Full Mouth Rehabilitation

FULL MOUTH
REHABILITATION
Guided By:-
Dr. Arun Gupta(Reader)
Dr. Soham Prajapati,
3rd Year PG.
22-8-2015, 7-9-15, 6-10-
2015
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Contents
• Introduction
• Objectives of Full Mouth
Rehabilitation
• Reasons for Full Mouth Rehabilitation
• Indications
• Contraindications
• Classification of patients requiring Full
Mouth Rehabilitation
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Contents
• Etiology of worn dentition
• Diagnosis
• Treatment planning
• Occlusal Plane Analyzing
• Vertical relation considerations
• Methods for determining vertical
relation
• Can vertical dimension be altered ?
• Methods of obtaining space for
restoring worn teeth

Contents
• Increasing occlusal vertical dimension —
Why, When & How
• Restoring the vertical dimension of
occlusion
• Centric relation
– Methods of recording centric relation
– Use of anterior jig
– Leaf guage
– Long centric
• Occlusal Equilibration in natural dentition

Contents
• Various Philosophies
– PANKEY MANN SCHUYLER
PHILOSOPHY
– HOBO‘S TWIN TABLE PHILOSOPHY
– HOBO’ S TWIN STAGE PHILOSOPHY
• Maintenance Phase
• Conclusion
• References

Introduction
• The personality of an individual is often judged by his
looks.
• A beautiful smile always gives pleasure. However, the
personality may be falsely interpreted by ugly and
impaired teeth.

Introduction
• “The time should be over where we are the dentists of
the tooth or may be of two or three teeth at a time. Let
us be the doctors of the mouth”
- McCollum

INTRODUCTION
• Peter E. Dawson stated, ”Patient lose their
teeth in two ways: either the teeth break
down, other supporting structures break
down”
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• The term occlusal rehabilitation has been defined as the
restoration of the functional integrity of the dental
arches by use of inlays, crowns, bridges and partial
dentures.
DAWSON PE EVALUATION, DIAGNOSIS AND TREATMENT OF OCCLUSAL
PROBLEMS, ST. LOUIS CV MOSBY, 2nd Edition, 164-68
Definition

• Mouth Rehabilitation: Restoration of the form and
function of the masticatory apparatus to as near normal
as possible (GPT-4)
Definition
FULL MOUTH REHABILITATION
The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63.
10/400

Cheryl Cole : World‘s Best Smile (2013)

12/400

Introduction
• The word rehabilitate implies ‘To restore to
good condition or to restore to former
privilege’.

Introduction
• The term ‘full mouth rehabilitation’ is used to
indicate extensive and intensive restorative
procedures in which the occlusal plane is modified in
many aspects in order to accomplish
“EQUILIBRATION”.

Introduction
• Complete mouth rehabilitation is a dynamic
functional endeavor and it embodies the correlation
and integration of all component parts into one
functioning unit.

Introduction
• Planning and executing
the restorative
rehabilitation of a
decimated occlusion is
probably one of the
most intellectually and
technically demanding
tasks facing a
PROSTHODONTIST.
The stakes are high and
failure is costly.
AHUJA.P., OCCLUSAL REHABILITATION. A CASE REPORT. JIPS 1999, 25-28

Objective Of Full Mouth Rehabilitation
• All patients requiring full mouth rehabilitation have
one problem in common: stress and strain.
• Usually the stress is due to malfunction or to
poorly related parts of the oral mechanism.
Irving Goldman: The goal of full mouth rehabilitation, J PROSTHET DENT 1951,
vol 2, 246-251
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Objective Of Full Mouth Rehabilitation
• Our objective is to minimize these stresses so that
they are not destructive.
• In order to prevent this stress from being
destructive, the best thing to do is to distribute it
evenly or an as great area as possible, over as
many teeth and as much tissue as possible, with
the teeth providing a means by which the forces
are distributed.
Irving Goldman:The goal of full mouth rehabilitation, J PROSTHET DENT 1951,
vol 2, 246-251
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Reasons For Full Mouth Rehabilitation
• The most common reason for doing full mouth rehabilitation
is to obtain and maintain the health of periodontal tissues.(
Ever wondered why, severe worn teeth (Bruxers) have
less pocket depth and theortically no pocket depth?)
• Temperomandibular joint disturbance is another reason.
(Dawson, Lindhe & Nyman)
• Need for extensive dentistry as in case of missing teeth,
worn down teeth and old fillings that need replacement.
• Esthetics, as in case of multiple anterior worn down teeth
and missing teeth.
Lucia W. O. : Modern Gnathological Concepts
St.Louis: C.V.Mosby co.1961
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Indications Of Occlusal Rehabilitation
– Restore impaired occlusal function
– Preserve longevity of remaining teeth
– Maintain healthy periodontium
– Improve objectionable esthetics
– Eliminate pain and discomfort of teeth and
surrounding structures.
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Contraindications Of Full Mouth
Rehabilitation
• Malfunctioning mouths that do not need extensive
dentistry and have no joint symptoms should be
best left alone. Prescribing a full mouth
rehabilitation should not be taken as a preventive
measure unless there is a definite evidence of tissue
breakdown.
• In short, it can be concluded that :
No pathology- No treatment.
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Its Not A Contraindications Of Full

Classification Of Patients Requiring
Occlusal Rehabilitation

Classification by Turner and Missirlain
(1984)4
• The patients were classified into
three categories –
• 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
Kenneth Turner & Donald Missirlian:Restoration of the extremely worn dentition, J
PROSTHET DENT 1984, vol 52, 467-474
28/400

(1984)
• Category 1 -
– A typical patient in this category has few posterior teeth
and unstable posterior occlusion. There is excessive wear
of anterior teeth. Closest speaking space of 3 mm and
interocclusal distance of 6 mm. There is some loss of facial
contour that results in drooping of the corners of mouth.
Kenneth Turner & Donald Missirlian: Restoration of the extremely worn dentition, J
29/400

(1984)
30/400

(1984)
• Category 1 -
– Patients with dentinogenesis imperfecta with
excessive occlusal attrition, around 35 years of age
and appearing prognathic in centric occlusion also
belongs to this category.
– Closest speaking space of 5 mm and interocclusal
distance of 9 mm indicates there is loss of
occlusal vertical dimension with concomitant
occlusal wear.
31/400

(1984)
Goud, Anil, and Saee Deshpande. "Prosthodontic rehabilitation of dentinogenesis
imperfecta." Contemporary clinical dentistry 2.2 (2011): 138.
32/400

(1984)
• Category 2- Patient has adequate posterior
support and history of gradual wear. Closest
speaking space of 1 mm and interocclusal
distance of 2-3 mm.
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(1984)
• Continuous eruption has maintained occlusal vertical
dimension leaving insufficient interocclusal space for
restorative material. Manipulation of mandible into
centric relation will often reveal significant anterior
slide from centric relation to maximum
intercuspation.
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(1984)
• Category 3 –
– Posterior teeth exhibit minimal wear but anterior teeth
show excessive gradual wear over a period of 20-25 years.
35/400

(1984)
• Category 3 –
– Centric relation and centric occlusion are coincidental with
closest speaking space 1mm and interocclusal distance 2-
3mm. It is most difficult to treat because vertical space
must be obtained for restorative material.
36/400

Classification by Breaker
• 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.
Breaker S.C, Clinical procedures in occlusion Rehabilitation,W. B. Saunders,
Philadelphia 1958
37/400

• Class III – Patients with collapse of vertical dimension of
occlusion because of excessive attritional wear of
occlusal surfaces.
Philadelphia 1958
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• 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.
Philadelphia 1958
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• Group III – Patients requiring maxillofacial surgery of
orthodontic treatment as an aid in restoring the lost
vertical dimension.
Philadelphia 1958

• 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.
Philadelphia 1958
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Etiology Of Extremely Worn Dentition
• Occlusal wear is most often attributed to attrition.
Attrition is defined as ‘ the wearing away of one
tooth surface by another tooth surface’. The causes
for worn dentition are –
– Congenital abnormalities -
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
Bernard smith :Tooth wear : Etiology and diagnosis Gerodontology Text Book 1994,
88-102
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– Amelogenesis Impertecta
Khodaeian, Niloufar, Mahmoud Sabouhi, and Ebrahim Ataei. "An Interdisciplinary
Approach for Rehabilitating a Patient with Amelogenesis Imperfecta: A Case
Report." Case reports in dentistry 2012 (2012).
43/400

– Dentogenesis Impertecta
Goud, Anil, and Saee Deshpande. "Prosthodontic rehabilitation of dentinogenesis
imperfecta." Contemporary clinical dentistry 2.2 (2011): 138.
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• The causes for worn dentition are –
– Parafunctional occlusal habit
– Abrasion
– Erosion
88-102
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• The causes for worn dentition are –
– Loss of posterior support
• Posterior collapse that results from missing, tipped,
rotated , broken down teeth, malposition and occlussal
interference exerts undue force on anterior teeth
resulting in teeth mobility and excessive wear of clinical
crown.
88-102
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Diagnosis & Treatment Plan
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Diagnosis
• The following aids should be used -
– Medical history
– Dental history
– Behaviour evaluation
– Radiographs – Complete mouth periapical radiographs and
orthopentamograph
John Bowley, John Stockstill : A preliminary diagnostic and treatment
protocol, D. Clin. North America1992, vol 36, 551-597
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Diagnosis
• The following aids should be used -
– Photographs – colour of teeth and gingiva is recorded and
photographs are necessary to recall to patient’s mind the
state of his mouth prior to restorative dentistry.
– Clinical examination
• Diagnostic wax-up
– Computer imaging – It is helpful to demonstrate the
various treatment options. Computer aided image
manipulation can be used to create the future appearance.
– CBCT
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Diagnostic wax-up
• Before diagnostic wax-up, the occlusal discrepancies
in centric and eccentric occlusion should be
eliminated.
• Diagnostic preparation of gypsum stone teeth that
will require prospective crowns is carried out. This
will reveal any resistance or retention form problems
caused by short axial walls.
50/400

Diagnostic wax-up
• Thus planning of subgingival margins or surgical
crown lengthening required can be done. Then wax is
used to appropriately shape all crowns and final
prosthesis is planned.
• This diagnostic wax-up can be used to prepare an
elastomeric putty mould and used for temporization
or sectioned through long axis of tooth to act as
reduction guide intra-orally.
51/400

Treatment plan
• Comprehensive treatment plan must be established
prior to start of the treatment .
• Communication and patient education are essential
in order to match the dentist’s and patient’s
definition of success.
• Treatment plan is divided into-
1) Pre- prosthetic phase
2) Prosthetic phase
3) Maintenance phase
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Treatment plan
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)
Harry Shrunik : Treatment Planning For Occlusal Rehabilitation, J PROSTHET DENT
1959, vol 9, 988-100
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Treatment plan
• Prosthetic phase
– Prosthetic full mouth rehabilitation is divided into-
• Immediate treatment
• Definitive treatment
1959, vol 9, 988-100
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Treatment plan
– In some cases like amelogenesis imperfecta in a child,
postponing treatment until adulthood may cause adverse
psychological effect and impair correct relationship
between maxillary and mandibular teeth.
1959, vol 9, 988-100
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Treatment plan
– Preformed nickel-chromium crowns are placed on first
permanent molars and second deciduous molars to
stabilize occlusion and halt attrition.
– Vertical dimension is not altered. As anterior teeth and
premolars erupt, polycarbonate resin crowns are given.
Second molar is fitted with nickel crown to preserve
vitality. After all permanent teeth are erupted, these
restorations serve as transitional treatment until
adulthood.
1959, vol 9, 988-100
56/400

Treatment plan
• Definitive treatment
– Once all teeth have erupted and adulthood is reached,
the size of pulp horns decreases compared to
newly erupted teeth. A definitive treatment can then
be planned.
1959, vol 9, 988-100
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Diagnostic Impression, Facebow
Transfer & Articulation
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Definitions
• 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.
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Various Occlusal Plane Analyser
Broadrick’s Occlusal Plane Analyzer (BOPA)
Simplified Occlusal Plane
Analyzer
Custom Made Occlusal Plane Analyzer
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Broadrick’s Occlusal Plane Analyzer
(BOPA)
• Dr. Lawson K Broadrick
• Availbility :- Broadrick flag; Teledyne Water
Pik, Fort Collins, Colo
• It is used for analyzing the Curve of Spee &
developing an acceptable curve of Occlusion
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(BOPA)
Anterior Survey Point
64/400

(BOPA)
Posterior Survey Point
65/400

(BOPA)
Condylar Element Used As The Posterior Survey Point
66/400

(BOPA)
Acceptable Plane of Occlusion 67/400

Simplified Occlusal Plane Analyzer
(SOPA)
• This simplified method reduces the time
required for occlusal plane analysis because
the analysis point for surveying the occlusal
plane is already related to the condylar axis.
• Availability: Denar® Simplified Occlusal Plane
Analyzer, Whip Mix Corporation – West, CO
80525
68/400

(SOPA)
Insert a flag onto the SOPA base
69/400

(SOPA)
Occlusal Plane Scribed On the Mandibular Cast that will go through the condylar axis
in one simple step 70/400

(SOPA)
Arc the compass lead to the back molar (Figure 5). This establishes the optimum
occlusal plane height for the posterior teeth. Note: If the molar is missing, the
occlusal plane can be scribed on a wax rim.
71/400

Can Vertical Dimension Be Altered?
• Out of the experience
gained in occlusion of
natural teeth has come an
awareness that there are
certain underlying
treatment principles.
• These principles are so
important that they cannot
be overemphasized.

• Sicher (1949) and Silverman(1952). They
concluded that 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.
Sicher H. : Oral Anatomy,St.louis C.V. Mosby co.1949
Meyer Silverman : Vertical dimension must not be increased, J PROSTHET
DENT 1952, v0l 2, pg 756-779
73/400

• Harry Kazis and Albert Kazis stated that
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.
Harry Kazis : Complete mouth rehabilitation through
Fixed denture prosthodontics, J PROSTHET DENT
1969, vol 10, pg 296-303
74/400

• Silverman (1956) said that 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 increased beyond the normal for each
patient.
• Increasing the vertical dimension only 1mm will
cause discomfort to the patient .
Meyer Silverman : Pre-extraction records to avoid premature aging of the
denture patient, J PROSTHET DENT 1955, july, pg 465-475

• 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.
Joseph Landa : The freeway space and its significance
in the rehabilitation of the masticatory apparatus,J PROSTHET DENT 1952, vol
2, pg 756-779

• Dawson(1974)53 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.
• Increase in vertical dimension interferes with the
optimum length of the resting muscles which
serve as a stimulus to produce hypertonicity.
77/400

• Closing the vertical dimension does not interfere
with muscle lengths.
• When 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.
78/400

• 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.

• 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.
• He found that subjects experienced moderate
symptoms of discomfort initially but symptoms
decreased later and no clinically demonstrable
symptoms were found.
Carlsson et al : Effect of increasing vertical dimension on the masticatory
system in subjects with natural teeth,J PROSTHET DENT 1979, vol 41, pg 284-
289
80/400

• 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.
Rivera-Morales : Relationship of the vertical dimension of occlusion to the
health of masticatory
system, J PROSTHET DENT 1991, vol 65, pg 547-553
81/400

• He concluded that moderate increase in vertical
dimension of occlusion does not create problem
provided that occlusal stability is provided.
Carlsson et al : Effect of increasing vertical dimension on the masticatory
system in subjects with natural teeth,J PROSTHET DENT 1979, vol 41, pg 284-
289
82/400

Increasing occlusal vertical dimension
— Why, When & How
• VD is unrelated to temporomandibular
disease (TMD) and 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.
Carlsson G E, Ingervall B, Kocak G. The effect of increasing vertical dimension
on the masticatory system in subjects with natural teeth. J Prosthet Dent 1979;
41: 284-289.

— Why, When & How
• The vertical dimension of occlusion (VDO)
is determined by the repetitive
contracted length of the closing muscles,
hence increase in VDO cannot be
maintained as the jaw to jaw relationship
will always return to the original
dimension ie the MUSCLES always WIN.
Kohno S ,Bando E. Die funktionelle anpassung der Kaumuskulatur Bei Starker
Bissagbung (functional adaptation of masticatory muscles as a result of large
increases in vertical dimension). Dtsch Zahnarztl ZI1983; 38: 759-764.

— Why, When & How
• Wear does not result in loss
of VD, as the alveolar process
lengthens to make up for
this.
• But the position of the
condyles does affect muscle
length and hence the VDO.
Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-
285. St Louis, MO: CV Mosby, 1989.

— Why, When & How
When looking at changes in VD it is paramount to mount
the study casts in centric relation (CR).
Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-
285. St Louis, MO: CV Mosby, 1989.

— Why, When & How
• Treatment options
1. Equilibrate
2. Reposition
3. Restore
4. Surgical osteotomy
5. Orthognathic surgery
D. R. Bloom and J. N. Padayachy, Increasing occlusal vertical dimension — Why,
When & How, BRITISH DENTAL JOURNAL VOLUME 200, NO.5 MARCH 2006
C 88/400

VERTICAL DETERMINANTS
• There are four philosophies for condylar position
when determining VD. All work on the basis of a
canine protected occlusion.
C 89/400

1. Gnathological
– Involves use of 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.
Lucia V O. Modern gnathological concepts. pp 41-56. St Louis, MO: CV Mosby,
1961.

2. 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.
C 91/400

3. 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’.
C 92/400

4. Neuromuscular
– Based on the principles of muscle activity
determined by electromyography.
Lucia V O. Modern gnathological concepts. pp 41-56. St Louis, MO: CV Mosby,
1961.

• Joint or muscle pain
This is not a problem, as altering VD does not
produce pain of more than one to two weeks’
duration; any pain is a result of increased temporary
muscle awareness.
Christensen J. Effect of occlusion raising procedures on the chewing system.
Dent Pract Dent Rec 1970; 20: 233-238.
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POSSIBLE CLINICAL CONCERNS
BEHIND CHANGING VD

BEHIND CHANGING VD
• Stability
– When closing VD there is very little relapse; it may
open by up to 1 mm within the first year and will
then remain stable. Such a small amount is not
detectable by the clinician or the patient.
– When opening the VD some patients can remain
stable, others can relapse a little, and others a lot,
but again this may go unnoticed dentally.
C 95/400

• Muscle activity
– VD increases electromyographic
activity of the elevator muscles
when clenching.
– This is short lived, as if readings
are taken two to three months
later they will have returned to
base line values.
Lindauer S J, Gay T, Rendell J. Effect of jaw opening on masticatory muscle EMG
— force characteristics. J Dent Res 1993; 72: 51-55.
96/400
BEHIND CHANGING VD

• Muscle activity
– The postural muscle tone (ie the rest position) reduces
when VD is increased but is also back to normal within
three months.
Lindauer S J, Gay T, Rendell J. Effect of jaw opening on masticatory muscle EMG
— force characteristics. J Dent Res 1993; 72: 51-55.
97/400
BEHIND CHANGING VD

BEHIND CHANGING VD
• Phonetics
• This can sometimes be a problem for the ‘S’ sounds.
Initially wait for one month to see if the patient can
adapt (this will usually be the case) before
considering any changes.
Hammond R G, Beder O E. Increased vertical dimension and speech
articulation errors. J Prosthet Dent 1984: 52: 401-406.

BEHIND CHANGING VD
• Phonetics
– If not then this will need to be corrected by
creating space. Generally this will be by
shortening the lower incisors as shortening the
upper incisors will have aesthetic implications -
how depends on the lower incisor position when
the ‘S’ sound is created:
Hammond R G, Beder O E. Increased vertical dimension and speech articulation
errors. J Prosthet Dent 1984: 52: 401-406.

BEHIND CHANGING VD
1. If ‘S’ is generated with the lower incisors in the
cingulum area of the upper incisors (ie behind and
above the upper incisal tip), shortening the lower
incisors will leave them out of contact when the teeth
are in occlusion. For this reason the VD will then need
to be reduced.

BEHIND CHANGING VD
2. If ‘S’ is generated by the incisors being more edge-to
edge the lower incisors can be reduced and the linguals
of the upper incisors built out to maintain contact.

BEHIND CHANGING VD
C 102/400
• When changing incisal
position restoratively, it is
paramount to do this in
provisional restorations first.
• Provisional restorations can
be modified in the mouth
until all guidelines have been
precisely followed and the
patient completely happy

BEHIND CHANGING VD
C 103/400
• As ever a diagnostic wax-up
will aid in such treatment
planning.
• 1. Stable CR contacts.

BEHIND CHANGING VD
C 104/400
• 2. Upper half of the labial
surface. After CR the second
most important determination
is upper incisal edge position.

BEHIND CHANGING VD
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• However, this will not be precise
until the upper half of the labial
contour has been determined.
• There is no bulge in nature from
the alveolus to upper labial
surface ie the upper half of the
labial surface is continuous with
the labial surface of the alveolar
process.

BEHIND CHANGING VD
C 106/400
3. Lower half of labial surface. This is
in two planes - for incisal position
and to allow the lip closure path to
slide along the labial
surface hence the need to roll in the
incisal tip.

BEHIND CHANGING VD
C 107/400
• 4. Incisal edge. This should rest
along the inner vermillion border
of the lower lip and is best
determined by observing the
patient to counting from 50 to 55
ie ‘F’ sound.

BEHIND CHANGING VD
C 108/400
• This needs to be in harmony with
the neutral zone, lip closure path,
phonetics, envelope of function
and aesthetics.

BEHIND CHANGING VD
C 109/400
5. Anterior guidance. This is
determined by the protrusive path
but should include a ‘long centric’
that allows a little freedom before
this path is engaged and so the lower
incisors are not bound in.

BEHIND CHANGING VD
C 110/400
6. Contour of the lingual surface from
the centric stop to the gingival
margin. There should be no
interferences with the ‘T’, ‘D’ or ‘S’
sounds.

Methods of Obtaining Space To
Restore Worn Anterior Teeth
• Dahl Appliance -If wear is localized
– E.g. Upper anterior teeth.
– Method of choice
Robert Wassel : Tooth wear : Space creation with Dahl Appliance
Gerodontology text book 1994,103-108
111/400

• The Dahl Concept refers to the relative axial tooth
movement that is observed when a localized
appliance or localized restorations are placed in
supra-occlusion and the occlusion reestablishes full
arch contacts over a period of time.
• The combination of intrusion of the anterior teeth in
contact with the appliance and eruption of the
separated posterior teeth creates the interocclusal
space.
Poyser, N. J., Porter, R. W. J., Briggs, P. F. A., Chana, H. S., & Kelleher, M. G. D.
(2005). The Dahl Concept: past, present and future. British dental journal,
198(11), 669-676.
112/400

• The anterior bite platforms of removal orthodontic
appliances were, and still are, used for overbite
reduction.
198(11), 669-676.

DAHL APPLIANCE
198(11), 669-676.

• Grind opposing teeth -
– Possible esthetic and pulpal problems
• Restore the lost Vertical dimension
– Indicated only if majority of posterior teeth need full
coverage restorations
198(11), 669-676.

• Crown Lengthening - May be required to increase axial wall
height to aid in crown retention
• Extraction or _ Rarely indicated but may be required
Surgical Repositioning where gross over-eruption has
occurred
Robert Wassel : Tooth wear : Space creation with Dahl Appliance
Gerodontology text book 1994,103-108
119/400

Centric Relation

Centric Relation
• There are two aspects of taking centric relation53
– Proper manipulation of mandible as in equilibration
position when no bite record is taken
– Manner of taking bite record for correct articulation of
mounted models.
121/400

Methods Available To Guide The
Mandible Into Centric Relation
1. Chinpoint Guidance method
• Guichet described this method. It places the
condyles in most posterior and superior position
which can result in trauma to TMJ. Hence use of this
method is not advocated.
122/400

2. Bilateral Manipulation
method
Dawson introduced this method
that guides the condyles into most
superior position in the glenoid
fossa. Condyle is within 0.02 mm
accuracy in three dimensions with
this method.

2. Bilataral Manipulation
method
– This small area supports the
concept of point centric in
which the centric relation
position and maximum
intercuspation are
coincident.
124/400

• Manipulation for Centric
Relation
125/400

• Manipulation for Centric
Relation
126/400

3. Unguided method
• Brill introduced a muscular position which allows
patient’s natural muscle functions to position the
mandible into centric relation position.
127/400

Method For Taking Centric Bite
Records
• 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.
128/400

Mandibular Deprogramming
• Mandibular deprogramming can be 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 Guage
– Cotton role
129/400

• 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
130/400

Waxbite Procedures
• It is the most popular procedure because of its
simplicity. 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.
131/400

– Modification of wax bite can be used with
additional wash of zinc oxide eugenol paste to
reline for greater accuracy.
Waxbite Procedures

Waxbite Procedures
– Lucia explained a two stage
procedure in which tenax wax
is used for indentation of
upper teeth and soft wax is
then added to indent the lower
teeth.
– This method is not suitable for
patients having extremely
mobile teeth or large
edentulous area.
133/400

Anterior Stop technique
– Anterior stop techniques are the easiest to learn
and offers greatest flexibility.
– Accuracy can be achieved even with loose teeth,
posterior edentulous areas and patients with
temperomandibular joint discomfort.
– This technique allows the condyles to seat up
without any possible deviation from posterior
teeth.
134/400

– The term ‘anterior stop’ refers here to contact in
the incisor area only. It may be made from acrylic
or hard compound, on mounted models or
intraorally.
135/400

– 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 can be used as the posterior bite record
material.
136/400

• It is indicated whenever there is a danger that teeth
will move or soft tissues be compressed by the bite
record.
• Preformed bases can 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.
Readapted Bases
137/400

• 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
Readapted Bases
138/400

• 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.
Central Bearing Point Technique
139/400

• Principle
– Anterior jig prevents posterior
teeth from occluding and thus
disrupts the proprioceotive
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.
Anterior Jig
140/400

Principle
– Jig breaks the patient’s habitual closure pattern
and acts as the third leg of the tripod by creating
resistance while stopping the closure.
Anterior Jig
141/400

Procedure
– A ball of red compound is softened and added to
upper incisors so that their lingual surfaces are
completely covered.
– The 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.
Anterior Jig
142/400

Procedure
• 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.
Anterior Jig
143/400

Procedure
• 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.
Anterior Jig
144/400

• Leaf Guage was first introduced by Dr. James .H.
Long in 1973
• It is the most useful and practical alternative to
anterior jig.
Leaf Guage
145/400

• Leaf guage can be used for-
– Centric relation interocclusal records
– Occlusal equilibration
– Relieve painful spasms of lateral pterygoid
muscle.
Leaf Guage
146/400

• Previously they were made of unexposed X- ray
films after developing to remove the emulsion
coating. Clear film was then cut into 1 cm X 5 cm
sections.
• Recently, leaf gauges of uniform 0.1mm thickness
which are sequentially numbered are described.
They are convenient and measure the exact vertical
opening between the incisors.
Leaf Guage
147/400

• Recently, leaf gauges of uniform 0.1mm thickness
which are sequentially numbered are described.
They are convenient and measure the exact vertical
opening between the incisors.
Leaf Guage
148/400

• Woelfel described a disposable leaf guage made of
firm paper.
• Williamson used leaf guage to deprogram the
proprioceptive impulses from the periodontal
membrane.
• Golsen and Shaw recommended leaf guage in
occlusal adjustment and for centric relation records.
Leaf Guage
149/400

• McHorris advocated leaf guage for centric
interocclusal records and relieving painful spasm of
lateral pterygoid muscles.
• Rosenbulm in 1985 found that when leaf guage was
placed between the anterior teeth and subjected to
patient’s own biting force, it permitted the condyles
to seat themselves to the muscle dictated centric
relation position.
Leaf Guage
150/400

• Alber’s et al stated in 1997 that the use of cotton
roles for initial joint compression and retrusion
followed by recording with leaf guage appears to be
the best method for obtaining accuracy.
• Huffman (1987) advocated use of leaf guage for
occlusal equilibration.
• Woelfel (1991) used leafguage wafer technique to
record jaw relation.
Leaf Guage
151/400

• Solomon and Shetty (1996) found obtaining centric
relation with the use of leaf guage to be accurate
compared to unguided technique and operator
guided closure
Leaf Guage
152/400

• Procedure
• Arbitary number of leaves are placed at the
maxillary anterior midline parallel to the lingual
plane of central incisors. Patient is instructed to
close on back teeth until lower incisors touch on
back side of leaf guage.
Leaf Guage Procedure
153/400

• Leaves are added or subtracted until patient can
barely feel a posterior tooth touch while closing
firmly on leaf guage.
• Often the patient can often feel a posterior tooth
contact in 15- 52 seconds after the jaw is closed
with a ‘half hard’ closing force.
154/400

• This procedure is repeated after adding a leaf guage
until the patient can close for 2-5 minutes without
feeling a posterior tooth contact.
155/400

Long Centric
• The fit of the condyle into the disc is not like the fit of
machine ball in bearing. Some front- back play is
permitted by the disc that allows the condyles to
hinge freely.
• So there will be a slight difference between the firm
terminal hinge closure of centric relation and a light
closure from rest position.
158/400

Long Centric
• The term ‘Long Centric’ could be
defined as ‘freedom to close the
mandible either into centric
relation or slightly anterior to it
without varying the vertical
dimension of occlusion.
• This term is now referred to as “
Freedom in Centric”.
159/400

Long Centric
160/400

Long Centric
• Posselt in 1952 studied the positional difference
between retruded contact position and intercuspal
positin and found 1.25+1 mm difference between
them.
• Schuyler in 1959 found the initial contact from rest
position to be 1 mm anterior to the border path
produced along the transverse horizontal axis.

Long Centric
• Ramfjord and Ash advocated 0.5 to 0.8 mm space
between retruded contact position and maximum
intercuspation.
• Dawsonin 1974 advacated freedom in centric
relation of occlusion of 0.2 mm which allows space
between condyle and fossa.

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.

Long Centric
• All interference to terminal closure should be
eliminated.
• If centric relation interference is present, path of
closure will be dictated by the proprioceptors instead
of the muscles.
• When interference in centric relation is eliminated by
equilibration ‘long centric will usually be provided
automatically.

Long Centric
• 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.
• There is no relationship between the length of a
‘slide’ and length of a ‘long centric’.

Long Centric
• Length of a slide is the result of interference of the
teeth whereas long centric is dependant on anatomy
of the condyle disc relationship and varying patterns
of muscle activity in different individuals.
Centric occlusion Centric relation Freedom in centric
before adjustment before adjustment after adjustment
Fig-21
166/400

Long Centric
• Length of a slide is the result of interference of the
teeth whereas long centric is dependant on anatomy
of the condyle disc relationship and varying patterns
of muscle activity in different individuals.
Centric occlusion Centric relation Freedom in centric
before adjustment before adjustment after adjustment
Fig-21
167/400

Long Centric
• To determine the patient’s long centric two different
colours of marking ribbon are used.
• Red ribbon is used first to mark slight closure from
postural rest position without head rest.
• Then green or blue ribbon is used for marking centric
relation points. When both points are identical, ‘long
centric’ is not essential.

Long Centric
• When red mark is forward of green, each centric stop
should be extended forward at the same vertical.
• Green marks should not be ground. A knife edge
inverted cone carborundum stone is used for
accurate grinding.

Long Centric

Long Centric
• Not all patients require long centric. Their centric
closure and closure from rest are identical.
• If such patients are given a long centric, they will not
use it but it will not hurt them either. There are no
contraindications for providing the freedom.

Various Philosophies
• PANKEY MANN SCHUYLER PHILOSOPHY
• HOBO‘S TWIN TABLE PHILOSOPHY
• HOBO’ S TWIN STAGE PHILOSOPHY
PHILOSOPHIES IN FULL MOUTH REHABILITATION 172/240

PANKEY MANN SCHUYLER
PHILOSOPHY

PANKEY MANN SCHUYLER PHILOSOPHY
• One of the most practical
philosophies is the rationale
of treatment that was
originally organized into a
workable concept by Dr.
L.D. Pankey utilizing the
principles of occlusion
espoused by Dr. Clyde
Schuyler.
PHILOSOPHIES IN FULL MOUTH REHABILITATION
174/240

• Schuyler’s principles were:
– A static coordinated occlusal contact of the
maximum number of teeth when the mandible is in
centric relation.
Schyuler C H : Factors in Occlusion applicable to restorative dentistry , J Prosth
Dent 3 : 722- 82 , 1953
175/240

• Schuyler’s principles
were:
– An anterior guidance
that is in harmony
with function in
lateral eccentric
position on the
working side.
Dent 3 : 722- 82 , 1953
176/240

– Disclusion by the anterior guidance of all posterior
teeth in protrusion.
Dent 3 : 722- 82 , 1953
177/240

– Disclusion of all non-
working inclines in lateral
excursions.
– Group function of the
working side inclines in
lateral excursions
Dent 3 : 722- 82 , 1953
178/240

• In order to accomplish these goals, the following
sequence is advocated by the PMS philosophy:
– PART I : Examination, Diagnosis, Treatment planning and
Prognosis .
– PART II : Harmonization of the anterior guidance for best
possible esthetics, function and comfort.
179/240

– PART III: Selection of an acceptable occlusal
plane and restoration of the lower posterior
occlusion in harmony with the anterior guidance in
a manner that will not interfere with condylar
guidance.

– PART IV: Restoration of the upper posterior
occlusion in harmony with the anterior guidance
and condylar guidance. The functionally generated
path technique is so closely allied with this part of
the reconstruction.
181/240

• Advantages
– It is possible to diagnose and
plan the treatment for entire
rehabilitation before
preparing a single tooth.
– It is a well-organized logical
procedure that progresses
smoothly with less wear and
tear on the operator, patient
and technician.
182/240

• Advantages
– There is never a need for
preparing or building more
than 8 teeth at a time.
– It divides the rehabilitation
into separate series of
appointments. It is neither
necessary nor desirable to do
the entire case at one time.

• Advantages
– There is no danger of
getting at sea and
losing patient’s vertical
dimension. The
operator always has an
idea where he is at all
times.
184/240

• Advantages
– The functionally generated
path and centric relation are
taken on the occlusal
surface of the teeth to be
rebuilt at the exact vertical
dimension to which the
case will be reconstructed.
185/240

• Advantages
– All posterior occlusal contours are programmed by
and are in harmony with both condylar border
movements and a perfected anterior guidance.
186/240

• Advantages
– There is no need for time consuming
techniques and complicated equipment.
187/240

• Advantages
– Laboratory procedures are simple and controlled to an
extremely fine degree by the dentist.
188/240

• Advantages
– The PMS philosophy of occlusal rehabilitation can
fulfill the most exacting and sophisticated demands if
the operator understands the goals of optimum
occlusion.
189/240

Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC
REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 190/240

REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3
193/240

HOBO‘S TWIN TABLE PHILOSOPHY

• Another philosophy was given by
Dr. Sumiya Hobo which is
followed in rehabilitation of
dentate patients.
• He proposed Twin table concept
which developed anterior guidance
to create a pre-determined,
harmonious disclusion with the
condylar path.
Hobo S : Twin Table technique for occlusal rehabilitation : Part I – Mechanism
of Anterior guidance , J Prosth Dent 66 (3) : 299-303 , 1991
195/240

• The technique utilizes 2
different customized
incisal guide tables.
• The first incisal table is
termed incisal table
without disclusion.
196/240

• It is fabricated by preparing die systems with
removable anterior and posterior segments. This table
helps us achieve uniform contacts in the posterior
restorations during eccentric movements.
197/240

• The other incisal table is made when the articulator
can simulate border movements by placing 3 mm
plastic separators behind the condylar elements. This
is termed the incisal guidance with disclusion.
198/240

• The first incisal guide table is used to fabricate
restorations for posterior teeth.
• The second guide table is used to achieve incisal
guidance with disclusion.
199/240

200/240

• As explained in the concept, an incisal table without
disclusion was made without anterior guidance. The
wax patterns were fabricated for the posterior teeth to
achieve uniform contacts.
201/240

• The incisal table with disclusion was fabricated next
by using 3 mm acrylic separators behind the condylar
elements. Disclusion of 0.5 mm was achieved on the
working side and 1 mm is achieved on the non-
working side.
202/240

203/240

• This is done for each condylar element one at a time
and protrusive movement by placing separators
behind both condylar elements.
• Once the incisal table is refined, the metal copings
are fabricated and try in of the same is done.
204/240

• This is followed by ceramic build-up of the copings
and cementation after analysis of the eccentric and
centric movements.
205/240

HOBO’ S TWIN STAGE
PHILOSOPHY

HOBO‘S TWIN STAGE PHILOSOPHY
• Dentists have tried for
years to prevent harmful
horizontal occlusal forces
on teeth caused by
mandibular eccentric
movements. The
pantograph and fully
adjustable articulators are
results of their efforts.
Hobo S: Oral rehabilitation . Clinical determination of Occlusion. Quintessence
publication, London.
207/240

• During development, the concept that focuses on the
condylar path as the reference of occlusion was
utilized.
• This concept was derived from the belief that
condylar path was unchangeable in the living body
whereas anterior guidance could be freely changed by
the dentist.
208/240

• But the condylar path has been shown to have
deviation and minimal influence on disocclusion
arising questions on the validity of the concept.
209/240

• The deviation of the incisal path is less than that of
condylar path. However, when individual variation
and the occurrence rate of malocclusion is
incorporated, the incisal path would not be a reliable
reference for occlusion. Thus the cusp angle was
considered as a new reference for occlusion.
210/240

• Though independent of
condylar path as well as incisal
path, a standard value for cusp
angle was determined such that
it may compensate for wear of
natural dentition due to caries,
abrasion and restorative works.
211/240

Contraindications:
• Abnormal curve of Spee
• Abnormal curve of Wilson
• Abnormally rotated teeth
• Abnormally inclined teeth
212/240

• Basic concept of twin stage procedure:
– In order to provide disocclusion, the cusp angle
should be shallower than the condylar path.
213/240

• Basic concept of twin stage
procedure:
– 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.
214/240

– Since anterior teeth help produce disocclusion,
when a dental technician waxes the occlusal
morphology and tries to reproduce a shallower
cusp angle, the anterior portion of the working cast
becomes an obstacle.
215/240
215/240

– Also, when fabricating the anterior teeth to
produce disocclusion, some guidance should be
incorporated. In this methodical approach
described by Hobo, a cast with a removable
anterior segment is fabricated.
216/240
216/240

– Reproduce the occlusal morphology of the
posterior teeth without the anterior segment and
produce a cusp angle coincident with the standard
values of effective cusp angle (Referred to as
‘Condition 1’).
217/240

– Secondly, reproduce the anterior morphology with
the anterior segment and provide anterior
guidance which produces a standard amount of
disocclusion (Referred to as ‘Condition 2’).
218/240

219/240
219/240

• Condition 1:
– Posterior wax patterns are fabricated such that
there are smooth gliding contacts from centric
relation to protrusive and lateral movements.
– This would ensure a uniform amount of posterior
disclusion during lateral and protrusive excursions
when the anterior guidance is established later.
220/240

221/240

• Condition 2:
– The anterior segment of the removable die system
is replaced onto the cast and wax patterns are
fabricated with the articulator settings.
– Anterior dies are replaced onto the casts and wax
up is completed to achieve adequate aesthetics.
222/240

• Condition 2:
– The palatal contours are adjusted according to the
anterior guidance to provide immediate disclusion
away from centric relation. After cutback to create
space for porcelain, the wax patterns were cast
with a nickel chromium metal ceramic alloy.
223/240

• Condition 2:
– The crowns were tried on the cast and trimmed so
as to achieve uniform bilateral contacts in centric
relation.
– Metal try in was subsequently done intraorally and
verified for fit and contacts.
– Ceramic layering was subsequently carried out and
prosthesis was cemented using Glass ionomer
luting cement.
224/240

225/240

Discussion
• Early gnathological concepts focused primarily on
condylar path as it was theorized to be a constant
through adulthood.
• Anterior guidance was considered to be at the
discretion of the dentist.
• McCollum and Stuart concluded from a study
conducted on 10 patients that condylar guidance is
dependent on the anterior guidance.

Discussion
• In Prosthodontics, the condylar path has been
considered the main determinant of occlusion.
• According to the Twin table technique by Hobo, the
cusp shape factor and angle of hinge rotation is
derived from the condylar path. These factors
contribute to the determination of an ideal anterior
guidance.

Discussion
• However, in the Twin Stage procedure, the cusp angle
was considered as the most reliable determinant of
occlusion.
• This was in accordance with the proven data from
studies that cusp angle was 4 times more reliable than
condylar and incisal paths.

Discussion
• Pankey Mann Schyuler’s philosophy advocates that
condylar guidance does not dictate anterior guidance.
• Thus it believes in harmonization of the anterior
guidance for best possible esthetics, function and
comfort and the determination of an occlusal plane
based on anterior guidance.

Maintenance Phase
• After placement and cementation of a prosthesis the
patient treatment continues with carefully structured
sequence of follow-up appointments to monitor the
dental health, stimulate meticulous plaque control
habits, identify incipient disease and introduce any
corrective measures if required.

Maintenance Phase
• Adequate scaling is done periodically to maintain
gingival health.
• Margins of restoration must be evaluated to detect
secondary caries.
• Oral hygiene aids prescribed are tooth brushes, oral
floss, interdental brush, oral irrigation devices and
oral rinses.

Maintenance Phase
Recall schedule
• After maintaining adequate oral hygiene, patient is
recalled at 1 month, 3 months, 6 and 12 months.
After 1 year patient is recalled annually for check-up
and prophylaxis.

Conclusion
• As the goal of medicine is to increase the life
span of the functioning individual, the goal of
dentistry is to increase the life span of the
functioning dentition.

References
1. Dawson PE, Evaluation, Diagnosis and Treatment of Occlusal
Problems, St. LOUIS CV MOSBY, 2nd edition, 164-68
2. AHUJA.P., OCCLUSAL REHABILITATION. A CASE REPORT. JIPS
1999, 25-28
3. Irving Goldman: The goal of full mouth rehabilitation , J
Prosth Dent 2(2) : 246 -51, 1952
4. Mann A W, Pankey L D: The Pankey Mann philosophy of
occlusal rehabilitation, Dent Clin North Am 7: 621-38 , 1963
5. Mann A W, Pankey L D: Oral Rehabilitation, J Prosth Dent 10:
135-62 ,1960
6. Schyuler C H : Factors in Occlusion applicable to restorative
dentistry , J Prosth Dent 3 : 722- 82 , 1953
234/240

References
7. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A
SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013,
Vol.3, ,No. 3
8. Hobo S : Twin Table technique for occlusal rehabilitation : Part I –
Mechanism of Anterior guidance , J Prosth Dent 66 (3) : 299-303 ,
1991
9. Hobo S: Twin Table technique for Occlusal rehabilitation: Part II –
Clinical procedure , J Prosth Dent 66 (4) : 471- 77 , 1991
10. Hobo S: Oral rehabilitation . Clinical determination of Occlusion.
Quintessence publication, London.
11. Kazis Harry: Complete Mouth Rehabilitation through restoration
of lost vertical dimension , J.A.D.A 37 : 19, 1948.
12. Kazis Harry: Functional aspects of complete mouth rehabilitation.
J Prosth Dent 4 (6): 833-842, 1954
235/240

References
13. Harry Kazis, Albert Kazis : Complete Mouth Rehabilitation through
fixed partial denture Prosthodontics. J Prosth Dent 10 (2): 296-303
, 1960.
14. Joseph. S. Landa: An analysis of current practices in mouth
rehabilitation. J Prosth Dent 5(4):527-37, 1955
15. The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent
2005;81:63.
16. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed
prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 46-64.
17. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE.
Fundamentals of fixed prosthodontics. 3rd ed. Chicago:
Quintessence; 1997.p. 85-103, 191-2.
18. V Rangarajan, Textbook Of Prosthodontics, pg 470
19. Joseph E. Ewing, Fixed Parial Prosthesis, 2nd Edition, 14-20.
236/240

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