FULL MOUTH

REHABILITATION

PRESENTED BY : Dr. V.Anusha

3rd year, M.D.S DEPT. OF PROSTHODONTICS
 CONTENTS
2

PART 1
o Introduction
Definition
Indications
Classification
Occlusal approach and schemes
Review of occlusal schemes
 Terminologies

 Hobo’s philosophy for full mouth rehabilitation

 Hobo’s Twin table technique

 Hobo’s Twin stage technique

 References
2
CONTENTS:
• INTRODUCTION
• DEFINITION
• RESONS FOR FULL MOUTH REHABILITATION
• INDICATIONS
• CONTRAINDICATIONS
• GOALS AND OBJECTIVES
•

3
 INTRODUCTION

• Crooked, discolored and missing

teeth - negate the good looks

• Recent advances in dental technology, materials and equipments, -

simplified the task of rebuilding, restoring, and rehabilitating diseased
mouths.

• This has enabled dentists to preserve many teeth which would have
been sacrificed.

4
Peter E. Dawson stated, ”Patient lose their teeth in two
ways: either the teeth break down, other supporting
structures break down”

5
 DEFINITIONS
3
• OCCLUSAL REHABILITATION :
The restoration of the functional integrity of the dental
arches by use of inlays, crowns, bridges and partial dentures.

• FULL MOUTH REHABILITATION is defined as the

restoration of the form and function of the masticatory
apparatus to as nearly a normal condition as possible

6
 The objective of full mouth
4
rehabilitation
o A static centric occlusion in harmony with centric relation.

o Even distribution of stresses in centric occlusion and on eccentric

functional inclines.

o Equalization of forces directed against supporting structures

o Restoration of normal healthy function of the masticating apparatus

7
 Reasons For Full Mouth
Rehabilitation
1.To obtain and maintain the health of periodontal tissues

2. Temporomandibular joint disturbance (Dawson, Lindhe & Nyman)

• Disharmony of function between movements of joints and

articulation

• Muscular dysfunction
•
3. Need for extensive dentistry as in case of missing teeth, sever worn
down teeth and old fillings that need replacement.

4.Esthetics, as in case of multiple anterior worn down teeth and missing

teeth.

8
OALS OF FULL MOUTH REHABILITATION

Freedom from diseases in all masticatory system structures

Maintain healthy periodontium

Stable TMJS

Stable occlusion

maintain healthy teeth

Comfortable function

Optimum esthetics
9
 INDICATIONS CONTRAINDICATIONS
• Restore impaired occlusal • Malfunctioning mouths that do
function not need extensive dentistry and
have no joint symptoms - left
• Preserve longevity of alone.
remaining teeth
• Prescribing a full mouth
• Maintain healthy rehabilitation should not be
periodontium taken as a preventive measure
unless there is a
• Improve objectionable definite evidence of tissue
esthetics breakdown.
• pain and discomfort of teeth • No pathology- No treatment.
and surrounding structures

10
 THE DESIGN OF MASTICATORY SYSTEM

COMPONENTS OF THE MASTICATORY SYSTEM: 1. Teeth

2. Periodontal tissues
3. Articulatory system

ARTICULATING SYSTEM

All the three should be in harmony.

11
 MASTICATORY SYSTEM DISORDER
Associated with dysfunction, discomfort, or deformation of any or parts
of the total masticatory system, which includes

OCCLUSAL DISEASES:
Disequilibrium with a harmonious interrelationship between TMJ‟s the
masticatory musculature and the occluding surfaces of the teeth

Basic mechanisms of tooth surface deformation Signs & symptoms

1. Stress -produce micro fractures &abfractions 1. Attrition wear
2. Friction –abrasion, & wear of tooth surfaces 2. Abrasion
3. Corrosion - erosion 3. Erosion of enamel
4. Abfractions
5. Splayed teeth
Etiology Of Extremely Worn Dentition 6. Sensitive teeth
1. Congenital abnormalities 7. Sore teeth
2.Parafunctional occlusal habit- Bruxism 8. Hyper mobility
3.Abrasion 9. Split teeth & fractured cusps
4.Erosion 10.Painful musculature 12
5.Loss of posterior support
 TEMPRO MANDIBULAR DISORDERS
1) Masticatory muscle disorder
2) Structural intracapsular disorder
3) Conditions that mimic TMDs

Categories of TMD

Category I –Occluso muscular disorders with no intracapsular defects

Category II- Intra capsular disorders that are directly related to occlusal
disharmony and are reversible in re-establishing comfortable function if the
occlusion is corrected

Category III- Intracapsular disorder that are not reversible, but because of
adaptive changes, can function comfortably if occluso muscle harmony is
reestablished.

Category IV- Nonadopted intracapsular disorders that may be either

primary or secondary to occlusal disharmony or may be untreated
13
 CLASSIFICATION OF PATIENTS REQUIRING OCCLUSAL
REHABILITATION
6
Classification by Turner and Missirlain (1984)

Category 1 - Excessive wear with loss of vertical dimension.

Category 2 - Excessive wear without loss of vertical dimension of occlusion

but with space available.

Category 3 - Excessive wear without loss of vertical dimension of occlusion

but with limited space available

Turner KA, Missirlian DM (1984) Restoration of the extremely worn dentition. J Prosthet 14
Dent 52:467–474
 Category-1: Excessive wear with loss of
vertical dimension of occlusion (VDO)
7

• Few missing posterior teeth and unstable posterior occlusion.

• Excessive wear of anterior teeth.

• Closest speaking space of 3 mm and interocclusal distance of 6 mm.

• Some loss of facial contour -drooping of the corners of mouth.

Treatment: Trial restorations that restores occlusal vertical dimension to estimated optimal
position

A removable occls
Teeth are prepared and
overlay splint / 6 -8 2-3
Final restorations
provisional fixed months
treatment partial weeks
restorations placed
denture
15
 Category-2: Excessive wear without loss of
VDO but with space available
o Adequate posterior support and history of gradual wear.
8

o Closest speaking space of 1 mm ,

o interocclusal distance of 2-3 mm

o Anterior slide from centric relation to the patient’s maximum

intercuspation.
o continuous eruption - maintained occlusal vertical dimension

o insufficient interocclusal space for restorative materials unless

occlusal vertical dimension is increased
Treatment
 Restoration of the posterior teeth - stability in centric relation in combination with
enameloplasty of opposing teeth

Short clinical crowns-Strict parallelism of opposing axial walls, and supplemental pins or
grooves

Programmed occlusion essential , crown lengthing – gingivoplasty , osteotomy

16
 Category-3: Excessive wear without loss
of VDO but with limited space
•9 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

• Closest speaking space of 1 mm and an interocclusal

distance of 2–3 mm.
• In such cases vertical space must be obtained for restorative materials.

Treatment
 Orthodontic movement
 Restorative repositioning
 Surgical repositioning of segments
 Programmed occlusal vertical dimension modification.

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 CLASSIFICATION BY BRECKER
Group I
Class I Patients with collapse of vertical dimension of occlusion because of shifting of
existing teeth caused by failure to replace missing teeth.

Class II Patients with collapse of vertical dimension of occlusion because of loss of all
posterior teeth in one or both jaws with remaining teeth in unsatisfactory occlusal
relationship.

Class III Patients with collapse of vertical dimension of occlusion because of excessive
attritional wear of occlusal surfaces

Group II

Class I Patients with all or sufficient natural teeth present, with satisfactory occlusal
relationship.

Class II Patients with limited teeth present but in satisfactory occlusal relationship requiring
aid in the form of occlusal rims.
18
Group III
Patients requiring maxillofacial surgery or orthodontic treatment as an aid in
restoring the lost vertical dimension.

Group IV
Patients in whom sectional treatment is required over extended periods of time
because of status of health of the patient, age or economic factor.

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 EXAMINATION DIAGNOSIS AND TREATMENT PLANNING IN FMR

DIAGNOSIS DIAGNOSTIC AIDS

Ist appointment • Medical history
• Listen to patient’s opinion and
expectations • Dental history
• Make diagnostic casts
• Behaviour evaluation
• Radiographs
• Bite records and facebow
• Radiographs – Complete mouth
transfer periapical radiographs and
orthopentamograph
Tentative treatment plan done
• Photographs – to remind previous
IInd appointment state of mouth prior to restorative
• Individual tooth is meticulously therapy
examined
• Extracted or restored • Clinical examination
• Serve as abutments for RPDs or
fixed prosthesis • Diagnostic wax-up

• Computer imaging 20
 TREATMENT PLAN

Treatment plan is divided into-

1) Pre- prosthetic phase

2) Prosthetic phase
3) Maintenance phase

1) Pre- prosthetic phase

- To develop proficiency in diagnosing the need of occlusal rehabilitation, Periodontist ,
Orthodontist , Endodontist , Oral Surgeon and Prosthodontist must all be integrated in
establishing an environment conducive to oral health. (POEOP)

Periodontal consideration
Orthodontic consideration
Endodontic consideration
Oral surgical considerations
Prosthodontic considerations
21
2) Prosthetic phase
Prosthetic full mouth rehabilitation is divided into-

- Immediate treatment

Preformed nickel-chromium crowns placed on first permanent molars and second

deciduous molars- to stabilize occlusion and halt attrition. Vertical dimension not
altered. As anterior teeth and premolars erupt, polycarbonate resin crowns are
given.

-Definitive treatment

In adulthood the size of pulp horns decreases compared to newly erupted teeth. A
definitive treatment can then be planned.

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 Occlusal
11
Approach
• occlusion is reconstructed according to the
Confirmative patient’s existing intercuspal position.
approach • It is adopted when small amount of
restorative treatment is undertaken.

• New occlusal scheme is established around a

suitable condylar position which is the centric
Reorganized relation position.
approach • occlusion reorganised if the existing
intercuspal position is unacceptable and needs to
be changed or when extensive treatment is to be
undertaken to optimize patient’s occlusion.

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 REPEATED
FRACTURE OR
FAILURE OF
TEETH OR
RESTORATION

UNACCEPTABLE LACK OF
INTEROCCLUSAL
FUNCTION AND SPACE FOR
AESTHETICS RESTORATION

TRAUMA FROM
BRUXISM
OCCLUSION

before after

5
 ELEMENTS OF AN OCCLUSION

1.Evaluate centric relation position -restored with this position coincident with maximal
intercuspation.

2.Evaluate Vertical dimension of occlusion (VDO). The joints, muscles, and teeth must
be placed at an acceptable VDO.

3.Evaluate posterior occlusal plane -This has a direct effect on posterior cusp height
and vertical overlap of the anterior teeth.

25
4.Evaluate maxillary anterior incisal edge location-represents an extension of the
maxillary posterior plane of occlusion. This is important in both functional and
esthetic treatment planning.

5. Incisal edges of the mandibular incisors in conjunction with the lingual contours of
the maxillary anterior teeth, function as the anterior determinant of occlusal
function.

6. Finally, a protective posterior occlusal surface design must be established to fit the
function and esthetics of the previous five components of the occlusion.

26
 Ligaments and muscles of TMJ
The ligaments of the joints are five:

1.Capsular ligaments: Anterior, Posterior, External & Internal segments

2. Temporomandibular ligaments

3. Sphenomandibular ligaments

4. Articular disk

5. Stylomandibular ligaments
Muscles Of Mastication

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 FUNCTIONS
 capsular ligaments - encapsulate the MUSCULAR ACTION ON THEMANDIBLE:

joint. 1 Depression or opening of the mouth –

Suprahyoids, Infrahyoids, Platysma, Lateral
pterygoid

2 Elevation or Closure of mouth -

Temporalis ,Masseter, Medial
pterygoid

3 Protrusion, bilateral - external pterygoid,

internal pterygoid ,masseter– superficial
fibers

4 Protrusion, unilateral - medial & lateral

pterygoid on protruding side, masseter –
superficial fibers

5 Retrusion, bilateral - temporalis – deep

fibers.
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 CENTRIC RELATION
96
Centric relation is defined as a maxillomandibular relationship independent of
tooth contact, in which the condyles articulate in the anterior-superior position
against the posterior slopes of the articular eminences; in this position the
mandible is restricted to a purely rotary movement; from this unstrained,
physiologic, maxillomandibular relationship, the patient can make vertical, lateral
or protrusive movements; it is a clinically useful, repeatable reference position.
(GPT 9)

29
Maximum intercuspal position :
The complete intercuspation of the opposing teeth independent of condylar
position ,i,.e best fit of the teeth regardless of the condylar position .

Centric occlusion: The occlusion of opposing teeth when mandible in centric

relation. This may or may not coincide with the maximum intercuspal position.

CR is a bone to bone relation while MIP and CO are tooth to tooth relation.

In natural dentition, MIP may not coincide with centric relation.

30
 The mandible is in centric relation if five criteria
are fulfilled:
1. The disk is properly aligned on both condyles.
101

2. The condyle-disk assemblies are at the highest point possible against the
posterior slopes of the eminence.
3. The medial pole of each condyle-disk assembly is braced by bone.
4. The inferior lateral pterygoid muscles have released contraction and
are passive.
5. The TMJs can accept firm compressive loading with no sign of
tenderness or tension.

The condyles can freely rotate on a fixed

axis in centric relation up to about 20 mm
of jaw opening without moving out of the
fully seated position in their respective
fossa

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  Thus a bite record made at any point of opening on the
correct centric relation arc (shown in red) is still in
100
centric relation.
 If the casts are mounted on an articulator with the
correct condylar axis, the vertical dimension can be
increased or decreased without introducing any error.

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 Methods of manipulation for centric relation

1. Chinpoint Guidance method

Guichet described this method.

 It places the condyles in most posterior and superior position - can result in trauma
to TMJ.
 this method is not advocated

33
 Methods of manipulation for centric relation
105
BILATERAL MANIPULATION
 Recline the patient all the way back. Point the chin up.
 Pointing the chin up makes it easier to position the fingers
on the mandible and prevents the tendency of some patients
to protrude the jaw.

 Stabilize the head. Lower the patient’s head enough

so you can cradle it between your rib cage and
forearm

 After the head is stabilized, lift the patient’s chin

again to slightly stretch the neck.

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 Gently position the four fingers of each hand on the
lower border of the mandible. The little finger should be
107
slightly behind the angle of the mandible.
 Position the pads of your fingers so they align with the
bone, as if you were going to lift the head.
 Keep all four fingers tightly together.

 Bring the thumbs together to form a C

with each hand.

35
  With a very gentle touch, manipulate the jaw so it
slowly hinges open and closed. As it hinges, the
mandible will usually slip up into centric relation
109
automatically if no pressure is applied. Any
pressure applied before the condyles are
completely seated will be resisted by the lateral
pterygoid muscles.

 After the mandible feels like it is

hingeing freely and the condyles seem
to be fully seated up in their fossae,
the mandible is in centric relation.

36
3. Unguided method

Brill introduced a muscular position which allows patients natural

muscle functions to position the mandible into centric relation position

Most patients have a reflex closure , an engram determined and

guided by the teeth. Proprioceptive mechanism determines path of
mandibular closure and is responsible for awareness of position of
mandible in space.

To enable the condyles to be placed in an unstrained position, the

musculature must first be deprogrammed from its habitual closing
pattern

37
 Mandibular deprogramming
Done by-
Ask the patient to bite on these with anterior teeth for 5 - 10
minutes. The memory position of teeth intercuspation is lost.

Anterior Jig
Leaf Gauge
Cotton roll
The Lucia jig
The Pankey Jig
The NTI device.
The best bite appliance

38
Anterior Jig
Anterior jig prevents posterior teeth from occluding
and disrupts the proprioceptive memory
.
As the anterior stop is rigid on contact with lower
incisor teeth, anterior resistance is created and a
mandibular leverage is created with naturally braced
tripod effect along with two condyles.

Principle

Jig breaks the patients habitual closure pattern

39
Procedure
A ball of red compound is softened and added to
upper incisors so that their lingual surfaces are
completely covered.

—the patient patient closes into the compound until
the posterior teeth barely miss the contact while in
supine position ,the lower central incisors contact the
smooth lingual incline of the jig at only one point.

The jig incline must stop the mandible before

posterior tooth contact and should be angled 45 - 60
degrees posteriorly and superiorly from the occlusal
plane

 The jig can also be made of

autopolymerizing acrylic resin on mounted
casts and then adjusted intraorally.

After the jig is made posterior bite record is
taken.
40
Leaf Gauge
Leaf Gauge was first introduced by Dr. James.H. Long in
1973
• It is the most useful and practical alternative to anterior
jig.
• Leaf gauges - Uniform 0.1mm thickness
•
They are convenient and measure the exact vertical
opening between the incisors.

• Leaf guage can be used for-

Centric relation interocclusal records

Occlusal equlibriation
—Relieve painful spasms of lateral pterygoid muscle.

41
 CENTRIC BITE RECORD

Anterior bite stops - muscle deprogrammers.

They do this by separating the posterior teeth so
deflective posterior interferences cannot
influence the musculature to displace the
condyles

The four basic techniques for making a centric

bite record are:
1) Waxbite procedures
2) Anterior stop technique
3) Use of pre-adapted bases
4) Central bearing point technique

42
1. Waxbite Procedures
 Hard wax is used which becomes brittle
when cooled and is dead soft when
warm.

 Extra hard baseplate wax is an excellent

bite material. When it is warm it
becomes soft enough not to cause
movement of teeth. It should be brittle
and not bend to mould itself to fit the
models as it will mask the errors if not
rigid

 Modification of wax bite - additional

wash of zinc oxide eugenol paste to
reline for greater accuracy

This method is not suitable for patients having

extremely mobile teeth or large edentulous
area
43
2. Anterior Stop technique

Easiest to learn and offers greatest flexibility.

Accuracy achieved even with loose teeth, posterior

edentulous areas and patients with TMJ discomfort.

This technique allows the condyles to seat up

without any possible deviation from posterior teeth.

The term anterior stop - contact in the incisor area

only.
It may be made from acrylic or hard compound, on
mounted models or intraorally.

Bite record for posterior teeth can be made with a

variety of materials- Plaster, zinc oxide eugenol
paste, self cure acrylic or wax and heavy bodied
silicone .

44
3. Readapted Bases

It is indicated whenever there is a danger that teeth will move or

soft tissues be compressed by the bite record

Preformed bases - stabilize hypermobile teeth in correct position

while the bite record is being made.

 It is made with triple layer of extra hard baseplate wax adapted on

an accurate model, usually of the upper arch to avoid dislodgement
by the tongue.

Heated strip of dead soft wax should be added over it in edentulous

region to indent the lower teeth in centric occlusion without tooth to
tooth contact

45
4. Central Bearing Point Technique

It enables free movement of the mandible without influence

of teeth proprioceptives.

Drawback is that vertical dimension must be increased

considerably to accommodate the clutches and bearing point
apparatus

If the terminal axis is not recorded precisely it will result in

mounting error.

46
 VERTICAL
DIMENSION

111 Vertical Dimension: The distance between two selected
anatomic or marked points, one on a fixed and the other on a
movable member.

 Vertical Dimension of Rest: The postural position of the

mandible when an individual is resting comfortably in an
upright position and the associated muscles are in a state of
minimal contractual activity.

 Vertical Dimension of Occlusion: The distance between two

selected anatomic or marked points when in maximal
intercuspal position.

 The mandible-to-maxilla relationship, established by the repetitive

contracted length of the elevator muscles, determines the VDO.

VDR – VDO = 2 – 4MM(FREE WAY SPACE )

47
• Anterior teeth are the dominant factor in determining vertical
dimension.
• VD is unrelated to temporomandibular disease (TMD)

• there is no evidence to suggest that by changing VD one can treat

TMD.
• However, VD can be increased or decreased for the best functional
and aesthetic anterior contact in Centric relation

• Techniques to evaluate VD include pre treatment record , incisor height

measurement , phonetic evaluation , patient relaxation , assessment of
facial appearance , radiographic evaluation , neuromauscular evaluation

48
 Rules for Determining the
113
VDO on Patients with Teeth
 1. The VDO that requires the least amount of dentistry to satisfy
esthetic and functional goals is always the VDO of choice.
Extensive treatment done solely for the purpose of increasing the
vertical dimension is contraindicated.
 2. Maximal intercuspation of the posterior teeth determines the
existing VDO. This dimension will be in harmony with the jaw-to-
jaw relationship established by the repetitive contracted length of
the elevator muscles.
 3. The muscle-determined VDO must be measured from origin to
insertion of the elevator muscles. This is best measured clinically
from the zygoma to the angle of the mandible, the origin to
insertion dimension of the masseter muscle.

49
  4. The position of the condyles during maximal intercuspation must be
considered when evaluating VDO. This is so because any change up or down of
114 the condyles affects muscle length during maximal intercuspation.
 5. If the VDO must be changed, it should be determined at the point of anterior
teeth contact. If posterior interferences prevent anterior contact in centric
relation and occlusal equilibration is determined to be the best choice of
treatment, the posterior teeth may be adjusted until anterior contact is achieved
in centric relation

 6. Changing the VDO by either increasing or decreasing it is tolerated well by patients

and within reason causes no harm to teeth or supporting structures if tooth contact
and the condyles are completely seated in centric relation during maximal
intercuspation.
 7. Changes in the true VDO are not permanent. The VDO will return to its original
dimension measurable at the masseter muscle. Unnecessary increases in the VDO
are contraindicated as they are not maintained.

50
• Wear does not result in loss of VD, eruption forces occur
through out the life causes teeth to erupt to move vertically
with the alveolar bone until they meet resistance equal to
eruption forces i.e forces of elevator muscles .

Measurements from fixed bony landmarks show that the dimension to the
cementoenamel junction (A) increases with tooth wear. The dimension from
bone landmark to occlusal surface (B) remains even with severe wear

51
 Can vertical dimension be altered?
- Sicher (1949) and Silverman(1952).
as the teeth wear or become abraded, the teeth and alveolar bone elongate
through growth to maintain the original vertical dimension with the maintenance
of the same closest speaking space. However, occlusal wear may occur more
rapidly than continuous eruption depending upon the etiology of the wear.

Harry Kazis and Albert Kazis

Treatment of reduced vertical dimension is not designed to increase the vertical
dimension beyond the normal, but is intended to restore the amount of vertical
dimension that has been lost. A young person will tolerate a greater correction of
vertical dimension and become adjusted more easily to a reduction in the
interocclusal distance as necessitated by the changes

Silverman (1956)6)
• Closest speaking space can range from 0 to 10mm in different patients and
that there is no average closest speaking space. But it is constant in an
individual. Vertical dimension must not be increas4e2 d beyond the normal for
each patient. . It is better to use a vertical dimension that is too small than to
use one that is too great

•
52
Landa(1955)

• stated that increasing the vertical dimension places the muscles of mastication and
temperomandibular joint under strain. The crown to root ratio is also affected and
hence ‘bite raising’ is contraindicated.

Dawson(1974)

• even when the teeth have grown down to the gum line the vertical dimension is not
lost because of the eruption of the teeth along with the alveolar bone.It is not practical
to restore severely worn dentition without restoring the vertical dimension to obtain
space for the restorative material, the dimension can be increased to 1-1.5 mm.The
potential problems of restoring the vertical dimension are clenching, muscle fatigue,
soreness of teeth, muscles and joints, headache,intrusion of teeth, fracture of porcelain
, occlusal instability due to shifting of restored teeth and continual wear..In such cases,
checking and periodic occlusal adjustment must be done upto a year before normal
stability returns.

53
Carlsson et al(1979)
Increased the vertical dimension in natural dentition by cementing acrylic resin splints
in lower canines, premolars and molars for 7 days.
moderate symptoms of discomfort initially but symptoms decreased later and no
clinically demonstrable symptoms were found.
moderate increase in vertical dimension of occlusion does not create problem
provided that occlusal stability is provided.

Rivera-Morales(1991)

Experiments in animals proved that moderate changes in occlusal vertical dimension

does not cause hyperactivity of masticatory muscles and symptoms of
temperomandibular dysfunction.Occlusal vertical dimension is a variable range like
other quantifiable aspects of a body.

54
 When Must The Vertical Dimension Be Changed?
Extremely worn dentition
Restoring severe arch mal- relationships
Extreme occlusal plane problems
Anterior open bite

Why Not Increase The VD?

Occlusal treatment – develop harmony in masticatory system
Disharmony in the system – adaptive response – return the system to equilibrium

Adaptive response to increase in vd -

• lengthened teeth to intrude into alveolar bone to regain original jaw to jaw
relationship .
• wear away the increased dimensions by bruxing .
• Muscles attempting to regain its normal length of contraction increase
loading on lengthened tooth – supporting tissues exceeds their capacity to
remodel – hypermobility of teeth.
• The goal of occlusal therapy is to minimize the requirements for adaptation.

55
 Vertical Determinants

There are four philosophies for condylar position when determining VD.
All work on the basis of a canine protected occlusion.
Gnathological
use fully adjustable articulators to determine
condylar path from the hinge axis and setting
this path for a 5 degree increase to ensure no
posterior interferences

Bioaesthetics
Works via a fixed numerical value based on
incisal relationship. Distance between gingival
margins of 18-20 mm in an unworn class one
occlusion, with upper incisal length of 12 mm,
lower incisal length 10 mm, 4 mm overbite and
1 mm overjet.
56
Centric relation based
Following the principles of P. Dawson whereby
CR is defined as when the heads of the
condyles are in their most superior position
within their sockets, lateral pterygoid muscle is
relaxed and the elevator muscles are
contracted with the disc properly aligned

Neuromuscular
Based on the principles of muscle activity
determined by electromyography.

57
 Possible Clinical Concerns Behind Changing VD

• Joint or muscle pain

• Stability
• Muscle activity
• Phonetics

58
 Equilibrate
Methods of obtaining space for Reposition
Restore
restoring worn teeth Osteotomy
orthognath
 Selective grinding ic

 Crown lengthing - Includes gingivoplasty, osteoectomy .

2- 3mm of supporting bone can usually be removed without jeopardizing periodontal support

 Splints and provisional restorations

• There are occasionally situations where restoration of a worn dentition can be
accomplished only by increasing occlusal vertical dimension, even though a loss of vertical
dimension is not diagnosed.
• modification of vertical dimension should be accomplished through
cautious trialswith removable occlusal splints

Removable occlusal Evaluated Teeth preparation and

splint for provisional fixed
• Given for 6-8 week comfort restorations
and • Evaluated for 2-3 months
functio 59
 Occlusal splints

Permissive occlusal splints Directive occlusal splints

• have a smooth surface on one • Direct the lower arch into a
side that allows the muscles to
specific occlusal relationship that
move the mandible without
in turn directs the condyles to a
interference from deflective
tooth inclines into centric predetermined position.
relation. • very limited use
• reserved for specific
conditions involving
intracapsular TMDs.

Anterior deprogramming splint is contraindicated

60
 DAHL APPLIANCE

• Partial coverage splint, 2-4 mm thick,

depress the opposing teeth against which it
contacts and to allow the unopposed teeth
to overerupt.
• It contacts anterior teeth and allows
posterior teeth to erupt.
• Alveolar remodeling ensures that anterior
teeth are not intruded into the bone, with a
resulting loss of crown height

• Dahl described the use of cobalt

chromium appliance but its modifications
of acrylic and bonded composite have
been used satisfactorily.

• Most space is created between 2-4

months of continuous wear

61
 Occlusal considerations in full mouth rehabilitation
• No one type of occlusion that is optimum for all
patients.
• starting point in designing occlusal contours is to
shape and locate the centric contacts so that the
forces are directed parallel to the long axes of the
teeth.
• Ideal occlusion can be defined as an occlusion
compatible with the stomatognathic system,
Types of centric
providing holding contact
efficient mastication and good
esthetics without
Centric relation creating
contact physiologic
is usually establishedabnormalities
on restorations
(inHobo)
one of three ways

Surface to surface contact/Mashed potato

• It is stressful and produces lateral interferences

and hence it should be avoided
Tripod contact
62
contact
Tripod contact
• Contact is made on sides of the cusps that are
convexly shaped.
• can be given in posterior disclusion cases where
anterior teeth are strong enough.
• cannot be used when posterior teeth are in
group function (convex cusps immediately
disengage upon leaving centric relation.)
• It is difficult with achieve with no actual
indications and no advantage over cusP tip to
fossa contact.

Cusp tip to fossa contact

• It provides excellent function, stability,
resistance to wear and aids easy to equilibrate
by shaping the fossa inclines without disturbing
the centric holding contacts.

63
Physiologic occlusion:

Box states "A physiologic occlusion is one in which the relationship between
the 'teeth and periodontal tissues is such that under occlusal stress no injury
is produced by them and, the tissues are best able to withstand the forces of
occlusion without the initiation of pathologic changes in the periodontium.

Functional occlusion:

An arrangement of teeth, which will provide the highest efficiency

during all the excursive movements of the mandible, which are
necessary during function.

Therapeutic occlusion:
The arrangement of teeth and their opposing occlusal surfaces satisfy' functional and
esthetic requirements, while distributing and directing forces of occlusion over as
many teeth as possible during function of the mandible.
There are three recognized concepts-
Bilaterally balanced occlusion
Unilateral balanced occlusion
Mutually protected occlusion

64
 Balanced Occlusion/ Balanced Articulation
•
13
The bilateral, simultaneous, anterior and posterior
occlusion contact of teeth in centric and eccentric
positions.

• Ferdinand Graf Von Spee who in 1890

The occlusal surfaces of all natural mandibular teeth
glide against the natural maxillary teeth.

useful in complete denture construction, in which

contact on non-working side is important to prevent
tipping of dentures.

For natural dentition bilateral tooth contact during

excursive movements of mandible does not function
well

65
 Unilaterally Balanced Occlusion (Group function)

Definition: Multiple contact relations between the maxillary and mandibular

teeth in lateral movements on the working side whereby simultaneous
contact of several teeth acts as a group to distribute occlusal forces.- GPT 9

• Schuyler in 1929
• Laterotrusive contacts on buccal cusps only
• No mediotrusive contacts

Beyron in 1969 has listed characteristics of this type of occlusion:

• Teeth should receive stress, along the long axis.

• Total stress should be distributed among the tooth segment in

lateral movement.

• No interference occur from closure into ICP.

• Keep proper interocclusal clearance.

• Teeth contact in lateral movement without interferences. 66

 Mutually Protected Occlusion or Canine – Protected
Definition: An occlusal scheme in which the posterior teeth
prevent excessive contact of the anterior teeth in maximal
intercuspal position, and the anterior teeth disengage the posterior
teeth in all mandibular excursive movements.- GPT 9

D’Amico in 1958 stated that cuspid protected articulation and

disocclusion were natural adaptations for preventing destructive
occlusion

Features of a mutually protected occlusion(Dawson in 1974) are:

• Uniform contact of all teeth around the arch
• Stable posterior tooth contacts with vertically directed resultant forces.
• Centric relation coincident with maximum intercuspation. CR = IP.
• No contact of posterior teeth in lateral or protrusive movements.
• Anterior tooth contacts harmonizing with functional jaw movements.

67
 Advantages : (Lucia 1961)
• As minimum amount of tooth contact is involved, this makes for better penetration of
food.
• A cusp to fossa relationship produces an interlocking , thereby giving maximum
support in centric relation in all direction. Force is nearly closely to the long axis of
each tooth.
• This occlusion fulfills criteria for ideal occlusion

Disadvantages :
• Mutually protected occlusion is contraindicated when the Periodontium of the
anterior teeth is compromised.

• In Class III and cross-bite cases mutually protected occlusion is contraindicated.

• Missing canine or a prosthetic canine contraindicated MPO.

• Arbitrary amounts of posterior disclusion.

NOTE: Posterior disclusion

• can be achieved by two different types of anterior guidance: anterior

68
group function and canine- protected occlusion.
 Occlusal scheme

Patient presents with Occlusal scheme

Natural canine protected Canine protected

Natural group function Group function

Canine missing or periodontally Group function

weak
Opposing complete denture Balanced or monoplane

Where no posterior tooth remaining Canine protected

69
Selecting occlusal form for
stability

70
 Occlusal equilibration in natural dentition

occlusal equilibration :
• refers to the correction of stressful occlusal contacts through
selective grinding.
• It is a phase of treatment that eliminates only that part of
tooth structure that is in the way of harmonious jaw function.

Equilibration procedures

Eliminating Harmo
Eliminatin Eliminating interference to nizatio
g n
interferen posterior tooth Of
ce to lateral Anterio
interferences excursions r
terminal with protrusive guidan
hinge axis ce
closure excursion
s. 71
136
 Interference to Centric Relation
Centric interference can be differentiated into two
types-
Interference to arc of closure : basic grinding rule MUDL

72
 Interference to the line of closure

If interfering incline causes the mandible to deviate the line of closure

towards cheek
Grinding rule– grind the buccal incline of upper or the lingual incline of loweror both
inclines
If interfering incline causes the mandible to deviate the line of
closure towards tongue
Grinding rule– grind the lingual incline of upper or the buccal incline of lower or
both inclines 73
 GRINDING RULES

Rule 1: Narrow stamp cusps before

reshaping fossae

Rule 2: Don’t shorten a stamp cusp

TILTED TOOTH

74
 Rule 3: Adjust centric interferences first

1.By adjusting centric interferences first, you have improving cusp- tip
position.
2.When cusp-tip position is given first priority, occlusal grinding is
more evenly distributed to both arches.
3. eccentric interferences can be eliminated with speed and simplicity.

Rule 4: Eliminate all posterior incline contacts. Preserve cusp tips only.

• If all eccentric contacts on posterior teeth are to be eliminated, any posterior

incline that marks in any excursion can be reduced.
• Centric stops must be preserved, but all other contacts can be shaped so that
they are discluded by the anterior guidance.

75
 Lateral excursion interferences
Dictated by two determinants:
1.The border movements of the condyles, which act as the
posterior determinant
2. The anterior guidance, which acts as the anterior determinant

Determine type of occlusion- Group Function - posterior disclusion

Cusp tips are centric holding stops hence adjustings to be done on fossa inclines

2 TYPES – 1. balancing side – BULL RULE

2. working side - LUBL RULE

PROTRUSIVE INTERFERENCES
Correction done in case of steep anterior guidance Grinding
rule- DUML
76
 LONG CENTRIC / FREEDOM IN CENTRIC

• Defined as ‘ freedom to close the mandible either into centric relation or

slightly anterior to it without varying the vertical dimension of occlusion.

• When interference in centric relation is eliminated by equilibration ‘long

centric will usually be provided automatically.

• The most important aspect is that the vertical dimension of occlusion must
be the same from back to front of each long centric contact area.

77
Contact in centric relation Clearance for long
centric

NOTE: relief required is never more than 0.5mm,so it should not necessary to mutilate
teeth to accommodate long centric 78
 Providing long centric by equilibration

• When Interferences to CR are eliminated by equilibration Long centric is

automatically acquired
• Equilibrated patient is free to move into centric or into his original convenience
position or any where in between
• Freedom to do so the mandible will close directly into centric or a few mm
anterior to it , depends on the anatomy and the musculature .
• Length of the long centric is determined by the anatomy of the condyle disk
relationship.
• Equilibration should not cause extensive flattening of the cusps and reduce the
Efficiency of chewing for that careful use of small stones on the interfering
inclines only has to be used.

Occlusal inclines restricting mandibular movement are potential stress producers

79
 Procedure

• To determine the patient’s long centric two different colours of marking

ribbon are used
• green or blue -centric relation points
• Red ribbon -closure from postural rest position
• knife edge inverted cone carborundum stone is used for accurate grinding
• There are no contraindications for providing the freedom.

80
 Reading the marks
2.red mark extend forward from
1.Red mark covered by Green green centric mark

• Shows a need for long centric

• Indicate that terminal
hinge Closure and light • Should not grind the green centric
closure from rest are marks equilibration complete when
identical there are no red marks on the inclines
• In perfected occlusion the red marks
will still extend forward from green but
at the same VD
• VD will slightly open posteriorly
but very minimally

81
3.Red mark extend backward from 4.Green centric marks missing
green from red marks

• Only reason that the dentist has not

correctly manipulated the CR • The equilibration is incomplete
• Teeth with some degree of mobility
are being move when patient taps
• To check mobility different color
ribbon should be used for
comparing light contacts from firm
contacts

82
Symptoms indicating requirement of long centric

• Patient says they are comfortable when lying down but interfere while
sitting up
• Patient says teeth fit fine when dentist pushes the jaw back but hit
only on front teeth if close it themselves

Advantage of long centric

Freedom of movement in centric occlusion provides patient comfort and
reduces the tendency to bruxism and other traumatogenic influence on the
supporting structures.

83
 ANTERIOR GUIDANCE

The centric relation contacts the most critical tooth contour in the entire
occlusal scheme is also the most universally mismanaged.

Instability in anterior guidance – probability of allowing posterior

occlusal inferences

84
 The matrix of
142
functional anatomy
 The matrix of functional anatomy describes
six specific surfaces of upper anterior teeth
that define their contour boundaries.

85
 Determining incisal edge position
1. Interferences to centric relation are eliminated

second most important determination - upper incisal edge

position.
2.upper half of the labial contour
• There is no bulge in nature from the alveolus to upper
labial surface i.e. the upper half of the labial surface is
continuous with the labial surface of the alveolar process.
3.Lower half of labial contour - determine horizontal
position of incisal edges
• Lower lip easily slide by the incisal edge to seal contact
with the upper lip –lip closure path .
• Preparation done in two planes
Note : restoration with too forward incisal edges –
inadequate preparation for lower half of the labial surface

86
4. Contour of incisal plane:

• Incisal edge should fit the internal contour of the

lip when the patient smiles gently

• Contact of the incisal edge at the vermilion border of the lower lip
Determine the correct vertical and horizontal position for incisal edge.

• This relationship is important for phonetics of the F and V positions as well

as for the best esthetics.

Process: Upper incisal edges best determined by observing the patient to counting
from 50 t 55 ie 'F' sound. This needs to be in harmony with the neutral zone, lip
closure path, phonetics, envelope of function and aesthetics.

87
 5.Contour of anterior guidance – harmony with the envelope of function
The Five Steps to Harmony

Step 1. Establish coordinated centric relation stops on

all anterior teeth.

Step 2. Extend centric stops forward at the same

vertical dimension to include light closure from the
postural rest position.

Step 3. Determine the incisal edge position

88
 Step 4. Establish group function in straight
protrusion

Step 5. Establish ideal anterior stress

distribution in lateral excursions

Evaluate S sounds. The closest speaking position should produce no whistle or lisp.

89
6.Contour from the centric relation stop to the gingival margin

• Round off the cingulum contour to blend into the centric relation stop .
Preserve the forward half of the stable stop for contact with the lower incisal edge.

• There should be no interference with the 'T', 'D' or 'S' sounds.

90
 RESTORING LOWER ANTERIOR TEETH

• Lower incisal edges are the starting point for anterior guidance and “the view”
when speaking.
• The arrangement of the entire occlusal scheme starts with the lower anterior teeth

5 important goals in

1. Esthetics
2. Phonetics
3. Occlusal plane
4. Anterior guidance
5. Stability

91
• The restoration of lower anterior teeth requires two key determinations :
1. incisal edge position
2. incisal edge contour

INCISAL EDGE POSITION

The determination of incisal edge position requires three decisions:

 1. The curvature of the incisal plane

 2. The height of the incisal plane

 3. The horizontal position of the incisal edges

92
The Curvature of the
Incisal Plane:
• Important to phonetics
131
• During s sound pronunciation – jaw to jaw relationship is in harmony with envelope of
function.

• More convex the incisal plane is on the upper teeth, the more convex it will be on the
lower teeth

93
 The height of the incisal plane:

Relating lower incisal edges to the occlusal plane:

In ideal instance ,lower incisal edges forms continuous gently curve that is an
extension of posterior occlusal plane .

The lower incisal edge is at the

height of the juncture of the upper
and lower lips when the teeth are
together..
On a lateral cephalometric
radiograph, this usually positions the
incisal edge slightly above the
functional occlusal plane.

94
Relating lower incisal edges to the lips
Speaking:“The view” when speaking is
of the incisal
edges of the lower anterior teeth. A varying
usually
amount hidden during contour
of labial speech may also be on
display. The upper teeth are

Smiling:
Only the upper anterior teeth are typically on
display during smiling. The lower incisors are
usually hidden during a big smile.

Lips slightly parted:

When the jaw is at rest and the lips are
slightly parted in a half smile, both upper
and lower labial surfaces are about equally
on display. 95
Horizontal position of the lower incisa edges:

 The key to determining the horizontal position of lower

incisal edges lies in establishing stable holding contacts with
the upper anterior teeth.

96
 Lower incisal edge contour
• The most important contour on the lower incisal edges - labio-incisal
line angle.

• The “leading edge” is important for natural appearance - to achieve a

stable
• holding contact against the upper lingual stop.

• Use of the Esthetic Checklist reminds the technician to do this on every

lower anterior restoration

• Lingual incisal line – natural looking incisal edges .

• Extensive wear – moves lower teeth forward and move upper teeth
lingually

• In diagnostic wax up – move thick incisal edges lingually to permit better

lingual contours on the restorations

97
 Occlusal plane

1.The average plane established by the incisal and occlusal surfaces of the teeth.
Generally, it is not a plane but represents the planar mean of the curvature of
these surfaces.

2: The surface of wax occlusion rims contoured to guide in the arrangement of

denture teeth.

3.A flat or curved template used in arranging denture teeth.

98
 Determination of Plane of Occlusion
• The plane of occlusion refers to an imaginary surface that theoretically
touches the incisal edges of the incisors and the tips of the occluding
surfaces of the posterior teeth.

Curvatures of the anterior teeth are determined by

1) Establishment of the esthetically correct smile line on the upper teeth.

2) The relationship of the lower incisal edges to the anterior

guidance.

3)And the requirements for phonetics

The curvatures of the posterior plane of occlusion are divided into

1) Anteroposterior curve called the curve of Spee.

2) Mediolateral curve, referred to as the curve of Wilson.

99
Curve of spee
• The curve of Spee anteroposterior curvature of the occlusal surfaces,
beginning at the tip of the lower cuspid and following the buccal cusp
tips of the bicuspids and molars and continuing to the anterior border
of the ramus

• The anteroposterior curvature of the occlusal plane is to permit

protrusive disclusion of the posterior teeth by anterior guidance &
condylar guidance.

100
The curve of Wilson
• The mediolateral curve that contacts the buccal and lingual cusp tips on
each side of the arch.

• It results from inward inclination of the lower posterior teeth, making the
lingual cusps lower than the buccal cusps on the mandibular arch

• The buccal cusp are higher than the lingual cusps on the maxillary arch
because of the outward inclination of the upper posterior teeth.

101
 Various Occlusal Plane Analysers
Broadrick Occlusal Plane Analyzer (BOPA)
- Dr. Lawson K Broadrick (1963)

• incorporating the curve of Spee in harmony with the anterior and

condylar guidance, allowing total posterior tooth disoclusion on
mandibular protrusion

• prevents the introduction of protrusive interferences

102
Anterior Survey Point Posterior Survey Point

103
Condylar Element Used As The acceptable Plane of Occlusion
Posterior Survey Point

104
Simplified Occlusal Plane Analyzer(SOPA)

105
 A SOPA is preset at 4 inches from the condylar axis. The SOPA
works with DenarR (Teledyne Waterpik™) articulators

Occlusal Plane Scribed On the Mandibular Arc the compass lead to the back
Cast that will go through the condylar axis molar. This establishes the optimum
in one simple step occlusal plane height for the posterior
teeth 106
107
 Custom Made Occlusal Plane Analyzer

Custom Made Occlusal Plane Analyzer: Fabrication and Technique

Mayank Shah International Journal of Advanced Dental Science and
Technology 2013, Volume 1, Issue 1, pp. 17-2

108
109
110
 Posterior occlusion
• Posterior teeth should have equal intensity contacts that do not interfere
with either the temporomandibular joints (TMJs) in the back or the anterior
guidance in the front.
• The requirements for perfected posterior occlusions start with the lower
posterior teeth followed by upper posterior teeth

Three key determinants for lower posterior teeth

1. Plane of occlusion
2. Location of each lower buccal cusp tip
3. Position and contour of each lower fossa

Restoration of posterior teeth should not be considered until the condyles

positioned with acceptable comfort in centric relation & until anterior
guidance is correct .
111
 Placement of Lower Buccal Cusps
• determined on the basis of providing the optimum effect for buccolingual
stability, mesiodistal stability, and noninterfering excursions.

Buccal cusp placement for buccolingual stabilitystability

• Upper central groove position is analyzed.
• On each upper occlusal surface, a line is drawn from mesial distal in the
central groove.
• The ideal contact point for each lower buccal cusp tip is usually located
somewhere on this line.
• In some tilted teeth, it is advantageous to move the central groove to gain
better direction of forces through the long axis.
• If moving the central groove will enable the stresses to be directed more
nearly through the long axis of any upper tooth, the improved central groove
position should be so noted on the upper cast by drawing a new line.

112
• A mark is made on each lower tooth to indicate the position of the buccal
cusp that would be optimum for buccolingual stability and direction of
force
• Alignment of the optimum lower buccal cusp position against optimum
upper central groove position is evaluated.

113
 Mesiodistal placement of lower buccal cusps

• The best mesiodistal stability is attained by placement of the lower buccal

cusps in upper fossae.
• Placement in the fossae directs the stresses properly through the long axis,
eliminates any possibility of plunger cusp food impaction at contact, and is
stable.
• There is no tendency for cusp tips to migrate out of properly contoured fossae.

114
Locating the lower buccal cusps for noninterfering excursions

• Determining which fossa the lower buccal cusp should contact

depends on where the centric relation.
• The mesiodistal placement of each lower buccal cusp is determined
when one locates it in the fossa that permits excursions from centric
relation without interference

115
 Conturing cusp tips

• Cusp –tip – to fossa contact , tip of each lower buccal cusp should be small
enough to fit into normally contoured fossa.

• If anterior guidance permits lateral side shift – cusp tip contact the base of the
fossa
with out touching the fossa walls in centric relation .

• if anterior guidance is steeper than the fossa walls – no lateral side shift – sides
of the cusp contact the fossa walls

116
 Placement of lower lingual cusps
• In normal tooth-to-tooth relationships, the tip of the lower lingual cusp never
comes in contact with the upper tooth.
• Even though the buccal incline of the lower lingual cusp can be made to
contact in working excursions
• Act as a gripper and a grinder by passing close enough to the upper lingual
cusps to aid in tearing, crushing, and shearing the food.
• The position of the tip should have enough lingual overjet to hold the tongue
out of the way.
• The measurement between buccal cusp tip and lingual cusp tip should not be
much greater than half of the total buccolingual width of the tooth at its widest
part.
• lower lingual cusp height should be about a millimeter shorter than the
buccal cusp.
• Cusp height can be lowered further in the first premolar

117
 Countouring the lower fossae

• As the mandible moves right or left from centric relation, its front
end should be guided down the lingual incline of the upper canine.
• When it serves as the lateral anterior guidance, the lingual incline
of each upper canine dictates the fossa contour of each lower
incline that faces it

118
 If Only Lower Posterior Teeth Are to Be Restored
• Cusp tip position and fossa contours for lower posterior restorations are aligned
and contoured in relation to the existing upper teeth on the opposing cast.
• Lower fossa contours will be established to conform to the upper lingual cusps.
• Fossa walls can be carved to be discluded by the anterior guidance without
complication.

If Both Upper and Lower Posterior Teeth Are to Be Restored

• If posterior disclusion is the goal - fossa walls flatter than the lateral anterior
guidance, and establishing an acceptable occlusal plane that permits the
anterior guidance to disclude the posterior teeth in all excursions.

• The simplest method for ensuring that fossal walls through the use of a
fabricated fossa contour guide.

119
 Making the fossa contour guide
157

 Step 1: The regular incisal guide pin is removed and replaced with the
special fossa-contour pin. The blade of the pin is indented into a mound
of wax on a flat plastic guide table.

120
158

 Steps 2 and 3: The upper bow is moved into left and right excursions,
allowing the contours of the lateral anterior guidance to determine
the path that the guide pin cuts into the wax.

121
159

 Steps 4 and 5: When the lateral guidance paths have been cut sharply
into the wax, the special pin is raised. It is then used to hold a handle for
the fossa guide.

122
160

 Step 6: A creamy mix of self-curing acrylic resin is flowed into

the indentation in the wax.

123
161

 Steps 7 and 8: Resin is wiped into the hollow end of the handle, and the
pin is lowered so that the two portions flow together. The resin is allowed
to set hard. The guide can then be removed.

124
  Step 9: Because of the design of the special wax-cutter pin, the lateral
162 anterior guidance angle will be evident as a sharp line running along the
bottom edge of the acrylic guide. The edge is marked with a pencil, and
any excess acrylic resin may be ground off in front of the line.

125
  Steps 10 and 11: To ensure posterior disclusion, the fossa walls must be
flatter than the lateral anterior guidance, so the fossa guide angle is
163
flattened on the sides and the tip is rounded to a more opened-out fossa.

126
  Steps 12 and 13: The fossa guide can be used to contour the wax
patterns or as a guide for shaping occlusal surfaces in porcelain. The
164 tip of the guide should be able to touch the base of the fossa
without interference from the walls of the fossa.

127
 Upper posterior teeth

• last segment to be restored.

• It is the fixed posterior segment, and its cusps, inclines, grooves, and
ridges are placed and contoured to accommodate the many border
movements of the lower posterior teeth.

128
 Length of group function contact in working excursion
1. group function on the working side , we aware that all teeth do not stay in excursive contacts
for the same length of stroke

2. As the mandible starts its move to the working side , all of the posterior teeth may contact in
harmony with the anterior guidance and the condyle

3. As the mandibule moves further to the side ,the first teeth to disengage from contact are the
most posterior molars.

4.The disengagement is progressive , starting with the back molar, which has the
shortest contact stroke , forward to the canine ,which has the longest contact stroke

129
130
 Balancing excurtions

• Balancing inclines must be relieved on the natural teeth regardless of the

method used to record the border movements.

Types of posterior occlusal

contours
There are three basic decisions to make regarding the design of
posterior occlusal contours:
1. Selection of the type of centric relation contacts
2. Determination of the type and distribution of contact in lateral
excursions
3. Determination of how to provide stability to the occlusal form

131
OCCLUSAL REHABILITATION: PHILOSOPHIES

132
 • GNATHOLOGICAL CONCEPT:

16 McCollum together with Stuart proposed this concept


Anterior guidance was independent of the condylar path and described
condylar path as a fixed entity in adults.
 The concept of balanced occlusion was applied to restoration of the natural
dentition by McCollum, Schuyler and others.
 In their report in 1960 they adopted the concept of mutually protected
occlusion .
 point centic contact
 Maximum intercuspation coincide with centric relation
 Cusp to fossa relationship
 Narrrow occlusal table

Gary M. DeWood. Gnathology and Pankey-Mann-Schuyler : fulfilling the requirements of occlusion in

oral rehabilitation
The University of Toledo The University of Toledo Digital Repository 2004 133
Limitations:
• Point – centric and cusp to fossa tripodization complicates the
need to obtain precise restoration.

• Need for fully adjustable articulator

134
 Freedom in centric concept:

18
SCHUYLER first introduced the Concept Of ‘FREEDOM IN CENTRIC’’ and
supported the theory that centric relation was rather a biological area
of the TMJ than a point.

 In this concept, ‘‘there is a flat area in the central fossae upon which
opposing cusps contact which permits a degree of freedom (0.5–1 mm) in
eccentric movements uninfluenced by tooth inclines’’.

 It relies on cusp-to-surface mechanics. – affects chewing efficiency

 Schuyler suggested that incisal guidance without freedom of movement

from a centric relation occlusion to a more anterior tooth intercuspation

135
SMIPLIFIED OCCLUSAL DESIGN:

• Cusp –fossa relation with only one contact per tooth

• Anterior disclusion during eccentric movements
• Freedom in centric occlusion
• Can be adapted to most anterior guidance and varying degrees of group
function

136
 THE PANKEY– MANN–SCHUYLER (PMS) PHILOSOPHY

Pankey utilizing the principles of occlusion espoused by Dr. Clyde Schuyler .

20

The goals of full mouth rehabilitaton are fulfilled by the following these
principles :

1. A static coordinated occlusal contact of the maximum number of the

teeth in centric relation
2. An anterior guidance that is in harmony with the function in lateral
eccentric positions on the working sides
3. Disclusion by the anterior guidance of all posterior teeth in protrusion
4. Disclusions of the non –working side inclines in lateral excursions
5. Group function of the working side inclines in lateral excursions
6. Freedom of centric by incorporating long centric

Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in treatment planning and
in restoring lower posterior teeth. J Prosthet Dent 10:135–150
Pankey LD, Mann AW (1960) Oral rehabilitation: part II.Reconstruction of the upper teeth using a 137
functionally generated path technique. J Prosthet Dent 10:151–162
 Sequence advocated by the PMS philosophy
127

Part 1. Examination , diagnosis , treatment planning , prognosis

Part 2. Harmonization of the anterior guidance for the best possible

1.Esthetics 2.Function 3.Comfort

Part 3. Selection of an acceptable occlusal plane , Restoration of the

lower posterior occlusion in harmony with the anterior guidance in a
manner that will not interfere with the 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 to this reconstruction technique.

138
 Advantages of the P-M-S technique are:
1.
129 Possible to diagnose for entire rehabilitation before a single tooth is
prepared
2. It is well organised logical procedure that progresses smoothly
3. There is never need to prepare or rebuild more than 8 teeth at a time
4. It divides the rehabilitation into series of appointments
5. There is no danger of losing patients present vertical
dimension
6. All posterior contours are programmed by and are in harmony with
both condylar border movements and perfect anterior guidance

Limitations:
Cusp to fossa marginal ridge contact
Functional generated path way technique - cause errors

139
 PROTOCOL:

1. Anterior teeth are to be restored first in order

to establish anterior guidance and esthetics .

2.Occlusal plane determined using broadrick

occlusal plane analyser.

3.Lower posteriors restored according to the

established occlusal plane .

4.Meyers functional generated pathway

technique – establish occlusal pattern of upper
posteriors

5.Upper posteriors adjusted – group function

occlusion is establishe during lateral excursion

140
Functional generated pathway :

“A registration of the paths of movement of the occlusal surfaces of teeth or

occlusal rims of one dental arch in plastic or other media attached to the teeth
or occlusal rims of the opposing arch” . (GPT – 9)

Meyer initially described the functionally generated path as a

removable prosthetic procedure.

Adapted to use in oral rehabilitation by Arvin Mann it is accomplished

through the creation of a stone core.

Prepared teeth are coated with Tacky Wax, a wax that is soft enough to
move when chewed against.

141
Steps to functionally generated pathway:

1. Occlusal preparation 2. Tacky wax attached

3. GuideA mandible in 4. Guide mandible on

working side. non working side.
142
 5. Guide mandible 6. Functional impression
in forward position tray

8. Position loaded tray on

7. Mounting stone painted on occlusal surface
tracing

143
9. Excess trimmed off 10. Impression is made
from the tray of prepared tooth

11. Bite registration

12. Bite registration record used
to produce master cast
144
 Cast with prepared Axial contours and
The wax added
tooth is mounted on the proximal contacts
technique is used to
lower member of the are checked before
form the occlusal
twin stage occlude. preceding to the
morphology.
Anatomic cast is seen on occlusal surface.
upper left member and
functional core on the
upper right member

145
The functional To mark the wax
core is painted pattern, the
with white liquid freshly painted
shoe polish functional corei, closed
against it

Occlusal contacts
on the wax pattern
for mutually
protected occlusion
A, and unilaterally
balanced occlusion Restoration is
B. adjusted to fit
against the
functional core 146
 Hobo’s Philosophy

• They believed in posterior disclusion in eccentric movements

• 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.

147
• In this case, during the protrusive
movement the mandible does not
rotate around the intercondylar
axis but only translates.
• Translation as defined means
"parallel displacement of a body"
(the mandible).
• Since maxillary and mandibular
molars slide in contact during
eccentric movement, disocclusion
does not occur

148
 Anterior guide component

• In this case, the mandible

translates and rotates around the
intercondylar axis; the maxillary
and mandibular molars
disocclude.
• McHorris (1979) Incisal path
should be 5 degrees steeper than
the condytar path.
• However, when setting the sagittal
lncisal path inclination 5 degrees
steeper than the condylar path,
the amount of disocclusion during
protrusive movement is only 0.2
mm, about one-fifth the standard
value (1.0 mm).
• If the incisal path is steeper
than 5 degrees, the patient
will complain of
149
• In this case, the mandible does
not rotate around the
intercondylar axis, it only
translates.

• However, since the cusp angle is

shallower than the condylar
path, the maxillary and
mandibular molars disocclude.
• Thus, the component influencing
the amount of disocclusion when
the cusp angle is shallower than
the condylar path is referred to as
the cusp shape component as
a mechanism of disocclusion.

150
 • This shows the case when the
sagittal inclination of the condylar
path is 40 degrees, the incisal path
is steeper than the condylar path
and the cusp angle is shallower
than the condylar path.
ANTERIOR GUIDE COMPONE
• In this case, the mandible
translates and rotates
simultaneously around the
intercondylar axis.

Anterior guide component + cuspal component = wide disocclusion

Influence of the amount of disclusion : cuspal angle , incisal path ,

condylar path
151
 Angle of hinge rotation
35
 The mandible rotates around the intercondylar axis
during eccentric movements when anterior guidance is steeper than the
condylar path .The factor that compensates for the difference in
steepness is the angle of hinge rotation.
 Takayama and Hobo analyzed disclusion relative to the angle of hinge
rotation by using kinematic formulae.
 The results indicated that the angle of hinge rotation contributed to
posterior disclusion by approximately 0.2 mm for protrusive
movement and 0.5 mm on average for lateral movement on both
working and nonworking sides.

152
37

When the right and left condyle moves 3 mm in protrusive movement

and the nonworking condyle moves 3 mm in lateral movement, the
amounts of disclusion were

 1.1 +- 0.6 mm during protrusive movement

 0.5 +- 0.3 mm on the working side and
 1.0 +- 0.6 mm on the nonworking side during lateral movement
measured at the mesiobuccal cusp tip of the mandibular first
molar.

153
 The actual disclusion during protrusive and lateralmovements on the
38 nonworking side differ from the angle of hinge rotation.
This leaves residual amounts of disclusion unaccounted for, namely, 0.9 mm
in protrusive and 0.5 mm on the nonworking side.

Thus suggesting that the angle of hinge rotation was not solely responsible
for disclusion.
The residual amounts can also be attributed to another determinant of
disclusion, the CUSP SHAPE FACTOR.

154
 Measured Angle of Cusp shape
value hinge factor
(mm) rotation (mm)
(mm)
Protrusive 1.1 0.2 0.9

Working 0.5 0.5 0

Nonworking 1.0 0.5 0.5

155
 Buffer space

• The deviation in the condylar path during eccentric movements was

attributed to the shock-absorbing nature of the articular disk. Hobo and
Takayama refered to this deviation in condylar path as a “buffer space.”

• The molars must disclude slightly more than the deviation in the condylar
path ( BUFFER SPACE ) to avoid occlusal interferences.

156
 HOBO AND TAKAYAMA – said incisal guidance and codylar path are
dependent factors
 Hobo adopted the concept of posterior disclusion and gave
the TWIN-TABLES and twin stage technique

Twin-tables technique -Hobo (1991)

• Posterior teeth are restored using two customized incisal tables: without
disclusion; and with disclusion
• They did not include freedom in centric.

157
• First incisal guide table is used to fabricate restorations for
posterior teeth without disclusion

• The second guide table is used to achieve incisal guidance with

disclusion

• For the twin-tables technique, the working condylar path is set on

the articulator to move directly outward along the transverse
horizontal axis to produce a neutral line.

• A semiadjustable arcon-type articulator with a box-shaped fossa

element mimics such a working condylar path.

• When a fully adjustable articulator is used, the working condylar

path is reset to zero both in the frontal and the horizontal planes
so that the working condyle moves straight outward

158
  Diagnostic casts are mounted on
semiadjustable articulator.
47

 Anterior portion of maxillary cast is easily

made removable by using dowel pins.

159
 WITHOUT
49
DISCLUSION
 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.

 To make molars glide smoothly

through maximum intercuspation, any
interference that prevents even
posterior contacts is removed. Areas
are marked with indelible pen.

160
 Wax is added to any surface on tooth
that does not contact with opposing
occlusal surfaces, until it has even
51
contact.

 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.

161
 Vinyl sheet 1 mm thick is placed on tip of
mesiobuccal cusp of mandibular first molar on
54
nonworking side.

 When articulator is closed, incisal pin is

directed laterally and upward. Resin
cone is formed to record this position.

162
 WITH
53
DISCLUSION
 Three-millimeter thick plastic space is placed in nonworking-side
fossa box to approximate lateral movement

163
 Mounted maxillary and mandibular
working casts and two incisal tables.

56

Anterior portion of maxillary working cast is

removed after wax outlines are completed

164
 Incisal table without disclusion and condylar
path of articulator act as guides for even,
gliding contacts in posterior occlusal wax-ups.
58

 After completion of posterior waxing,

incisal table with disclusion is attached
to articulator.

165
  Anterior segment is repositioned. Melted wax is added on lingual
surfaces of anterior teeth; then articulator is closed and moved
60
through all border movements to form anterior guidance.

166
  Restorations with incorporated predetermined disclusion on
articulator.
61

167
 Limitations

• The cusp angle was fabricated parallel to the measured condylar path, and
the cusp angle became too steep
• To obtain a standard amount of disclusion with steep cusp angle, the
incisal path has to be set at an angle that is extremely steep
• The customized guide tables were fabricated by means of resin molding.
• Was technique sensitive

168
 TWIN STAGE PROCEDURE

22

 THE TWIN-STAGE Procedure was developed as the advanced version of

the Twin-Table technique.
 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.

Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a new method to reproduce precise
eccentric occlusal relations. Int J Periodontic Restor Dent 17:113–123 169
This concept 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. 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

170
Basic concept of twin stage procedure:
— In order to provide disocclusion, the cusp angle should be shallower than the
condylar path.

Standard values of effective cusp angles on molars

Cusp angle Cusp angle on

molars (deg)
Protrusive effective cusp angle 25

Working side effective cusp 15

angle
Non working side effective 20
cusp angle

Standard cusp angle – standard deviation

171
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.

HOBO‘s TWIN STAGE PHILOSOPHY

Contraindications:
- Abnormal curve of Spee
- Abnormal curve of Wilson
- Abnormally rotated teeth
- Abnormally inclined teeth

172
CONDITION -1

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.

CONDITION -2

Secondly, reproduce the anterior morphology with the anterior segment

and provide anterior guidance which produces a standard amount of
disocclusion .

173
 TWIN STAGE
62
TECHNIQUE

Without anterior Posterior wax-

Condition 1
segment up

With anterior Anterior wax-

Condition 2
segment up

174
63

175
 FABRICATION OF THE CUSP ANGLE
64
 According to "Condition 1,“
 Make the anterior segment of the maxillary or mandibular
cast removable using dowel pins. Remove the anterior
segment. Make the maxillary and mandibular casts on the
articulator so that they do not disocclude during eccentric
movement
Adjust an articulator to the following values: sagittal
condylar path inclination =25 degrees, Bennett angle=15
degrees, sagittal inclination of the anterior guide table=25
degrees and lateral wing angle=10 degrees.

176
65

 Wax the occlusal morphology of the posterior teeth so the

maxillary and mandibular cusps contact during eccentric
movement. Thus, a balanced articulation is obtained and
every cusp will have a standard cusp angle.

177
 FABRICATION OF ANTERIOR TEETH
66
 According to "Condition 2," adjust an articulator to the
following values: sagittal condylar path inclination=40
degrees, Bennett angle=15 degrees, sagittal inclination of
the anterior guide table=45 degrees, and lateral wing
angle=20 degrees
 Reassemble the anterior segment of the cast. The maxillary
and mandibular casts on the articulator produce the
standard amount of disocclusion.(anterior guidance
established)

178
67
 Wax the palatal contours of the maxillary anterior teeth so
the maxillary and mandibular incisors contact during
protrusive movement, and the maxillary and mandibular
canines on the working side contact during lateral
movement. Thus, anterior guidance is established and the
standard amount of disocclusion will be produced.

179
68

180
69

181
70

182
71

183
72

184
73

185
74

186
75

187
76

188
77

189
78

190
Nyman & Lindhe Concept:
Significant points in planning Oral Rehabilitation are-

• Used for advanced periodontitis

• CRCP and IP must have even contact

• When distal support present use anterior guidance for protrusive and canine
disclusion for excursions

• When long tooth born cantilever restoration arrange for balance occlusion

• Restorations fabricated on Semi-adjustable articulator.

191
Youdelis Concept:
Significant points in planning Oral Rehabilitation are

• For advanced periodontal cases

• CRCP and IP coincident (tripod contact)

• Simultaneous contact of posterior teeth in CRCP with forces

through long axis of teeth

• Anterior disclusion for protrusive & canine disclusion for

lateral excursions

• Foundation of Healthy Periodontium is stressed

• Main information is gained from diagnostic temporary

restoration

• Both fully or semi – adjustable articulator may be used

192
 Case
79
Report

193
 Diagnostic maxillary & mandibular
impressions were made with irreversible
80
hydrocolloid impression material and casts
were retrieved.

Occlusal equilibration was done in the patient’s

mouth by removing the occlusal interferences so
that centric relation coincided with maximum
intercuspal position. Again impressions were
made and the casts were articulated using an
earpiece face bow (Hanau Springbow) over which
maxillary occlusal splint was fabricated at
increased vertical dimension. The permissive
occlusal splint at centric relation position for 12
weeks was given to determine acceptability of
proposed change in occlusal scheme. 194
81

195
 Occlusal plane
82
analysis

196
83

197
84

198
85

199
86

200
 REFERENCES
87

 Turner KA, Missirlian DM (1984) Restoration of the extremely worn dentition. J

Prosthet Dent 52:467–474
 Gary M. DeWood. Gnathology and Pankey-Mann-Schuyler : fulfilling the
requirements of occlusion in oral rehabilitation
 The University of Toledo The University of Toledo Digital Repository 2004
 Stuart CE (1973) The contributions of gnathology to prosthodontics. J Prosthet Dent
30:607–608
 Stuart CE, Stallard H (1960) Principles involved in restoring occlusion of the natural
teeth. J Prosthet Dent 10:304–313
 Schuyler CH (1959) An evaluation of incisal guidance and its influence on restorative
dentistry. J Prosthet Dent 9:374–378
 Schuyler CH (1963) The function and importance of incisal guidance in oral
rehabilitation. J Prosthet Dent 13:1011–1029
 Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in
treatment planning and in restoring lower posterior teeth. J Prosthet Dent 10:135–
150
 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

201
88

 Hobo S (1991) Twin-tables technique for occlusal

rehabilitation.Part I: mechanism of anterior guidance. J Prosthet
Dent 66:299–303
 Hobo S (1991) Twin-tables technique for occlusal rehabilitation.
Part II: clinical procedures. J Prosthet Dent 66:471-477
 Hobo S, Takayama H (1997) Twin-stage procedure. Part 1: a
new method to reproduce precise eccentric occlusal relations.
Int J Periodontic Restor Dent 17:113–123
 Hobo S. Takayama H. effect of canine guidance on the working
conduler path. Int J Prosthodont 1989;2:73-9
 Hobo S. A kinematic investigation of mandibular border
movement by means of an electronic measuring system. Part III.
Rotational center of lateral movement. J PHOSTHET DENT
1984;52:66-72
202
89

203
 90

FULL MOUTH
REHABILITATIO
N

PRESENTED BY : ILA YADAV

PG STUDENT DEPT. OF PROSTHODONTICS
 CONTENTS
91

PART 1
 Definition

 Indications

 Classification

 Occlusal approach and schemes

 Review of occlusal schemes

 Terminologies

 Hobo’s philosophy for full mouth rehabilitation

 Hobo’s Twin table technique

 Hobo’s Twin stage technique

 References

205
 CONTENTS
92

PART 2
1) Centric relation
2) Vertical dimension
3) Neutral zone
4) Envelope of function
5) Long centric
6)PANKEY MANN SCHUYLER CONCEPT
Restoring lower anterior teeth
Restoring upper anterior teeth

206
 Restoring lower
93
posteriors- occlusal palne
analysis Restoring upper
posteriors- functionally
generated
technique
7)Solving specific path
problems
Deep over bite
Anterior overjet
Anterior open bite
End to end occlusions
Splayed teeth
8) Postoperative care
References

207
 PRIMARY REQUIREMENTS
FOR SUCCESSFUL OCCLUSAL
94
THERAPY
 1. Comfortable and stable TMJs - The jaw joints must be
able to function and accept loading forces with no
discomfort. This is always the starting point for any
dental treatment that involves the occlusal surfaces of
the teeth.
 2. Anterior teeth in harmony with the envelope of
function and in proper relationship with the lips, the
tongue, and the occlusal plane.
 3. Non-interfering posterior teeth - Posterior occlusal
contacts should not interfere with either the comfortable
TMJs in the back or the anterior guidance in the front.

208
 FORMULA FOR A
95
PERFECTED OCCLUSION
 The first step is to have simultaneous equal intensity
contacts on all teeth when the condyle-disk assemblies
are completely seated up in their respective sockets.
 The contact on the posterior teeth is on cusp tips
(represented by dots.)
 The lines on the anterior teeth represent continuous
contact from centric relation to incisal edges as the
mandible moves forward and laterally.
 The formula “dots in back, lines in front”

209
 THE NEUTRAL
117
ZONE
 Teeth are the most movable part of the masticatory
system. If outward horizontal forces from the tongue are
greater than inward forces exerted by the buccinator
muscle bands and the lips, the teeth will move
horizontally until the opposing forces are equal. This
zone where the opposing forces are equal is the neutral
zone.

210
118
The neutral zone
Considerations
 1.The teeth and their alveolar process are the most adaptive

part of the masticatory system .They can be moved

horizontally or vertically by light forces
 2.There is neutral zone within which muscular pressure

against the dentition is equalized from the opposite directions


3. If irregularities of the tooth position, allignment or
contour can be corrected within the neutral zone ,the
prognosis for the long term stability is good
 4. A problem occurs when the neutral zone is not where we

want the teeth to be

 5.A treatment decision then must allow determination of if and

how we can change the neutral zone to orient it where we

want the teeth to be

211
 Methods for altering the neutral zone
119 1.Orthodontics –by re aligning the teeth

2. Elimination of the noxious

habits 3.Myofunctional therapy
4. Reduction of the tongue size
(surgical)
5.Surgical lengthening of the buccinator
band 6.Vestibuloplasty

212
 THE ENVELOPE OF
120
FUNCTION
 Every tooth in the mandible (the only moving jaw) has
an envelope of motion that outlines the outer limits to
which each lower tooth can be moved.
 More than any other factor, the neutral zone programs
the envelope of function. This is so because the neutral
zone is the major determinant of how the anterior teeth
erupt into the mouth, and it is the position of the anterior
teeth that influences the neuromuscular programming
of functional jaw movements

213
121

 The envelope of function dictates incisal edge position

and consequentially determines the anterior
guidance.
 Variations in the envelope of function result naturally
from how the anterior teeth were guided during
eruption into their neutralzone position by the tongue
and the lips.
 Mechanoreceptors in and around the teeth program
the muscles for functional jaw movements. The incisal
edge position should be in harmony with the
envelope of function. 214
 LONG CENTRIC
122


Freedom to close the mandible either into
centric relation or slightly anterior to it without
varying the vertical dimension at the anterior teeth.
– DAWSON
 Long centric involves primarily the anterior teeth.

215
 How to record long
123
centric
 Gentle tapping (unguided) on a red marking ribbon
shows interferences to postural closure.
 Manipulation to centric relation with guided closure
overlays black centric relation contacts on red postural
contacts
 If red marks appear on inclines forward of centric
relation contacts (arrows),it indicates a need to extend
the centric relation contact forward.

216
124

 If the incline forward of centric relation

marks, it is relieved so the incline does not
touch during gentle unguided closure.
 The amount of relief required is never
more than 0.5 mm.

217
 PANKEY-MANN-
125
SCHUYLER CONCEPT

Practical philosophies for occlusal

rehabilitation is the rationale or treatment that
was originally organized into a workable
concept by
DR. L.D. PANKEY.
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.

218
128

219
132

The Height of the Incisal

Plane
1. Lips sealed: The lower incisal edge is at the height of
the juncture of the upper and lower lips when the teeth
are together. On a lateral cephalometric radiograph, this
usually positions the incisal edge slightly above the
functional occlusal plane.

220
133

 2. Speaking:
“The view” when speaking is of the incisal edges of the
lower anterior teeth. A varying amount of labial
contour may also be on display. The upper teeth are
usually hidden during speech.

221
134

 3. Smiling: Only the upper anterior teeth are typically on

display during smiling. The lower incisors are usually
hidden during a big smile.

222
135

 4. Lips slightly parted: When the jaw is at rest and the

lips are slightly parted in a half smile, both upper and
lower labial surfaces are about equally on display.

223
136

The horizontal position of the lower incisal

edges
 The key to determining the horizontal position of

lower incisal edges lies in establishing stable

holding contacts with the upper anterior teeth.

224
 Quick review: Determining
anterior tooth position and
143
contour
 Step 1: Refine and verify lower incisal edge
position, shape, and plane. If upper anterior
position has not been determined, it must
be done in combination with lower
determinations.

225
144

 Step 2: Establish centric holding stops. This

is always the first step. The correct anterior
guidance cannot be determined until all
interferences to centric relation have been
eliminated.

226
145

 Step 3: Lip support in line with alveolar

contour. The upper half of the labial contour
can be determined fairly well on the cast.
The upper impression must include the
complete contour of the alveolar process.

227
146

 Step 4: Lip-closure path. This is a

critical determinant for the incisal half of
labial contour. It can only be determined
in the mouth.

228
148

 Step 6: Refine incisal edge position (using F

and V sounds). Determination must be
made with gentle, softly spoken sounds.
Make sure incisal plane contacts inner
vermillion border during gentle speech.

229
149

 Step 7: Adjust for long centric (if needed).

Follow the rules for anterior guidance after
centric relation and incisal edges have
been determined.

230
150

 Step 8: Establish lingual contours

(anterior guidance) in harmony with the
envelope of function:
a. in straight protrusive
b. in lateral excursions

231
151

 Step 9: Evaluate S sounds. The closest

speaking position should produce no whistle
or lisp.

232
152

 Step 10: Evaluate cingulum contours (using

T and D). Round into centric stops.

233
 RESTORING LOWER
154
POSTERIOR TEETH
 The term PLANE OF OCCLUSION refers to
an imaginary surface that theoretically
touches the incisal edges of the incisors and
the tips of the occluding surfaces of the
posterior teeth.

234
 Occlusal plane
155
analysis
 Simplified occlusal plane analyser
 Broadrick’s occlusal plane analyser

A SOPA is preset at 4 inches from the condylar

axis. The SOPA works with DenarR (Teledyne
Waterpik™) articulators.
The Broadrick flag accomplishes the
same occlusal analysis on almost all
types of semiadjustable articulators.
235
156

236
 RESTORING UPPER
165
POSTERIOR TEETH
The maxillary posterior teeth are restored with a
FUNCTIONALLY GENERATED PATH MODEL
that incorporates all movements of the mandiblur
teeth against the maxillary teeth within the
patient’s constants (intercondylar distance,
terminal hinge axis, interocclusal relationship, and
condylar pathways) and the variables (tooth form
and position, vertical dimension of occlusion, and
anterior guidance) determined and captured in the
provisionals and subsequently transferred to the
completed restorations in the anterior and
mandibular posterior.
237
166

Meyer initially described the functionally generated path

as a removable prosthetic procedure. Adapted to use in
oral rehabilitation by Arvin Mann it is accomplished
through the creation of a stone core. Prepared teeth are
coated with Tacky Wax, a wax that is soft enough to
move when chewed against.

238
167

 The patient is directed to move through all

possible movements and chewing patterns.
The wax offers no resistance to the
movement and is thus carved into the shape
of the movements of the lower teeth against
it.

239
168

 The tacky wax shaped by the patient’s

movements

240
169

 Once shaped the image must be duplicated in a material

that will not distort in use. Fast setting dental stone is
used to create an impression of the tacky wax. This
stone core represents all movements of the mandible
and captures the effects of all constants and variables
present.

241
170

 The stone core is now articulated with the mandibular

arch on a Twin Stage articulator. the articulation of
the stone core, the twin stage with the maxillary teeth
(dies) opposing two mountings, the stone core and the
mandibular model.

242
171

 The twin stage articulator

243
172

 The final wax-up for castings can now be completed against

the opposing arch for proper shape and form and against the
functionally generated path for proper occlusion.

If immediate posterior disclusion is wanted point contacts
are created with the functionally generated path at the
desired place.
 For group function contact is created for all or part of the
functionally generated path representing the movement in
which contact is desired.
 Final castings created using the functionally generated path
and twin stage articulator)
 The final castings are tried in, adjusted as necessary to
create precise fit and occlusion, and cemented.

Occlusal adjustment is usually limited to adjustment
with a rubber wheel or point, even in full group function
contact cases.
244
 Requirements for
occlusal
173
stability
5 requirements
 1.Stable centric stops on all the teeth

 2. An anterior guidance that is in harmony with the

border movements of the envelope of function

 3. Disclusion of all posterior teeth in

protrusive movements
 4. Disclusions of all posterior teeth on the non

working side
 5. Non interferences of all posterior teeth on

the working side

245
 DEEP OVERBITE
174

 The first treatment option:

Reshape

246
175

 The second treatment option:

Reposition

247
176

248
177

 The third treatment option:

Restore

249
 ANTERIOR OVERJET
178

250
179

251
180

252
181

253
 ANTERIOR OPENBITE
182

• The first determination is what caused the open

bite.
• Anterior open bite in a patient with occluso-
muscle pain. Deflective interferences on molars
created a slide to maximal intercuspation. At
maximal intercuspation, no contact was
possible for the anterior teeth.

254
183

 Maximal intercuspation after occlusal

correction by equilibration. Anterior teeth
still could not contact opposing teeth

255
184

 Position of teeth after 10 months. No orthodontic treatment or

any other attempt was made to close the anterior open bite.
The teeth erupted to contact because the tongue no longer
maintained a posture to cushion the bite for protection of the
deflective premature contact.

 SURGICAL OPTION

256
 END TO END
185
OCCLUSION
 An end-to-end occlusion is very often treated as a
malocclusion simply because it does not conform
to the requirements of a Class I relationship.
 That is not an acceptable reason for altering any
occlusion. Instead, the decision to alter the
occlusal relationship should be based on a
careful evaluation of the following factors.
 STABILITY
 FUNCTION
 ESTHETICS
 NEUTRAL ZONE

257
186

 Stability is not totally dependent on cusp-

fossa alignment. End-to-end contact can be
stable if stops can prevent eruption in a
strong neutral zone.
 POSTERIOR END-TO-END RELATIONSHIPS

258
187

 A lower-cusp-tip–to–upper-flat-surface
relationship. This type of end-to-end
relationship can provide good stability as
long as lateral function contact is not
needed.

259
188

 The centralized lower cusps can contact in

working excursion to disclude the
balancing side. Contours can be made to
look quite natural.

260
 SPLAYED TEETH
189

 Splayed teeth are almost always

positioned within a strong neutral zone
corridor.

261
190

 Maximal intercuspation. There is a long slide from the

first contact at the most closed position. It is important to
determine if the slide forward is the cause of the
anterior teeth being flared and separated.

262
191

 If the anterior teeth can contact after a

deflective slide to maximal intercuspation, it is
okay to achieve contact in centric relation.
 If anterior contact cannot be achieved at the most
closed position, it indicates that there is a
tongue- or lip-biting habit that is responsible for
the separation.
 Before deciding on anterior contact in centric
relation, it is necessary to eliminate a habit pattern
that is a primary cause of the splaying and open
bite.
263
192

 Equilibration of casts.

264
193

 Anterior guidance

 Now it is apparent that an acceptable anterior

guidance can be maintained on the central incisors
and canines,
 So laminate restorations will be the ideal restorations.
It will be necessary to restore the lateral incisors with
full coverage to achieve contact in centric relation.
265
194

 Diagnostic wax-up.

 Neutral zone considerations. Splayed anterior teeth are

usually in the most balanced relationship between tongue
and lip pressures. Thus, it is important to maintain their
neutral zone position. The lines on the central incisors mark
the forward part of contour that should not be violated
when laminate restorations are made.
266
195

 Prepared teeth. Note centric relation contact on centrals

and canines.

267
 POST-OPERATIVE CARE
196

 Dr. Keith begins his instructions to the patient with

three
• “no’s”:
 1. No smoking. He points out the restrictive
effect of smoking on the capillary blood supply to
the periodontal tissues and explains why it is so
difficult to achieve long-term health of the
necessary supporting structures unless the patient
agrees to stop. He also clarifies smoking’s other
risks to general health.
 2. No hard candy. A habit of sucking on hard

candies can be devastating to the teeth,

especially at the cementoenamel junction where
decay can cause so many problems.
 3. No more than two soda drinks per week.
268
The corrosive effect of high-acid carbonated
197

 Patients should be told to report any of the

following indications of occlusal disharmony:
 1. Any discomfort in the teeth when chewing
 2. Any indication of a “high” tooth or any sign
that one or more teeth contact before the rest
when closing; any tooth that can be made to
hurt by biting on it
 3. Any sign of tooth hypermobility
 4. Any discomfort in the TMJ area
 5. Any limitation of function
269
 Reference
200
s
 Dawson PE. Evaluation ,diagnosis, and treatment of occlusal problems. 1989 2nd ed.
Cv Mosby Company, toronto.
 Jeffrey P okeson . Management of temporomandibular disorders and occlusion 5th
edition Mosby company toronto.
 Mann AW, Pankey LD (1960) Oral rehabilitation: part I. Use of the P-M instrument in
treatment planning and in restoring lower posterior teeth. J Prosthet Dent 10:135–
150
 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
 Gary M. DeWood. Gnathology and Pankey-Mann-Schuyler : fulfilling the
requirements of occlusion in oral rehabilitation The University of Toledo The
University of Toledo Digital Repository 2004
 Stuart CE (1973) The contributions of gnathology to prosthodontics. J Prosthet Dent
30:607–608
 Stuart CE, Stallard H (1960) Principles involved in restoring occlusion of the natural
teeth. J Prosthet Dent 10:304–313
 Schuyler CH (1959) An evaluation of incisal guidance and its influence on restorative
dentistry. J Prosthet Dent 9:374–378
 Schuyler CH (1963) The function and importance of incisal guidance in oral
rehabilitation. J Prosthet Dent 13:1011–1029
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271