PHILOSOPHIES IN FULL MOUTH REHABILITATION A SYSTEMATIC REVIEW Bharat Raj Shetty 1 , Manoj Shetty 2 , Krishna Prasad D. 3 , S. Rajalakshmi 4 , 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 Memorial 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 Emai l i d : drmanojshetty@gmai l .com Contact: 09845267087
ABSTRACT Complete mouth rehabilitation is a dynamic functional endeavour and it embodies the correlation and integration of all component 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
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INTRODUCTION As the goal of medicine is to increase the life span of the functioning individual, the goal of dentistry is to increase the life span of the functioning dentition. Dentistry uses its knowledge, skill and all the resources at its command in both maintenance work and rehabilitation to achieve its goal. (1) Occlusal rehabilitation is defined as the restoration of functional integrity of dental arch by the use of inlays, crowns, bridges and partial dentures. Successfully treat ing patients requires a thoughtful combination of many aspects of dental treatment such as patient education, sound diagnosis, periodontal therapy, operative skills, occlusal considerations, endodontic treatment and achieving harmony 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 harmonious relationship with the adjacent hard and soft tissues, all of which enhance the oral health and welfare of the patient. To summarize, the goals to be attained are: 1. Freedom from disease in all masticatory system structures 2. Maintainable healthy periodontium 3. Stable TMJs 4. Stable occlusion 5. Maintainable healthy teeth 6. Comfortable function 7. Optimum esthetics
INDICATIONS FOR FULL MOUTH REHABILITATION The primary indications for rehabilitation of the entire dentition are: 1. The restoration of multiple teeth which are missing, worn, broken down or decayed. 2. To replace improperly designed and executed crown and bridge framework. 3. Treat ment of temporomandibular disorders is also advised, though caution is advised. Reorganization of the occlusion can be considered if the existing intercuspal position can be considered unsatisfactory for various reasons - Repeated failure or fracture of teeth or restorations, Severe attritional wear, Lack of interocclusal space for restoration, Affected dentition, Unacceptable function, Unacceptable esthetics, Sensitive teeth, Painful musculature due to disharmony between occlusion and TMJs.
BIOLOGICAL CONSIDERATIONS DURING OCCLUSAL REHABILITATION (9, 10, 11)
To attain the various goals of full mouth rehabilitation, certain biological considerations are necessary along with the indicated conditions. Adoption of an alternative strategy by establishing a 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 maximum intercuspation position should be analyzed as vertical, horizontal and lateral components both at tooth and condylar level. The occlusal vert ical 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 Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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also be assessed as attaining optimal periodontal health is also an objective of the same. A study of the temporomandibular joint positions relative to the occlusal pattern by means of roentgen graphic evaluation and the effects of materials used on occlusal stability control of parafunction and temporomandibular disorders is necessary.
FUNCTIONAL ASPECTS OF FULL MOUTH REHABILITATION (10)
Complete mouth rehabilitation is a dynamic functional endeavour and it embodies the correlat ion and integration of all component parts into one functioning unit. The aim, therefore, must be reconstruction and rehabilitation of the entire dentition, satisfying all the related factors. The science of complete mouth rehabilitation rests upon three proved and accepted fundamentals: 1. The existence of a physiologic rest position of the mandible, which is a constant. 2. The recognition of a vert ical dimension 3. The acceptance of a dynamic, functional centric occlusion
PHILOSOPHIES FOLLOWED IN FULL MOUTH RECONSTRUCTION
One of the most practical philosophies is the rationale of treat ment that was originally organized into a workable concept by Dr. L.D. Pankey utilizing the principles of occlusion espoused by Dr. Clyde Schuyler. (5)
Schuylers principles were: (4)
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. Disclusion by the anterior guidance of all posterior teeth in protrusion. 4. Disclusion 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, Treat ment planning and Prognosis 2. PART II : Harmonizat ion 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. (2, 3)
Advantages of the Pankey Mann Schuyler technique: (5)
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. Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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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 patients 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 are programmed by and are in harmony with both condylar border movements and a perfected anterior guidance. 8. There is no need for t ime 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 fulfill the most exacting and sophisticated demands if the operator understands the goals of optimum occlusion.
CASE REPORT A healthy 18 year old female patient reported to the Depart ment of Prosthodontics with a chief complaint of discolored teeth. On clinical examination, chipping 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 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 dimension of 2 mm. Full mouth rehabilitation pertaining to the principles and goals of Pankey Mann Schuyler philosophy was planned.Maxillary and man dibular diagnostic 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 Broadricks occlusal plane analysis. This was followed by maxillary occlusal wax up to maximum intercuspation. Anterior wax up 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 impression, temporizat ion of the prepared 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 Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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plane verification and then cemented. This 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 1: a) Pre operative photograph of Case 1 to be treated by Pankey Mann Schuyler technique b) Broadricks occlusal plane analysis c) Tooth preparation of lower anteriors completed d) Provisionalizat ion of lower anterior teeth.
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
HOBO S TWIN TABLE PHILOSOPHY (6,7)
Another 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 pre- determined, harmonious disclusion with the condylar path. The technique utilizes 2 different customized incisal guide tables. The first incisal table is termed incisal table without disclusion. It is fabricated by preparing die systems with removable anterior 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 articulator can simulate 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 Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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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.
CASE REPORT: A 44 year old healthy male reported to the Depart ment of Prosthodontics with a complaint of worn out, sensitive teeth and difficulty 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 Hobostwin table technique. Pre-operative radiographic evaluation indicated endodontic treatment for certain teeth, which was treated. Diagnostic casts were mounted using facebow records onto a semi adjustable articulator (Whip mix- Arcon). Occlusal plane was evaluated using Broadricks occlusal plane analysis. Using phonetics and freeway space as a guide, the vertical dimension was evaluated. The need to increase the vertical dimension by 4 mm was seen and an overlay splint at the raised vertical dimension was cemented. This was followed by preparation of maxillary and mandibular teeth. The casts are mounted onto the articulator using facebow transfer. As explained in the concept, 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 disclusion was fabricated next by using 3 mm acrylic 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)
Figure 4 a) Pre operativephotograph of Case 2 to be treated by Hobos Twin Table technique b) Occlusal plane established using Broadricksocclusal plane analysis c) Maxillary full arch tooth preparation completed. d) Facebow transfer recording
HOBO S TWIN STAGE PHILOSOPHY (8)
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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. During development, the concept that focuses on the condylar path as the reference of occlusion was utilized. This concept was derived from the belief that condylar path was unchangeable in the living 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 for 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 compensate for wear of natural dentition due to caries, abrasion and restorative works. STANDARD VALUES OF EFFECTIVE CUSP ANGLE ON MOLARS CUSP ANGLE CUSP ANGLE ON MOLARS Sagittal protrusive effective cusp angle 25 Frontal lateral effective cusp angle (working side) 15 Frontal lateral effective cusp angle (non working side) 20 Table 1: Standard values of effective cusp angle on molars as advocated in Hobos 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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Figure 5 a) Recording of interocclusal centric relat ion 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
Contraindications: 1. Abnormal curve of Spee 2. Abnormal curve of Wilson 3. Abnormally rotated teeth 4. Abnormally inclined teeth
Case report: A healthy 38 year old patient reported to the Depart ment of Prosthodontics with a chief complaint of excessive tooth wear. Panoramic radiograph indicated endodontic treatment and restoration with post and core for few teeth. Once endodontic therapy was completed, Full mouth rehabilitation following 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 6 a) Condylar inserts inserted behind condylar elements b) Preparation of wax patterns c) Disclusion achieved in lateral excursive movement d) Post operative photograph of the completed full mouth rehabilitation
Teeth preparation was completed and final impression was made using addition silicone.Wax patterns were fabricated at an increased vertical dimension of 4mm and the prepared teeth were temporized using heat cure acrylic resin. Condition 1: Posterior wax patterns are fabricated such that there are smooth gliding contacts from centric relation to protrusive and lateral movements. This would ensure a uniform amount of posterior disclusion during lateral and protrusive excursions when the anterior guidance is established later. Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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Figure 7 a) Pre operative photograph of Case 3, to be treated using Hobos twin stage technique b) Wax mock up of the diagnostic models mounted on semi adjustable articulator c) Fabrication of wax pattern on the maxillary working cast d) Fabrication of wax pattern on the mandibular working cast Figure 8 a) Completed Posterior restorations in centric relation b) Uniform gliding contants from centric relation to lateral excursive movements c) Post operative photograph of 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 completed to achieve adequate aesthetics. The palatal contours are adjusted according to the anterior guidance to provide immediate disclusion away from centric relation. After cutback to create space for porcelain, the wax patterns were cast with a nickel chromium metal ceramic alloy. The crowns were tried on the cast and trimmed so as to achieve uniform bilateral contacts in centric relat ion. 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. (Figure 7, 8)
Table 2: Modificat ion of articulator settings for Hobos twin stage technique CONCLUSION In the tradit ional broad sense full mouth rehabilitation implies the involvement of all diagnostic, therapeutic, and restorative procedures at Horizontal condylar guidance Lateral condylar guidance Anterior guidance Lateral anterior guidance Modification of art iculator settings ( CONDITION 1) 25 15 25 10 Modification of art iculator settings (CONDITION 2) 40 15 45 20 Shetty, Shetty, Prasad, Rajalakshmi, Jaiman Full Mouth Rehabilitation
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our command for the treatment and prevention of dental disease. In the narrower, more 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 temperomandibular joint dysfunction. The condylar path, incisal path and cusp angle determine the amount of disocclusion during 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 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. McCollum and Stuart concluded from 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 from 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 from studies that cusp angle was 4 t imes more reliable than condylar and incisal paths. Pankey Mann Schyulers philosophy advocates that condylar guidance does not dictate anterior guidance. Thus it believes in harmonizat ion of the anterior guidance for best possible esthetics, function and comfort and the determination of an occlusal plane based on anterior guidance. Occlusal rehabilitation is a radical procedure and should be carried out in accordance with the dentists choice of treat ment based on his knowledge of various philosophies followed and clinical skills. A comprehensive study and practical approach must be directed towards reconstruction, restoration and maintenance of the health of the entire oral mechanis m. REFERENCES 1. Irving Goldman: The goal of full mouth rehabilitation , J Prosth Dent 2(2) : 246 -51, 1952 2. Mann A W, Pankey L D: The Pankey Mann philosophy of occlusal rehabilitation, Dent Clin North Am 7: 621-38 , 1963 3. Mann 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 TMJ to smile design, Mosby , St. Louis , 2007 6. Hobo S : Twin Table technique for occlusal rehabilitation : Part I Mechanism 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 Mouth Rehabilitation through restoration of lost vertical dimension , J.A.D.A 37 : 19, 1948. 10. Kazis Harry: Functional aspects of complete mouth rehabilitation. J Prosth Dent 4 (6): 833-842, 1954 11. Harry Kazis, Albert Kazis : Complete Mouth Rehabilitation through fixed partial denture Prosthodontics. J Prosth Dent 10 (2): 296-303 , 1960. 12. Joseph. S. Landa: An analysis of current practices in mouth rehabilitation. J Prosth Dent 5(4):527-37, 1955