8. Choice of Occlusal Concepts and
Philosophies
• The early concepts of occlusal philosophies originated from gnathological
concept. The term gnathology was first coined by Stallard in 1924.
McCollum founded gnathological society in 1926;
• Stuart became associated with gnathological society and published their
classic “research report” in 1955 and gave GNATHOLOGICAL CONCEPT
• Their observations led to the development of mandibular movements,
transverse hinge axis, maxillomandibular relationships, and an arcon fully
adjustable articulator.
• They believed that anterior guidance was independent of the condylar
path and described condylar path as a fixed entity in adults
• Occlusal Concepts in Full Mouth Rehabilitation: An Overview Bhawana
Tiwari • Komal Ladha • Aaruti Lalit

9. • The concept of balanced occlusion which included the idea that the most
posterior position of the condyles was the optimal functional position for
restoring denture occlusion was applied to restoration of the natural
dentition by McCollum , Schuyler and others.
• Schuyler supported balanced occlusion during his early clinical years but
later began to observe clinical failures
• In their report in 1960 , they adopted the concept of mutually protected
occlusion (canine-protected /organic occlusion which replaced the
concept of balanced occlusion

10. • Becker and Kaiser had given the concept of biological occlusion to
maintain the health and function of stomatognathic system.
• According to this concept,
• there should be no interferences between centric occlusion and CR,
• no balancing contacts,
• cusp to fossa occlusal scheme,
• cuspid protected or group function occlusion,
• no contacts in posteriors during protrusion,
• no cross tooth balancing contacts, and elimination of all possible fremitus
• An Appraisal on Occlusal Philosophies in Full-mouth Rehabilitation: A Literature Review. Ankita
Parmar

11. • A simplified occlusal design was given by Wiskot and Belser
based on the philosophy that in natural dentition, occlusal
contacts are few and not ideally placed.
• According to them, one occlusal contact per tooth usually a
cusp–fossa relation is sufficient instead of a tripod contact

12. • Early gnathologic concepts focused primarily on the condylar path and it was
believed that anterior guidance was independent of the condylar path
• Hobo and Takayama in their study revealed that anterior guidance influenced
the working condylar path and concluded that they were dependent factors.
• Hobo adopted the concept of posterior disclusion and gave the Twin-tables
Technique
• Twin-tables technique for occlusal rehabilitation: Part II--Clinical procedures(
j,protho dent

13. • According to hobo, posterior disclusion is dependent
on; the angle of hinge rotation created by the
angular difference between anterior guidance and
condylar path, and on inclination and shape of
posterior cusps which helps in controlling harmful
lateral forces.
• In this technique, molar disclusion is achieved by the
use of two incisal tables.

14. • The first incisal guide table termed as the incisal table without disocclusion is used to
fabricate restorations for posterior teeth.
• The second incisal table termed as the incisal table with disocclusion is used to achieve
incisal guidance with posterior disclusion
• The Twin-Stage Procedure was developed as the advanced version of the Twin-Table
technique
• Hobo and Takayama in their research concluded that cusp angle be considered as the
most reliable determinant of occlusion as cusp angle does not deviate and is 4 times
more reliable than the condylar and incisal path which show deviation
Twin-tables technique for occlusal rehabilitation: Part II--Clinical
procedures( j,protho dent)
Kalra, et al.: Full-mouth rehabilitation using twin-stage technique

15. • Hobo and Takayama in their study made observations similar to those of
Schuyler that anterior guidance and condylar guidance were dependent
not independent factors.
• They believed in posterior disocclusion in eccentric movements unlike the
PMS philosophy where group function is achieved on the working side .
• They did not include freedom in centric.

16. • In the twin-stage procedure, as cusp angle was the main
determinant of occlusion, the need to record condylar path
was not necessary.
• Therefore, complicated instruments such as the pantograph
and fully adjustable articulators are not required.
• This procedure is much simpler than the standard
gnathological procedure.

17. Gnathological concept
McCollum, Stuart, Stallard)
• balanced occlusion
• Maximum intercuspation coincides with centric relation
• Cusp to fossa relationship with tripodism
• Narrow occlusal table
Limitation
• Cusp-to-fossa tripodization complicate the need to obtain
precise gnathologic restorations
• Need for a fully adjustable articulator

18. Freedom in centric concept (Schuyler
• 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
• Limitation
• • Cusp-to-surface rather than cusp-to-fossa relation
affects chewing efficiency

19. Simplified occlusal design (Wiskott and
Belser)
• Cusp-fossa relation with only one occlusal
contact per tooth
• Anterior disclusion during all eccentric
movements
• Freedom in centric occlusion
• Can be adapted to most anterior guidances
and varying degrees of group function

20. Pankey, Mann and Schuyler Philosophy
(1960
• Maxillary cuspids in good functional contact
• Group function on working side
• Absence of nonworking side contacts.
• Freedom of movement in centric occlusion is necessary
• Long centric is incorporated in the lingual surfaces of maxillary
incisors
Limitation
• Cusp to fossae /marginal ridge contact
• Use of wax functionally generated path techniques can cause errors
• The PM philosophy was developed and its use advocated on a non-
arcon articulator, which may not accept interocclusal records made
at increased occlusal vertical dimension

21. Twin Table technique-Hobo (1991)
• Incisal guidance and condylar path are dependant factors
• two customised incisal tables: without disocclusion; and with
disocclusion
• Limitation
• The cusp angle was fabricated parallel to the measured condylar path,
and the cusp angle became too steep
• To obtain a standard amount of disocclusion with such a steep cusp angle,
the incisal path had to be set at an angle that was extremely steep.
• This made the patient uncomfortable

22. Twin Stage Procedure Hobo and Takayama
• Cusp angle is the main determinant of occlusion, the measurement
of the condylar path is not necessary
• The procedure can be indicated for single crowns, fixed
prosthodontics, implants, complete-mouth reconstructions, and
complete dentures
• Suitable for transmandibular disorder patients
• It can be incorporated easily with commonly used clinical techniques
such as facebow transfer, various centric recording methods, and
cusp-fossa waxing

23. Youdelis Scheme
• Cuspal anatomy is so arranged that if the
canine disclusion is lost through wear or tooth
movement, the posterior teeth drop into
group function
limitation
• Used in advanced periodontitis cases

24. Nyman and Lindhe Scheme
• When there are long tooth-borne cantilevered restorations,
balanced occlusion must be achieved
• When distal support is present, anterior disclusion is provided
Limitation
• For extremely advanced periodontitis cases
• Type of contacts not specified

25. Schuyler’s principles :
• 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. Disoclusion by the anterior guidance of all posterior teeth in protrusion
• 4. Disoclusion of all non-working inclines in lateral excursions.
• 5. Group function of the working side inclines in lateral excursions.

26. According to Pankey Mann philosophy, treatment is divided into 4
stages
• 1. PART I : Examination, Diagnosis, Treatment planning and Prognosis
• 2. PART II : Harmonization 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.
• Full mouth occlusal rehabilitation; by Pankey Mann Schuyler philosophy
Jinsa P. Devassy1, Ankitha Sivadas2, Shabas Muhammed3

27. • An organized approach to oral rehabilitation was
introduced by Pankey utilizing the principles of
occlusion advocated by Schuyler known as the Pankey–
Mann–Schuyler (PMS) Philosophy of Oral
Rehabilitation .
• philosophy based on the spherical theory of occlusion
• the ‘‘wax chew-in’’ technique described by Meyer and
Brenner , and on the importance of cuspid teeth as
discussed by D’Amico
• Occlusal Concepts in Full Mouth Rehabilitation: An Overview Bhawana Tiwari • Komal Ladha • Aaruti La

28. • In PMS technique, the incisal guidance was the
developed intraorally with acrylic resin to satisfy esthetic
and functional requirements.
• Optimal occlusal plane is selected as dictated by the
curve of Monson and mandibular posterior teeth are
restored in harmony with the anterior guidance such that
they will not interfere with the condylar guidance.
• Maxillary posterior occlusal surfaces are developed after
the completion of mandibular restorations by the
functionally generated path technique (FGP)

29. The PM instrument was based on Monson’s spherical theory of occlusion
and Monson articulator.
It was used to establish functional occlusal plane on the mandibular teeth .

30. This case report describes a full mouth occlusal rehabilitation done usinng
Pankey Mann Schuyler philosophy
This clinical case report describes the rehabilitation of a 59 years old
male patient complaining pain over left TMJ region especially at
morning. Examination revealed partially edentulous maxillary ridge,
severe attrition of lower anterior teeth, supra erupted lower first
molars (36 and 46) and it is impinging the maxillary alveolar ridge.
Full mouth occlusal rehabilitation; by Pankey Mann Schuyler philosophy Annals of
Prosthodontics & Restorative Dentistry, January-March 2017:3(1):29-33

31. Broadrick flag analyser
Needle point of the
caliper is placed
against the selected
point on premolar and
an arc was scribbed on
the flag (anterior
survey line)
The caliper was set at a
radius of 4 inch from
needle point to pencil
point
Full mouth occlusal rehabilitation; by Pankey Mann Schuyler
philosophy Annals of Prosthodontics & Restorative Dentistry,
January-March 2017:3(1):29-33

32. caliper point is held against
the condyle ball of the
articulator and another arc
is made in flag (condylar
survey line)
From the intersect point a
line is drawn from molar to
canine . Thus we got an
accepted occlusal plane for
the lower posteriors
To transfer this to mouth
a wax guide is made and
held against the teeth
and preparation line 1.5
mm below the plane is
marked on the teeth,
giving space for the
restoration

34. Advantages of the Pankey Mann
Schuyler technique:
• 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
• 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. The PMS philosophy of occlusal rehabilitation can fulfill the most
exacting and sophisticated demands if the operator understands the goals
of optimum occlusion
• Twin-tables technique for occlusal rehabilitation: Part II--Clinical
procedures Sumiya Hobo,

35. Disadvantage
.
• The concept of posterior disocclusion has made the use of FGP technique
advocated by PMS unnecessary in most occlusal restorations.
• As FGP technique utilizes wax to obtain the record there is great potential
for errors.
• Furthermore, PMS technique cannot be used if the teeth are
periodontally weak as FGP cannot be accurately recorded

36. HOBO ‘S TW IN TABLE PHILOSOPHY
• 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 predetermined,
harmonious disocclusion with the condylar path.
• The technique utilizes 2 different customized incisal
guide tables. The first incisal table is termed incisal
table without disoclusion and 2nd is with disocclusion

37. • In this method for creating molar disocclusion
by using a twin-tables technique (two table)
• One incisal table is used to incorporate a cusp-
shape factor and the other is used for the
angle of hinge rotation.
• It is fabricated by preparing die systems with
removable anterior and posterior segments.

38. INCISAL TABLE WITHOUT DISCLUSION
• The anterior portion of the maxillary cast is
removed to eliminate the effects of anterior
guidance.
• The articulator is then moved in forward, right,
and left directions .
• With the anterior segment of the maxillary cast
removed, the posterior teeth do not disclude
during eccentric movements,
• but the molars should glide smoothly through
maximum intercuspation.

39. Twin table Procedure
Diagnostic casts mounted on
semiadjustable articulator.
Anterior portion of maxillary cast is
easily made removable by using dowel
pins.

40. After anterior segment is removed, carbon
occlusal paper is placed between maxillary and
mandibular posterior teeth. Then articulator is
moved to simulate forward, right, and left
movement directions.
Wax is added to any surface on tooth
that does not contact with opposing
occlusal surfaces, until it has even
contact.

41. If maxillary and mandibular casts interdigitate
evenly, it indicates that cusp shape of molars
has been established. Chemical-cure acrylic
resin is placed on incisal table and resin is
molded by moving articulator in all eccentric
movements.
Same procedures are repeated to
complete two incisal tables. These
tables are called incisal tables without
disclusion.

42. INCISAL TABLE WITH DISCLUSION
• It is critical that anterior guidance is steeper
than the condylar path to ensure molar
disclusion.
• One of the incisal tables without disclusion is
placed on the articulator so that the tip of the
incisal pole contacts the incisal table in centric
relation.

43. • Two 3 mm thick plastic spacers are prepared to approximate the
protrusive movement position.
• When the plastic spacers are inserted behind right and left condyles on
the articulator, maxillary and mandibular casts are placed in a 3 mm
protrusive Position.
• A vinyl sheet 1.1 mm thick is applied to the mesiobuccal cusp tips of right
and left mandibular first molars, and the articulator is closed.
• This creates an average disclusion during protrusive movement of the
mandible
• Twin-tables technique for occlusal rehabilitation: Part II--Clinical
procedures Sumiya Hobo, J PROSTHET DENT 1991;66:471-7.)

44. Vinyl sheet 1 mm thick is placed on tip of
mesiobuccal cusp of mandibular first molar on
nonworking
side.
When articulator is closed, incisal pin is
directed laterally and upward. Resin cone is
formed to record this position.

45. Three cones made at protrusive, right, and left
lateral movements create angle of hinge
rotation.
required to produce the average disocclusion
during protrusive movement.
Three resin cones are connected to
form walls and triangular space
between centric relation contact of
incisal pin and top of wall is filled
with newly mixed resin.
Articulator is moved through all
border movements to mold incisal
table. This procedure produces incisal
table with disclusion.

46. FABRICATION OF RESTORATIONS
• After preparations are completed, the intraoral interferences
are removed by use of the previously marked diagnostic casts.
• An accurate final impression is made.
• The maxillary working cast is again made with a removable
anterior segment using dowel pins.
• A facebow is used to transfer the maxillary working cast and a
centric relation record is used to articulate the mandibular
working cast

47. Anterior portion of maxillary working
cast is removed after wax outlines are
completed.
Mounted maxillary and mandibular
working casts and two incisal tables.

48. Incisal table without disclusion and condylar
path of articulator act as guides for even,
gliding contacts in posterior occlusal wax-ups.
After completion of posterior
waxing, incisal table
with disclusion is attached to
articulator

49. Restorations with incorporated predetermined
disclusion on articulator
Anterior segment is repositioned. Melted wax
is added on lingual surfaces of anterior teeth;
then articulator is closed and moved through
all border movements to form anterior
guidance

50. • Disclusion is demonstrated with cemented
restorations.

51. • This is termed the incisal guidance with
disclusion.
• The first incisal guide table is used to fabricate
restorations for posterior teeth.
• The second guide table is used to achieve
incisal guidance with disclusion

52. Case -3 based on twin stage
• A 54-year-old male reported to the Department
of Prosthodontics with a chief complaint of
difficulty in chewing food and sensitivity to hot
and cold food items .
• The patient gave no significant medical history
and did not report any signs of
temporomandibular joint disorder or myofascial
pain dysfunction.

53. • Full-mouth reconstruction with the Hobo
twin-stage technique was planned to
reconstruct the attrited dentition in functional
harmony to the stomatognathic system while
providing a canine-guided disocclusion during
eccentric movements

54. • A Lucia jig was fabricated at an established
increased VDO at 4 mm.
• Interocclusal and protrusive records were made
using polyvinyl siloxane occlusal registration
material
• The patient’s casts were mounted on a
semiadjustable articulator using a facebow
record at increased VD
• Mandibular occlusal plane was analyzed using the
Broadrick’s occlusal plane analyzer

55. Standard value for condylar guidance
and anterior guidance
Full-mouth rehabilitation using twin-stage techniqueKalra, et al.:

56. Divider of Broadrick occlusal plane analyzer
was opened at 4 inches and a mark was
obtained on the flag by keeping one
end at the distal end of the canine and the
second end of the divider at the distobuccal
cusp of the last molar and another mark
crossing the first one was obtained.

57. • A diagnostic wax-up of the full-mouth restoration was carried out at the
increased vertical dimension for posterior teeth without the anterior
segment of maxillary cast in place. To produce standard effective cusp
angles, the condylar and the incisal guidance were set to Condition 1.
• At this position, the diagnostic wax-up was balanced in protrusive
excursion and lateral excursions.
• The anterior segment of the cast was reassembled and the condylar
guidance and incisal guidance were set again (Condition 2) and the wax-up
was completed so as to genernate posterior disocclusion

58. Condition 2 where the maxillary
anterior segment was replaced and
the anterior wax-up was completed
and checked for proper anterior
guidance to achieve disocclusion in
eccentric movements due to
canine-guided occlusion
Condition 1 of Hobo’s twin-stage procedure ,
wherein after removal of the maxillary
anterior segment , posterior segment
diagnostic wax-up was done in bilaterally
balanced occlusion

59. • Once the patient was adapted to this position, a final
full-arch impression for maxillary and mandibular teeth
was made using poly (vinyl siloxane) impression
material and casts were poured in die stone.
• This cast was mounted on a articulator using the
facebow transfer.
• Now, to transfer the vertical dimension and centric
relation, temporaries were removed from both
maxillary and mandibular left posterior region while
the temporaries of right and anterior maxillary and
mandibular region acted as a stop.

60. • 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.

61. Contraindication
• Abnormal curve osf spee and wilson
• Abnormally rotated tooth
• Abnormally inclined tooth

62. DISCUSSION
• Rehabilitation of occlusal form and function is
the primary goal of full-mouth rehabilitation.
Thorough examination, diagnosis, and choice
of appropriate occlusal scheme are the key to
successful prosthodontic rehabilitation

63. • After reviewing the various occlusal concepts, we are of the opinion that it
is best to achieve posterior disocclusion in full mouth rehabilitation to
avoid harmful lateral forces as was suggested by HoboAlthough, the
concept of gnathology provides stable long-term results due to mutually
protected occlusion and tripod contacts, in some patients, freedom in
occlusion may be required and therefore the PMS concept cannot be out
rightly dismissed.
• Indeed, some of the PMS concepts such as establishing an acceptable
occlusal plane prior to occlusal rehabilitation are incorporated into
everyday occlusal practice
• Furthermore, as the tripod contacts are very difficult to equilibrate it is
recommended that cusp-to-fossa contacts be achieved in the
reconstructed occlusion.
• Occlusal Concepts in Full Mouth Rehabilitation: A
Overview J Indian Prosthodont Soc

64. CONCLUSION
• Occlusal rehabilitation is a radical procedure
and should be carried out in accordance with
the dentist’s choice of treatment based on his
knowledge of various philosophies followed
and clinical skills. Further scientific research
and systematic reviews are needed to validate
occlusal treatment theories. Ultimately, the
clinician must evaluate and assess the
literature along with individual clinical
experiences

65. References
• Full mouth occlusal rehabilitation; by Pankey Mann
Schuyler philosophy
• Twin-tables technique for occlusal rehabilitation: Part
II--Clinical proceduresJ PROSTHET DENT
• 1991;66:471-7.)
• Occlusal Concepts in Full Mouth Rehabilitation: An
Overview
• ORAL REHABILITATION
• Part I. Use of the P-M Instrument in Treatment
Planning and in Restoring the Lower Posterior Teeth