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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.

As the goal of medicine is to increase the life span of

The restoration of mu ltiple teeth which are


missing, worn, bro ken down or decayed.

the functioning individual, the goal of dentistry is to

2.

increase the life span of the functioning dentition.

To

replace

imp roperly

designed

and

executed crown and bridge framework.

Dentistry uses its knowledge, skill and all the

3.

resources at its command in both maintenance work

Treat ment of temporo mandibular d isorders


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


inlays,

crowns,

bridges

and

partial

unsatisfactory for various reasons - Repeated failure

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

as patient education, sound diagnosis, periodontal

treatment

and

achieving

Unacceptable

function,

Unacceptable esthetics, Sensitive teeth, Painful

therapy, operative skills, occlusal considerations,


endodontic

dentition,

musculature due to disharmony between occlusion

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

harmonious relationship with the adjacent hard and

CONSIDERATIONS

DURING

OCCLUSAL REHA BILITATION (9, 10, 11)

soft tissues, all o f which enhance the oral health and


welfare of the patient.

To

To summarize, the goals to be attained are:

rehabilitation, certain bio logical considerations are

1.

attain

the

various

goals

of fu ll

mouth

necessary along with the indicated conditions.

Freedom fro m d isease in all masticatory

Adoption of an alternative strategy by establishing a

system structures
2.

Maintainable healthy periodontium

3.

Stable TMJs

4.

Stable occlusion

5.

Maintainable healthy teeth

6.

Co mfortab le function

7.

Optimu m esthetics

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
maximu m intercuspation position should be analyzed

INDICATIONS

FOR

FULL

as vertical, horizontal and lateral co mponents both at

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.

evaluation and the effects of materials used on


occlusal stability

control of parafunction

Disclusion by the anterior guidance of all


posterior teeth in protrusion.

and

4.

temporo mandibular disorders is necessary.

Disclusion of all non-working inclines in


lateral excursions.

5.
FUNCTIONA L ASPECTS OF FULL M OUTH

Group function of the wo rking side inclines


in lateral excursions.

REHABILITATION (10)
In order to accomp lish these goals, the following
Co mplete

mouth

rehabilitation

is

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

Examination,

Diagnosis,

Treat ment planning and Prognosis

functioning unit. The aim, therefo re, must be

2.

reconstruction and rehabilitation of the entire

PART II : Harmonizat ion of the anterior


guidance for best possible esthetics ,

dentition, satisfying all the related factors. The

function and comfort

science of comp lete mouth rehabilitation rests upon

3.

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, 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

1.

4.

PART IV: Restoration of the upper posterior


occlusion in harmony with the anterior

centric occlusion

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)
1.

principles of occlusion espoused by Dr. Clyde

It is possible to diagnose and plan the

Schuyler. (5)

treatment fo r entire rehabilitation before

Schuylers principles were : (4)

preparing a single tooth.

1.

2.

A static co-ordinated occlusal contact of the

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.

4.

5.

6.

7.

8.

9.

Full Mouth Rehabilitation

There is never a need for preparing or

decrease in vertical dimension

building more than 8 teeth at a time.

Radiographic examination revealed no requirement

It divides the rehabilitation into separate

of endodontic therapy for any teeth. 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.

vertical d imension of 2 mm. Full mouth rehabilitation

There is no danger of getting at sea and

pertaining to the principles and goals of Pankey

losing patients vertical dimension. The

Mann Schuyler philosophy was planned.Maxillary

operator always has an idea where he is at

and man dibu lar d iagnostic casts were mounted onto

all times.

a Whip mix (Arcon) art iculator using facebow

The functionally generated path and centric

records. Anterior wax up was done to appropriate

relation are taken on the occlusal surface of

shape, size and contour. Mandibular occlusal plane

the teeth to be rebuilt at the exact vert ical

was analysed using Broadricks occlusal plane

dimension to which the case will be

analysis. This was followed by maxillary occlusal

reconstructed.

wax up to maximu m intercuspation. Anterior wax up

All

of

appointments.

posterior

occlusal

It

is

contours

was observed.

are

was checked for proper anterior guidance to achieve

programmed by and are in harmony with

disclusion in eccentric movements. A splint was

both condylar border movements and a

fabricated with an increase in vertical dimension of 2

perfected anterior guidance.

mm to be worn by the patient for 6 weeks. The

There is no need fo r t ime consuming

mandibular anterior teeth were prepared

techniques and complicated equip ment.

Following imp ression, temporizat ion of the prepared

Laboratory procedures are simp le

first.

and

teeth was done at a raised vertical dimension. In

controlled to an extremely fine degree by the

order to maintain the increase in VD, the mandibular

dentist.

posterior also had to be prepared in order to prevent

10. The

PMS

philosophy

of

occlusal

posterior open bite. 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 fabrication of porcelain

understands the goals of optimu m occlusion.

fused to metal crowns for the mandibular anteriors.


Cementation of the crowns was done using glass

CASE REPORT

ionomer cement. The maxillary anterior teeth were

A healthy 18 year old female patient reported to the

prepared next. 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. On clin ical examination, ch ipping

in the same relat ion. PFM crowns were cemented.

of enamel was seen with respect to most teeth with

The mandibular posterior teeth preparations were

exposure of dentine. Generalized attrition was

refined and impressions made. Inclines of wax

observed with respect to all the occlusal surfaces.

patterns were carved using fossa contour guide. The

Utilizing phonetics and esthetics as a guide, 2 mm

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 patients. 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
Broadricksocclusal 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) Broadricks 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. He proposed Twin table concept which

d) Provisionalizat ion of lower anterior teeth.

developed anterior guidance to create a predetermined, 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.

an incisal table without disclusion was made without

The second guide table is used to achieve incisal

anterior guidance. The wax patterns were fabricated

guidance with disclusion.

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

Figure 3
a)

separators behind both condylar elements. Once the


Disocclusion of posterior teeth on lateral

incisal table is refined, the metal copings are

excursive movements

fabricated and try in of the same is done. 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.

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

Hobostwin

table

radiographic

evaluation

the

dentition

technique.

using

Pre-operative

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 mixArcon).

Occlusal

plane

was

evaluated

a)

using

Pre operativephotograph of Case 2 to be


treated by Hobos Twin Table technique

Broadricks occlusal plane analysis. Using phonetics

b) Occlusal

and freeway space as a guide, the vertical dimension

p lane

established

using

Broadricksocclusal plane analysis

was evaluated. The need to increase the vertical


c)

dimension by 4 mm was seen and an overlay splint at

Maxillary

full

arch

tooth

preparation

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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Shetty, Shetty, Prasad, Rajalakshmi, 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. The pantograph

philosophy:

as

advocated

in

Hobos

Twin

Stage

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

Basic concept of twin stage procedure:

was utilized. Th is concept was derived from the

In order to provide disocclusion, the cusp angle

belief that condylar path was unchangeable in the

should be shallower than the condylar path. To make

liv ing body whereas anterior guidance could be freely

a shallower cusp angle in a restoration, it is necessary

changed by the dentist. 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. The deviation of the incisal path is less

movement. Since

than that of condylar path. However, when individual

disocclusion, when a dental technician waxes the

variation and the occurrence rate of malocclusion is

occlusal morphology and tries to reproduce a

incorporated, the incisal path would not be a reliable

shallower cusp angle, the anterior portion of the

reference fo r occlusion. Thus the cusp angle was

working cast becomes an obstacle. Also, when

considered as a new reference for occlusion. Though

fabricating the anterior teeth to produce disocclusion,

independent of condylar path as well as incisal path,

some guidance should be incorporated. In this

a standard value for cusp angle was determined such

methodical approach described by Hobo, a cast with

that it may co mpensate for wear of natural dentition

due to caries, abrasion and restorative works.

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.

Secondly, 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).

ON

MOLARS
Sagittal

removable

anterior teeth

(Referred to as Condition 2).


15

(working

side)
Frontal lateral effective
cusp

angle

20

(non

working side)

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Int J Dent Case Reports

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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman

Full Mouth Rehabilitation

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 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.

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.

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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Shetty, Shetty, Prasad, Rajalakshmi, 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. 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.
After cutback to create space for porcelain, the wax

Figure 7
a)

b)

Pre operative photograph of Case 3, to be treated

patterns were cast with a nickel chro miu m metal

using Hobos twin stage technique

ceramic alloy. 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. Metal try in was subsequently done

Fabrication of wax pattern on the maxillary

intraorally and verified for fit and contacts. 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.

working cast

(Figure 7, 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

Hobos 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, therapeutic, and restorative procedures at

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Int J Dent Case Reports

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Shetty, Shetty, Prasad, Rajalakshmi, Jaiman

Full Mouth Rehabilitation

our command for the treatment and prevention of

guidance for best possible esthetics, function and

dental disease. In the narro wer, mo re recently

comfo rt and the determination of an occlusal p lane

acquired sense, the term refers to the extensive and

based on anterior guidance. 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 dentists choice of treat ment

equilibrat ion. (12) These modifications are motivated

based on his knowledge of various philosophies

by

various

in

esthetics,

followed and clin ical skills. A comprehensive study

function,

relieving

and practical approach must be directed towards

tempero mandibular joint dysfunction. The condylar

reconstruction, restoration and maintenance of the

path, incisal path and cusp angle determine the

health of the entire oral mechanis m.

amount of d isocclusion during eccentric movement.

REFERENCES
1. Irving Goldman: The goal of full mouth rehabilitation , J

restoration

factors: improvement
of

occlusal

The three philosophies followed in fu ll mouth

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

rehabilitation have different approaches and concepts


regarding the relationship of the factors that govern
disocclusion. Early gnathological concepts focused

3. M ann A W, Pankey L D: Oral Rehabilitation, J Prosth


Dent 10: 135-62 ,1960

primarily on condylar path as it was theorized to be a


constant through adulthood. Anterior guidance was

4. Schyuler C H : Factors in Occlusion applicable to


restorative dentistry , J Prosth Dent 3 : 722- 82 , 1953

considered to be at the discretion of the dentist.

5. Dawson P: Functional occlusion from TM J to smile


design, M osby , St. Louis , 2007

McCollu m and Stuart concluded fro m a study


conducted on 10 patients that condylar guidance is

6. Hobo S : Twin Table technique for occlusal


rehabilitation : Part I M echanism of Anterior guidance , J
Prosth Dent 66 (3) : 299-303 , 1991

dependent on the anterior guidance. (6, 7) In


Prosthodontics,

the

condylar

path

has

been

considered the main determinant of occlusion.

7. Hobo S: Twin Table technique for Occlusal


rehabilitation: Part II Clinical procedure , J Prosth Dent
66 (4) : 471- 77 , 1991

According to the Twin table technique by Hobo, the


cusp shape factor and angle of hinge rotation is

8. Hobo S: Oral rehabilitation . Clinical determination of


Occlusion. Quintessence publication, London.

derived fro m the condylar path. These factors


contribute to the determination of an ideal anterior

9. Kazis Harry: Complete M outh Rehabilitation through


restoration of lost vertical dimension , J.A.D.A 37 : 19,
1948.

guidance. However, in the Twin Stage procedure, the


cusp angle was considered as the most reliable

10. Kazis Harry: Functional aspects of complete mouth


rehabilitation. J Prosth Dent 4 (6): 833-842, 1954

determinant of occlusion. This was in accordance


with the proven data fro m studies that cusp angle was

11. Harry Kazis, Albert Kazis : Complete M outh


Rehabilitation through fixed partial denture Prosthodontics.
J Prosth Dent 10 (2): 296-303 , 1960.

4 t imes mo re reliable than condylar and incisal paths.


Pankey Mann Schyulers philosophy advocates that

12. Joseph. S. Landa: An analysis of current practices in


mouth rehabilitation. J Prosth Dent 5(4):527-37, 1955

condylar guidance does not dictate anterior guidance.


Thus it believes in harmon izat ion of the anterior

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