Master Class in Prosthodontics

Philosophies of Full Mouth Rehabilitation

Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University

Monson described teeth arrangement in which occlusal surfaces were aligned along the outer surface of a
sphere, with crista galli as center with a radius of 4 inch. [1] This philosophy of occlusal rehabilitation derived
curve of Wilson and Monson. The Spee, Wilson & Monson curves were designed to promote occlusal contacts
on entire arch during excursive mandibular movements. [2]

Balanced Occlusion:

Theory of balanced occlusion could have had its origin in 1890 when Von Spee presented his observation on the
function of natural teeth of man. Continuous forward and backward movement of mandible without separation
brought about more efficient grinding of food. However, balanced contacts in the natural dentition were
repeatedly associated with non axial loading resulting in tooth mobility, wear, TMJ dysfunction and fracture and
failure of restorations. It also accelerated periodontal breakdown. Thus this occlusal scheme and philosophy was
rejected.[3-4]

Balanced occlusion concept was later replaced by unilateral balanced occlusion or group function occlusion with
multiple contacts between maxillary and mandibular teeth on working side and disocclusion of all teeth contacts
on non-working side during excursion. This was considered to distribute stress and create a normal functional
relationship.[3]

During later part of 19th century Bonvill & Van Spee described basic concepts of occlusion. Bonvill stated, an
equilateral triangle would be formed by straight line drawn connecting centers of both condyles and connecting
these centers and a point at mesioincisal angle of the lower central incisor. This set the basis for development of
articulators on which models could be mounted to study occlusion. Von Spee stated that the points on the lower
jaw teeth which move in contact with those in the skull lie on the surface of a sphere thus explained about
eccentric movements.[3-4]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
 Clyde H. Schuyler

In 1959 Schuyler proposed contact of posterior teeth in protrusion and non-functioning side during lateral
eccentric relation contribute to periodontal disturbances and to pathology of temperomandibular joint disorder.
During correction of occlusal disharmony these contacts should be avoided.[5]

He proposed, for most favorable distribution of stress of natural dentition both anterior and posterior teeth make
and maintain an equalized functional contact in both centric and eccentric maxilla- mandibular relations
(Working side). This requires contact of anterior teeth in CR and a favorable Incisal guidance to permit or
maintain more favorable distribution of stress in eccentric position. He said planning & establishing a desirable
Incisal guidance should be the first step followed by formation of posterior tooth contours in functional harmony
with Incisal guidance.[5-7]

Incisal Guidance:

Ist step in occlusal rehabilitation establishes length of anterior tooth based on Esthetics, anterior teeth relation
and Incisal guidance. Posterior tooth surfaces are later formed to function in harmony with this guidance. All
anterior teeth need to contact uniformly both in centric and eccentric movement and there by distribute stress
over grater number of teeth. [6-8]

Freedom of movement in centric relation:

Schuyler proposed there is difference between anatomic subconscious closer and a voluntarily retruded closer
on the horizontal hinge axis. These closures vary with muscle tone and neuropathic influences with a forward ,
backward or lateral position of the head and position of body (sitting or reclining). He recognized desirability
of slight freedom of lateral and anteroposterior movement in centric occlusion. This freedom amounted to about
0.5 – 1mm.[6]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
 Occlusal surfaces of Posterior teeth:
Lateral inclination of occlusal surfaces of posterior teeth can be divided into functional & non-functional
inclination. Functional inclinations are those inclinations which make contact on working side which are
desirable. Non-functional inclinations are inclination which might make control on nonworking or balancing side
when are not desirable. [6-8]

Pankey–Mann –Schuyler philosophy of complete occlusal rehabilitation:

Utilizing the “principles of occlusion” espoused by Dr. Clyde Schuyler, Dr. Pankey integrated different aspects
of several treatment approaches into an orderly plan for achieving an optimum occlusal result.Dr. Arvin Mann
contributed to the concept by working with Dr. Pankey in the development of the first specialized instrument for
developing the occlusal plane. The instrument became known as the Pankey-Mann instrument and even though it
has long ago been replaced by a simpler system, the overall concept of treatment is still referred to as the
Pankey-Mann-Schuyler philosophy. (abbreviated to PMS)[7-9]
Since its inception, the philosophy has had as its goal the fulfillment of the following principles of occlusions
as advocated by Schuyler:
1. A static coordinated occlusal contact of the maximum number of teeth when the mandible is in centric
relation.
2. An anterior guidance that is an harmony with function in lateral eccentric positions on the working side.
3. Disclusion by the anterior guidance of all posterior teeth in protrusion.
4. Absence of interferences during lateral excursions on the non-working side.
5. Group function of the working-side inclines in lateral excursions[7-9]

To accomplish these goals, the following sequence is advocated by the PMS philosophy:
PART 1. Examination, diagnosis, treatment planning prognosis
PART 2. Harmonization of the anterior guidance for best possible esthetics, function and comfort
PART 3. 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.
PART 4. 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 is used to develop group function of working side. [7-9]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
The advantages of the technique are many. Some of the major ones are as follows:
1. It is possible to diagnose and plan treatment for the entire rehabilitation before a single tooth is prepared
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 or rebuilding more than eight 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.[7-9]

D’ Amico said cusp formation and intercuspal relation of teeth of man are basically the same as those of
dentition of the great apes. The dentition is designed for a shearing, cutting action and not for grinding action of
herbivore as proposed by Monson and Spheroid theory. Environmental factors incorporated abrasive substances
are the principles causes for rapid attrition of natural teeth. He also stated canine teeth serve to guide mandible
during eccentric movements when the opening teeth came into functional contact determine both lateral and
protrusive movements of the mandible. Canine teeth on contact with opposing teeth during eccentric movements
transmit greater degree of desirable periodontal proprioceptor impulses to the muscle of mastication, reducing
muscular tension and thereby reducing magnitude of applied force. This formed the basis of canine protected
occlusion.[10]

Gnathological concept: ( Mc Callum, Stuart & Stallord)

Charles E. Stuart and Stallord in 1960 proposed principles involved in restoring occlusion to natural teeth. They
said balanced occlusion do not provide stable occlusion. As soon as they are inserted they produce small wear
facets, these enlarge into planes, destroy ridges and cusps as occlusal surface wear away. In time mandibular
position changes from centric, occlusal prematurity develop, apply strain on Periodontium and TMJ. They
suggested balanced occlusion predisposes tooth for rapid wear. They also mentioned in natural tooth only one
position in which all tooth have to contact its opponent that is centric occlusion which coincides with rear most
position of mandible. In lateral mandibular deflection only cuspids have opposing contacts. In protrusive
movements only upper six anterior contact opposing teeth. He proposed immediate disocclusion of posterior
teeth in lateral excursion. Maximum chewing is accomplished with minimum occlusal contact.[11-12]
Gnathological concept proposed mutually protected occlusion, in which only posterior teeth contact in maximum
intercuspation and lower anterior are slightly out of contact in centric. In protrusion anterior teeth guide
posterior teeth, out of occlusion, in lateral excursion canine protection occlusion will disoclude all teeth out of
contact.[11-12]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
 Gnathologic concept proposed cusp to fossa occlusion in centric with TRIPODISM in which stamp cusp
(centric cusp) makes contact with opposing occlusal fossa at three points on ridges which form the fossa.
Three point contact achieved because of rounded nature of cusp ridges and fossa. Theses tripod contact
`immediately separated as mandible moved away from centric to excursions. They proposed tripodism provided
stability as occlusal forces are directed along the long axis of tooth, but these prescribed TRIPOD contact points
are very precise which are difficult to achieve.[11-13]

Occlusal schemes for patient with periodontal diseases:

Nyman and Lindhe proposed design consideration for patients with advanced periodontal disease. In these
cases they proposed cross arch design with adequate number and distribution of abutment teeth in most cases
exhibit stability inspite of extensive mobility of abutment teeth. They prescribed even simultaneous contact all
over dentition when patient occluded in intercuspal position. They also proposed simultaneous working & non-
working side contacts on cantilever extension. Anterior disocclusion was prescribed where distal abutment was
present. They proposed initially provisional FPD in acrylic to be inserted. Change in mobility is monitored for
stability for prolonged period of time only later it is converted to permanent FPD reproducing the occlusion in
provisional.[14]

Youdelis in 1971 proposed occlusal scheme for cases with advances periodontitis. He recommended
simultaneous TRIPOD contact of posterior teeth with in centric relation and maximum intercuspal position being
coincident to ensure forces are directed axially. Posterior teeth discussion by anterior in protrusion and canine
protection occlusion in lateral excursion, but if canine is lost, posterior teeth should provide group function.[15]

Wiskott and Belsor, proposed in natural dentition occlusal contacts are few and not ideally placed. Also
functional and para functional forces are not directed along the long axis of the tooth. Based on this, they
proposed a simplified occlusal scheme in which, one occlusal contact per tooth usually a cusp- fossa relation is
sufficient instead of a tripond contact, all interproximal contacts should be proper and tight as they stabilize the
tooth mesio-distally, anterior disclusion mechanics should be applied so that posteriors do not experienced in any
interference on lateral excursive movements, antero-posterior freedom of movement should be provided which is
achieved by having concave internal slopes in the cusps of posterior teeth. [16]
This technique helps maintain vertical dimension and allows chewing due to cusp – fossa relation. The overall
numbers of occlusal contacts are reduced and it can be used for small as well as extensive restorations. This
design ensures occlusal stability and satisfies esthetic demands. The system can be adapted to most anterior
guidances and varying degrees of group function. Occlusal adjustment is simple.[16]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
Twin Stage Procedure:

Proposed by Hobo & Takayama:

According to this philosophy condylar path, incisal path and cusp angle determine tooth contact during eccentric
movements when incisal path is parallel to the condylar path and cusp slope of maxillary and mandibular molars
are parallel to both condylar and incisal path, balanced occlusion occurs. In normal occlusion incisal path is
steeper than condylar path and cusp slope shallower than condylar path results in disocclusion of posterior
teeth.[17]
Based on a mathematical model they calculated the influence of condylar path, incisal path and cuspal angle on
disclusion.
Component Influence on disocclusion Amount of disocclusion
Condylar Path 0.02 mm 0.02 x 40 = 0.8 mm
Incisal Path 0.038 mm 0.38 x 45 = 1.76 mm
Cuspal Inclination 0.046 mm 0.46 x 25 = 1.5 mm

They proposed a two stage procedures to produce disocclusion.

In stage I (Condition 1) – Produced protrusive cusp angle of 250 and lateral cusp angle of 100 by producing
balanced articulator on articulator with predetermined programme.
In stage II (Condition 2) – Develop anterior guidance of 450
Similar proposal were put forth to achieve group function and balanced occlusion.[17]
ARTICULATOR PROGRAMMING VALUES FOR HOBO’S TWIN STAGE:

S. No SCHEME OF CONDYLAR CONDITION CONDITION ANTERIOR CONDITION CONDITION

OCCLUSION PATH 1 2 GUIDE 1 2
TABLE
1. BALANCED SAGITAL SAGGITAL 25 25
OCCLUSION CONDYLAR 25 25 ANGLE
INCLINATION

BENNETT LATERAL 10 10
ANGLE 15 15 WING
ANGLE

2. MUTUALLY SAGITAL 25 40 25 45
PROTECTED CONDYLAR SAGGITAL
OCCLUSION INCLINATION ANGLE

BENNETT 15 15 LATERAL 10 20
ANGLE WING
ANGLE
3. GROUP SAGITAL 25 40 SAGGITAL 25 45
FUNCTION CONDYLAR ANGLE
OCCLUSION INCLINATION

BENNETT 15 15 LATERAL 10 0
ANGLE WING
ANGLE
Twin table technique:

This concept was proposed by Hobo, molar disocclusion is determined by cusp shape factors and angle of hinge
rotation resulting due to difference between anterior guidance and condylar guidance. This techniques utilizes
two incisal table to achieve disocclusion. Patients cast is mounted on articulator and programmed. The anterior
segment is removed. This will eliminate influence of incisal guidance. All the eccentric movements are
reproduced in the articulator and molars are made to glides smoothly through maximum intercuspation . These
excursive movements are recorded on resin incisal guide table and is known as incisal guide table without
disocclusion.[18-19]
A second incisal guide table known as incisal guide table with disocclusion made by bringing about 3 mm
protrusive movement in articulator and by producing predetermined 1 mm disocclusion at first molar. In lateral
excursion 1 mm disocclusion at working side, 0.5 mm disocclusion at non working side was achieved. Resulting
incisal guidance is recorded by modifying the incisal table without disocclusion by addition of resin. This table is
known as incisal table with disocclusion is used to develop incisal guidance of anterior teeth.[18-19]

Master Class in Prosthodontics-Philosophies of Full Mouth Rehabilitation-Lecture by: Prof. (Dr.) Chethan Hegde, A.B.S.M.I.D.S., Nitte University
References:

1. Monson, George S.: Applied Mechanics to the Theory of Mandibular Movements, D. Cosmos 74:1039-
1053, 1932
2. Ferrario VF, Sforza C, Miani A Jr. Statistical evaluation of Monson’s sphere in healthy permanent
dentitions in man. Arch Oral Biol 1997;42:365-9
3. Schuyler C H. Fundamental principles in the correction of occlusal disharmony, natural and artificial. J
Am Dent Assoc.1935 22 1193-1202
4. Schuyler CH . Factors of occlusion applicable to restorative dentistry. J Prosthet Dent.1953. 3:772–782
5. Schuyler CH (1959) An evaluation of incisal guidance and its influence on restorative dentistry. J Prosthet
Dent 9:374–378
6. Schuyler CH (1969) Freedom in centric. Dent Clin North Am 13:681–686
7. Schuyler CH (1963) The function and importance of incisal guidance in oral rehabilitation. J Prosthet
Dent 13:1011–1029
8. Pankey LD, Mann AW (1960) Oral rehabilitation: part II. Reconstruction of the upper teeth using a
functionally generated path technique. J Prosthet Dent 10:151–162
9. Mann AW, Pankey LD. Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and in
restoring lower posterior teeth. J Prosthet Dent. 1960;10:135–150.
10. D’Amico A (1961) Functional occlusion of the natural teeth of man. J Prosthet Dent 11:899–12
11. Stuart CE (1973) The contributions of gnathology to Prosthodontics. J Prosthet Dent 30:607–608
12. Stuart CE, Stallard H (1960) Principles involved in restoring occlusion of the natural teeth. J Prosthet
Dent 10:304–313
13. Tiwari B, Ladha K, Lalit A, Naik BD.Occlusal Concepts in Full Mouth Rehabilitation: An Overview, J
Indian Prosthodont Soc14(4):344–351
14. Nyman S, Lindhe J. Considerations on the design of occlusion I prosthetic rehabilitation of patients with
advanced periodontal disease. J Clin Periodontol 1977;4:1-5.
15. Schluger S, Youdelis RA, Page RC, Johnson RH. Periodontal Diseases. Philadelphia, London: Lea &
Febiger; 1990. p. 541-5.
16. Wiskott HWA, Belser UC (1995) A rationale for a simplified occlusal design in restorative dentistry:
historical review and clinical guidelines. J Prosthet Dent 73:169–183
17. Hobo S, Takayama H (1997) Oral rehabilitation, clinical determination of occlusion. Quintessence
Publishing Co., Inc, Carol Stream, pp 32–33
18. Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part I: mechanism of anterior guidance. J
Prosthet Dent 66:299–303
19. Hobo S (1991) Twin-tables technique for occlusal rehabilitation. Part II: clinical procedures. J Prosthet
Dent 66:471–477

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