Indications for pankey man and schuler technique
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Pankey Mann Schuler technique indications occlusal rehabilitation dentistry
More detailed what type of fmr cases implant cimbinated fmr
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Pankey Mann Schuyler technique indications implant combined full mouth rehabilitation cases detailed
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Pankey Mann Schuyler indications implant combined full mouth rehabilitation
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PMS philosophy implant supported full mouth rehabilitation indications partially edentulous
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Here is a detailed breakdown of the Pankey-Mann-Schuyler (PMS) technique - its indications for FMR cases, and specifically how it applies to implant-combined FMR.
Indications for PMS-Based Full Mouth Rehabilitation
1. General Indications for PMS/FMR
| Condition | Details |
|---|---|
| Generalized tooth wear | Attrition (bruxism/parafunction), abrasion (hard brushing, dietary), erosion (GERD, acidic diet) causing loss of tooth structure, VDO collapse |
| Lost vertical dimension of occlusion (VDO) | Overclosure, deepened bite, altered face height - requires re-establishment of new VDO |
| Collapsed occlusion | Posterior support loss leading to anterior flaring, spacing, or deep overbite |
| Disorganized / non-reproducible centric relation | Habitual occlusion differs markedly from CR - reorganized approach required |
| Multiple failing/failing restorations | Old crowns, bridges, or fillings with recurrent caries, fractures, or marginal failure across multiple quadrants |
| Congenital/developmental conditions | Amelogenesis imperfecta, dentinogenesis imperfecta, ectodermal dysplasia - affecting enamel/dentin quality across all teeth |
| TMJ dysfunction with occlusal aetiology | Muscle pain, limited opening, clicking associated with occlusal disharmony |
| Periodontal disease with occlusal trauma | Stage III-IV periodontitis with secondary occlusal trauma requiring full occlusal reorganization after periodontal therapy |
| Combination syndrome | Maxillary edentulism opposing natural mandibular anteriors causing bone resorption anteriorly |
| Advanced caries | Generalized caries with structural loss necessitating full-arch reconstruction |
| Fractures | Multiple tooth fractures from trauma or parafunctional habits |
2. PMS-Specific Prerequisite Indications
The PMS philosophy uses a reorganized approach - meaning the existing occlusion is NOT preserved but entirely rebuilt in CR. It is specifically indicated when:
- Confirmative (additive) approach is NOT possible - the existing occlusion is too disorganized or the teeth too worn to preserve
- Group function occlusion is the planned occlusal scheme (PMS favors canine + posterior group function on working side, NOT pure canine guidance)
- Long centric (freedom in centric) is required - patients with significant parafunction benefit from the anterior freedom incorporated in the PMS lingual morphology of upper incisors
- Functionally Generated Path (FGP) technique is to be used for posterior occlusion - though this is less used today due to wax recording errors
- Periodontally sound teeth are present - PMS cannot be used if teeth are periodontally compromised, as FGP cannot be accurately recorded on mobile teeth
Implant-Combined FMR: When and Which Cases?
When implants are integrated into PMS-based FMR, the cases are classified by dentition status and extent of tooth loss:
Case Type A: Partially Edentulous - Posterior Teeth Missing (Most Common)
Scenario: Patient has retained anterior teeth (often worn) but missing one or more posterior segments (Kennedy Class I, II, III).
Why implants?
- Posterior support is essential in PMS philosophy (equal loading of teeth in CR)
- Without posterior stops, there is no stable platform for the FGP or Broadrick occlusal plane construction
- Implants replace the missing posterior teeth to restore the tripod of occlusal support before or in conjunction with anterior and posterior crown fabrication
PMS sequence with implants:
- Implants placed and osseointegrated first
- Mandibular posterior implant crowns fabricated first (PMS mandible-first sequence)
- Maxillary anterior guidance established
- Broadrick occlusal plane analysis performed
- Remaining maxillary posterior restorations completed
Case Type B: Partial Edentulism with Vertical Dimension Loss + Missing Teeth
Scenario: Patient has generalized wear on remaining teeth AND missing teeth posteriorly or anteriorly.
Details:
- VDO must be increased on the articulator before any restorations
- Implants provide additional abutments needed to distribute the increased occlusal load at the new VDO
- Provisional phase (6-8 weeks) is mandatory to test the new VDO on all teeth including implant provisionals before final restorations
- High risk for implant overload if VDO change is large - careful implant positioning and cantilever avoidance is critical
Case Type C: Terminal Dentition - Full Arch Implant Rehabilitation (Full Arch/Teeth in a Day)
Scenario: All or nearly all natural teeth are failing due to caries, severe periodontitis (Stage IV), or gross destruction. Teeth are extracted and implants placed.
Sub-types:
- Maxillary or mandibular full-arch implant (4-6 implants) - fixed implant bridge (All-on-4, All-on-6)
- Both arches replaced with implant-supported fixed prostheses
PMS philosophy adaptation:
- PMS principles still guide the occlusal scheme on implant prostheses
- CR is carefully established at a new VDO
- Group function or anterior guidance is built into the implant prosthesis (zirconia, PFM, or acrylic hybrid bridge)
- Posterior disclusion incorporated to protect implants from lateral forces
- The Broadrick occlusal plane is still used for curve of Spee planning on the implant bridge
Key difference from natural teeth PMS: FGP technique is NOT used on implants (osseointegrated implants lack proprioceptive feedback from PDL); instead, articulator-based waxing and digital design replaces the FGP step.
Case Type D: Combined Implant + Natural Teeth (Tooth-Implant Combined FMR)
Scenario: Some natural teeth retained as abutments, implants placed in edentulous spaces; crowns and implant crowns fabricated together.
Challenges specific to PMS:
- Implants lack the periodontal ligament (PDL) - they are ankylosed
- Natural teeth under load have 25-100 micron physiological movement; implants have ~3-5 microns
- In PMS combined cases, implant crowns are adjusted to be slightly out of occlusion in CR (10-20 micron relief) to avoid overloading the implant while natural teeth absorb the initial contact
- Group function is maintained but the implant crowns participate passively to prevent occlusal overload
Case Type E: Congenital/Developmental Conditions with Missing Teeth
Scenario: Ectodermal dysplasia, oligodontia, or severe hypodontia - multiple congenitally missing teeth combined with malformed retained teeth.
Why PMS?
- Both implants (for missing teeth) and crowns (for malformed retained teeth) are needed
- PMS philosophy organizes the sequencing of restorations in a predictable, stepwise manner
- Implants placed after growth is complete (typically 18-20 years for females, 20-22 for males)
Contraindications to PMS (Important Distinction)
- Periodontally compromised teeth - FGP cannot be accurately recorded on mobile teeth (though if FGP is replaced by digital workflow, this limitation is overcome)
- Single-arch cases - PMS is a full-mouth technique; single arch or single quadrant cases use simpler approaches
- Cases where confirmative approach is adequate - if VDO is acceptable and occlusion is stable, PMS reorganized approach is unnecessarily invasive
- Uncontrolled bruxism without splint therapy first - aggressive parafunction must be managed before final FMR
Summary Table
| FMR Case Type | Implant Role | PMS Applicability |
|---|---|---|
| Generalized wear, intact arches | Not needed | Classic PMS (crowns only) |
| Partially edentulous (post. missing) | Posterior implants to restore occlusal stops | PMS with implant abutments |
| VDO loss + missing teeth | Implants + crowns at new VDO | PMS reorganized approach |
| Terminal dentition (full arch) | Full arch implant bridges | Modified PMS (no FGP) |
| Tooth-implant combined arch | Mixed abutments | PMS with differential occlusal loading |
| Congenital/developmental (missing + malformed) | Implants for missing, crowns for retained | PMS sequencing after growth completion |
The PMS technique remains one of the most widely used frameworks for organizing implant-combined FMR because its stepwise, quadrant-by-quadrant sequencing (lower posteriors → upper anteriors → lower anteriors → upper posteriors) naturally accommodates phased implant placement and osseointegration timelines within the overall rehabilitation plan.
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