Review Article

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J Res Adv Dent 2014; 3:2s:38-42.

A Holistic Approach to Full Mouth Rehabilitation

Mukesh Kumar1 Sanjeev Kumar2* Sankalp Sharma3

1Reader, Department of Endodontics and Conservative Dentistry. Dr.B.R.Ambedkar Institute of Dental Sciences, Bihar, India.
2Senior Lecturer, Department of Prosthodontics, Dr.B.R.Ambedkar Institute of Dental Sciences, Bihar, India.
3Senior Lecturer, Department of Prosthodontics, Kothiwal dental College and Research Centre, Moradabad, Uttar Pradesh, India.

ABSTRACT

Background: Full mouth rehabilitation is a dynamic functional process and it includes the correlation and
integration of all components into one functional unit. In order to successfully restore and maintain the teeth,
one must gain insight into how the teeth arrived at this state of destruction. Tooth wear can result from abrasion,
attrition, and erosion.

Keywords: Full mouth rehabilitation, Prosthodontics.

INTRODUCTION vertical dimension of occlusion (VDO), and the

Since time immemorial, man has been
trying to emulate what God has created.
Harmonious occlusion always remains the dentist’s
prime concern and is the critical requirement for
successful oral rehabilitation. Restoration of the
severely worn dentition is one of the most
challenging procedures in dentistry. Research has
shown that these wear mechanisms rarely act alone
and there is nearly always a combination of the
processes. Tooth wear can result from abrasion,
attrition, and erosion. Evaluation and diagnosis
should account for the patient’s diet, history of
eating and/or gastric disorders, along with the
present state of the occlusion.
Behavioural factors that may contribute to
Para functional habits and/or nocturnal bruxism
are also important to understand and manage in
order to successfully restore and maintain a
healthier dentition. Once a complete understanding
of the etiology of the dentition’s present state is
appreciated, a treatment plan can be formulated,
taking into account the number of teeth to be
treated, condylar position, space availability, the
choice of restorative material.
To attain the various goals of full mouth
rehabilitation, certain biological considerations
are also 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. Adoption of an alternative strategy by
establishing a new occlusal scheme around a stable
condylar position should be considered. The
discrepancies between centric relation and
maximum intercuspation position should be
analysed at both tooth and condylar level. The
occlusal vertical 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 also be assessed to
attain the optimal periodontal health. A study of the
temporomandibular joint positions relative to
the occlusal pattern by means of radiographic
evaluation and control of Para function and
temporomandibular disorders is necessary1.

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Over time various concepts and philosophies have
evolved to attain reconstruction and rehabilitation
of the entire dentition. 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.
PHILOSOPHIES FOLLOWED IN FULL MOUTH
REHABILITATION 2,3
One of the most practical philosophies is
the rationale of treatment that was originally
organized into a workable concept by Dr.L.D.
Pankey utilizing the principles of occlusion as
dictated by Dr. Clyde Schuyler.
Schuyler’s principles were:
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. Disocclusion by the anterior guidance of all
posterior teeth in protrusion.
4. Disocclusion 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, and 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 that it may almost be considered
part of the concept.
Advantages of the Pankey Mann Schuyler
technique:-4
1. It is possible to diagnose and plan 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,
patient, operator and technician.
3. There is never a need for preparing 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
the patient’s present 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 vertical
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 time 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 fulfil the most exacting and sophisticated
demands if the operator understands the goals of
optimum occlusion.
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Fig 1: a) pre- operative view of the case treated by PMS
technique. b) Teeth endodontically treated followed by para
post. c) core build- up and teeth prepared. d) Broadrick’s
occlusal plane analysis. e)Post-operative view
Fig 3: a) Recording of interocclusal centric relation
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.
HOBO’ S TWIN STAGE PHILOSOPHY 7

HOBO ‘S TWIN TABLE PHILOSOPHY5, 6 Dentists have tried for years to prevent harmful
horizontal occlusal forces on teeth caused by
Another philosophy was given by Dr. Sumiya Hobo
mandibular eccentric movements. The
which is followed in rehabilitation of dentate
pantograph and fully adjustable articulators are
Patients. He proposed the Twin Table concept
results of their efforts. During development, the
which involved developing anterior guidance to
concept that focussed on the condylar path as the
create a pre-determined, harmonious disclusion
reference of occlusion was utilized. This concept
with the condylar path. The technique utilizes 2
was derived from the belief that condylar path
different customized incisal guide tables. The first
was unchangeable in the living body whereas
incisal table is termed incisal table without
anterior guidance could be freely changed by the
disocclusion. It is fabricated by preparing die
dentist. But the condylar path has been shown to
systems with removable anterior and posterior
have deviation and minimal influence on
segments. This table helps us achieve uniform
disocclusion raising questions on the validity of
contacts in the posterior restorations during
the concept. The deviation of the incisal path is less
eccentric movements. The other incisal table is
than that of condylar path. However, when
made when the articulator can simulate border
individual variation and the occurrence rate of
movements by placing 3 mm plastic separators
malocclusion is incorporated, the incisal path
behind the condylar elements. This is termed the
would not be a reliable reference for occlusion.
incisal guidance with disocclusion. The first
Thus the cusp angle was considered as a new
incisal guide table is used to fabricate restorations
reference for occlusion. Though independent of
for posterior teeth. The second guide table is used
condylar path as well as incisal path, a standard
to achieve incisal guidance with disclusion.
value for cusp angle was determined such that it
may compensate for wear of natural dentition due
to caries, abrasion and restorative works.

Basic concept of twin stage procedure:

In order to provide disocclusion, the cusp angle

should be shallower than the condylar path. To
Fig 2: a)pre- operative view of the case treated by Hobo’s
make a shallower cusp angle in a restoration, it is
twin table technique b)post- operative view
necessary to wax the occlusal morphology to

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produce balanced articulation so the cusp angle Frontal lateral effective
becomes parallel to the cusp path of opposing teeth 20
during eccentric movement. Since anterior teeth
help to produce disocclusion so when a dental CONCLUSION 8,9
technician waxes the occlusal morphology and
In the traditional broad sense, full mouth
tries to reproduce a shallower cusp angle, the
rehabilitation implies the involvement of all
anterior portion of the working cast becomes an
diagnostic, therapeutic, and restorative procedures
obstacle. Also, when anterior teeth are fabricated to
at our command for the treatment and
produce disocclusion, some guidance should be
prevention of dental disease. In the narrower
incorporated. In this methodical approach
term it refers to the extensive and intensive
described by Hobo, a cast with a removable anterior
restorative procedures in which the occlusal plane
segment is fabricated. The occlusal morphology of
is modified in many aspects to accomplish
the posterior teeth is reproduced without the
equilibration. These modifications are motivated by
anterior segment and cusp angle coincident with
various factors: improvement in esthetics,
the standard values of effective cusp angle is
restoration of occlusal function and relieving
produced . Secondly, anterior morphology is
temporomandibular joint dysfunction. The
reproduced with the anterior segment and
condylar path, incisal path and cusp angle
anterior guidance is provided which will produce a
determine the amount of disocclusion during
standard amount of disocclusion.
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 focussed
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. 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
Fig 4: a)Preoperative view. b)Bite recorded and articulated.
guidance. However, in the Twin Stage procedure,
c) mock wax up done in maxillary and mandibular arch with
the cusp angle was considered as the most
shallow cusp angle. d) post operative view (Frontal and
reliable determinant of occlusion. This was in
lateral )
accordance with the proven data from studies that
STANDARD VALUES OF EFFECTIVE CUSP ANGLE cusp angle was 4 times more reliable than condylar
ON MOLARS and incisal paths. Pankey Mann Schuler’s
philosophy advocates that condylar guidance does
CUSP ANGLE not dictate anterior guidance. Thus it believes in
CUSP ANGLE ON MOLARS (0) harmonization of the anterior guidance for best
possible esthetics, function and comfort and the
Sagittal protrusive effective cusp angle determination of an occlusal plane based on
25 anterior guidance. Occlusal rehabilitation is a
radical procedure and should be carried out in
Frontal lateral effective cusp angle (working
accordance with the dentist’s choice of treatment
side) 15
based on his knowledge of various philosophies

41
followed and clinical skills. A comprehensive 4. Mann A W, Pankey L D: Oral Rehabilitation, J
study and practical approach must be directed Prosthet Dent 1960; 10:135-62.
towards reconstruction, restoration and
maintenance of the health of the entire oral 5. Schyuler C H. Factors in Occlusion
mechanism. applicable to restorative dentistry, J Prosthet
Dent 1953; 3:772- 82.
CONFLICT OF INTEREST
6. Hobo S. Twin Table technique for occlusal
No potential conflict of interest relevant to this rehabilitation: Part I. Mechanism of Anterior
article was reported. guidance. J Prosthet Dent 1991; 66 (3): 299-
303.
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