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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 40-44

Full-mouth rehabilitation using twin-stage technique

1 Graded Specialist, (Prosthodontics), Command military Dental Center, Lucknow, Uttar Pradesh, India
2 Classified Specialist (Prosthodontics), Command military Dental Center, Pune, Maharashtra, India
3 Commandant, Command military Dental Center, Pune, Maharashtra, India
4 Commandant, Command military Dental Center, Lucknow, Uttar Pradesh, India
5 Orthodontist, Lucknow, Uttar Pradesh, India

Date of Web Publication17-May-2019

Correspondence Address:
Dr. Ashish Kalra
CMDC, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_62_18

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The wear and tear of the occlusal surfaces of teeth keeps on happening throughout life. However, excessive occlusal wear may lead to occlusal disharmony, pulpal trauma, esthetic disfigurement, and impaired function. Tooth wear can be classified as attrition, abrasion, and erosion depending on the cause. Therefore, it is important to identify the factors which contribute to excessive wear and reduce the vertical dimension of occlusion. This case report presents the rehabilitation of complete maxillary and mandibular arch in a 45-year-old male patient with severe attrition. The patient was treated using the Hobo's twin-stage approach with porcelain-fused-to-metal crowns on all maxillary and mandibular teeth.

Keywords: Full mouth, porcelain fused to metal (PFM), vertical dimension

How to cite this article:
Kalra A, Sandhu HS, Sahoo NK, Nandi A K, Kalra S. Full-mouth rehabilitation using twin-stage technique. Int J Oral Health Sci 2019;9:40-4

How to cite this URL:
Kalra A, Sandhu HS, Sahoo NK, Nandi A K, Kalra S. Full-mouth rehabilitation using twin-stage technique. Int J Oral Health Sci [serial online] 2019 [cited 2022 Aug 18];9:40-4. Available from: https://www.ijohsjournal.org/text.asp?2019/9/1/40/258580

  Introduction Top

The gradual wear of the occlusal surfaces of teeth is a continuous phenomenon which keeps on happening throughout the life of a patient. However, excessive occlusal wear may result in pulpal trauma, occlusal disharmony, impaired function, and esthetic disfigurement.[1] Tooth wear can be in the form of attrition, abrasion, and erosion. Therefore, it is important to identify the factors which contribute to excessive wear and reduce the vertical dimension of occlusion (VDO).[2] Mostly, the VDO is maintained by continuous tooth eruption and alveolar bone growth. The alveolar bone undergoes an adaptive process and compensates for the loss of tooth structure to maintain the VDO as the teeth are worn.[3],[4]

Esthetic and functional rehabilitation of the worn out dentition is always a significant clinical challenge. However, the rehabilitation of the severely worn dentition becomes more challenging when insufficient space for restoration is present. Proper diagnosis and careful comprehensive treatment plan are required in managing such patients. Full-mouth rehabilitation enhances the patient's self-esteem, confidence, and quality of life. Full-mouth rehabilitation is the procedure when restoration of the missing teeth involves the complete rehabilitation of the oral cavity, in terms of function and esthetics.

This case report describes the full-mouth rehabilitation of worn out dentition by twin-stage procedure to produce definite esthetic and occlusal scheme favorable to the patient.

  Case Report Top

A 45-year-old male patient reported with the chief complaints of difficulty in eating and unesthetic appearance of his face because of excessive wear of the upper teeth. Intraoral examination revealed a generalized loss of dental substance that was greater in the maxillary teeth [Figure 1]. The patient did not have temporomandibular joint disorder history and soreness of the masticatory muscles. Loss of 5 mm of vertical dimension (VD) was evident, and his phonetics was also altered. Periodontal charting was carried out, and based on the findings, the treatment plan was formulated involving oral prophylaxis, extraction of 36 and 16, followed by full-mouth rehabilitation with porcelain-fused-to-metal full-coverage fixed partial dentures and crowns at an increased VD of 4 mm with canine-guided occlusion to improve esthetic and functional value of the patient.
Figure 1: Showing the pre op intraoral frontal view

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The case was taken for the following objectives of treatment to:

  • Attain functional harmony
  • Reestablish form, function, and esthetics
  • Establish a canine-guided occlusal scheme.

A splint made up of hard sheet was given to the patient for 6 weeks. The adaptation of the patient to the increased VDO was evaluated during 2-month trial period. Muscle tenderness and temporomandibular discomfort were not found.

Occlusal equilibration was done in the patient's mouth by removing the occlusal interferences, so that centric relation coincided with the maximum intercuspal position. A Lucia jig was fabricated at an established increased VDO at 4 mm. Interocclusal and protrusive records were made using polyvinyl siloxane occlusal registration material (Jet Bite). The diagnostic impressions were made using irreversible hydrocolloid. The patient's casts were mounted on a semiadjustable articulator (Hanau H2) using a facebow record at increased VD. Mandibular occlusal plane was analyzed using the Broadrick's occlusal plane analyzer [Figure 2]. Divider of Broadrick occlusal plane analyzer was opened at 4 inches and a mark was obtained on the flag by keeping one end at the distal end of the canine and the second end of the divider at the distobuccal cusp of the last molar and another mark crossing the first one was obtained. Now, another end of the divider was kept on this intersection of the marks, and occlusal plane was marked on wax occlusal rim made on mandibular cast. The semiadjustable Hanau articulator was programmed to Condition 1 of Hobo's twin-stage procedure [Table 1], wherein after removal of the maxillary anterior segment [Figure 3], posterior segment diagnostic wax-up was done in bilaterally balanced occlusion. The settings were changed to Condition 2 where the maxillary anterior segment was replaced and the anterior wax-up was completed and checked for proper anterior guidance to achieve disocclusion in eccentric movements due to canine-guided occlusion [Figure 4].
Figure 2: Showing the Broadrick's occlusal plane analyzer

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Table 1: Showing values for hobo's twin stage technique

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Figure 3: Showing the separate anterior segment

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Figure 4: Diagnostic wax up

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Provisional crowns were fabricated with autopolymerizing resin using a vacuum-formed matrix produced from the diagnostic wax-up. Adjusted occlusion was transferred to a customized anterior guide table, which was made with acrylic resin (PATTERN RESIN; GC Corp., Tokyo, Japan). Tooth preparation of all maxillary and mandibular teeth was prepared [Figure 5], and definitive two-stage double-mix putty light-body impression was made with polyvinyl siloxane impression material (Aquasil, Dentsply) [Figure 6]. The interocclusal record was made with interocclusal recording material at established VD, and facebow was used for recording of orientation jaw relation. Provisional crowns were cemented with soft zinc polycarboxylate temporary cement (Hybond). After die cutting, the casts were mounted on semiadjustable articulator (Hanau H2) [Figure 7]. The wax patterns were fabricated, invested, and casted. The metal copings were retrieved, and metal try-in was done after finishing [Figure 8]. After the metal try-in, the ceramic was applied and bisque try-in was completed. Porcelain-fused-to-metal restorations were made using Condition 1 and 2 of Hobo's technique. The canine-guided occlusion was checked in the mouth, and after verification, the crowns were cemented with temporary polycarboxylate cement. After 2 weeks, once the patient was comfortable, all the crowns were cemented with resin-modified glass ionomer cement (FujiCEM; GC America, Alsip, USA) [Figure 9] and [Figure 10]. Postoperative orthopantogram was taken [Figure 11], and oral hygiene instructions and regular checkup were administered.
Figure 5: Showing the maxillary and mandibular teeth preparation

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Figure 6: Showing the final impression

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Figure 7: Showing the Die cutting

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Figure 8: Metal Try in

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Figure 9: Final Prosthesis in situ

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Figure 10: Canine guided occlusion

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Figure 11: Post op Orthopentogram

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  Discussion Top

Treatment of reduced VD is not designed to increase it, but is intended to restore the amount of VD lost. Such cases require the development of sufficient restorative space, which may lead to fulfilling the esthetics, functional, and occlusal parameters essential to long-term success. All our efforts for full-mouth rehabilitation are directed toward reestablishing a state of functional efficiency, in which the hard and soft tissues of the stomognathic system function in synchronous harmony. Dawson stated that interocclusal space is never lost and any loss is compensated by tooth eruption, alveolar bone expansion, and muscle action. Success in maintaining severe wear cases depends on the development of proper incisal guidance to allow for proper disocclusion within patient's envelop of motion.[5]

The etiology of tooth wear is multifactorial, and clinical controlled trials of restorative and prosthodontic approaches are limited in quantity and quality. The VD should be raised with occlusal splints before starting the treatment, and the overlay prostheses should be tried between 3 weeks and 5 months for deprogramming of temporomandibular joint.[6]

In this case, 4 mm of VD was raised as moderate amount of increase in VD is not harmful for temporomandibular apparatus. The patient was carefully monitored for 2 months to evaluate the adaptation to the removable occlusal overlay splints. No discomfort, wear, and muscle fatigue were observed during that period. The increase of VDO was determined by the patient's physiologic factors such as interocclusal rest space and speech. Arbitrary increase of VDO would lead to multiple complications.

Stuart and Stallard in 1957 said that the cuspid-protected occlusion concept had many advantages over the group function. Hobo and Takayama said that amount of disocclusion depends on the condylar path, incisal path, and the cusp angle.[7] Posterior disocclusion is very important in controlling harmful lateral forces. This case has demonstrated that if the condyles are seated in centric relation, additional restorative-required space may be obtained. Proper anterior guidance not only is essential for preventing the interferences in the condylar envelop of movement but also prevents the excessive wear.

  Conclusion Top

Multidisciplinary approach and proper treatment planning with adequate manual dexterity are required for creating the perfect esthetic with health. For doing the full-mouth rehabilitation treatment, all the imperfections in bite position should be removed, and the mandible should be seated in centric relation. Following this principle, it creates a smile that is esthetic, comfortable, and functional.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest

  References Top

Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74.  Back to cited text no. 1
Prasad S, Kuracina J, Monaco EA Jr. Altering occlusal vertical dimension provisionally with base metal onlays: A clinical report. J Prosthet Dent 2008;100:338-42.  Back to cited text no. 2
Dawson PE. Functional Occlusion – From TMJ to Smile Design. 1st ed. New York: Elsevier Inc.; 2008. p. 430-52.  Back to cited text no. 3
Jahangiri L, Jang S. Onlay partial denture technique for assessment of adequate occlusal vertical dimension: A clinical report. J Prosthet Dent 2002;87:1-4.  Back to cited text no. 4
Hoyle DE. Fabrication of a customized anterior guide table. J Prosthet Dent 1982;48:490-1.  Back to cited text no. 5
Yunus N, Abdullah H, Hanapiah F. The use of implants in the occlusal rehabilitation of a partially edentulous patient: A clinical report. J Prosthet Dent 2001;85:540-3.  Back to cited text no. 6
Hobo S. Twin-tables technique for occlusal rehabilitation: Part I – Mechanism of anterior guidance. J Prosthet Dent 1991;66:299-303.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1]


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