give indication contraindications for pankey mann and schyler philpoly of fmr also tell how pankey is suitable for combination case of tooth as well as imlant suported fmr
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Pankey-Mann-Schuyler (PMS) Philosophy of Full Mouth Rehabilitation (FMR)
What is PMS Philosophy?
The Pankey-Mann-Schuyler (PMS) philosophy, introduced in 1960 by Lindsey D. Pankey and Arvin W. Mann, with occlusal concepts advocated by Schuyler, is an organized, step-by-step approach to full mouth occlusal rehabilitation. It is based on Monson's spherical theory of occlusion and uses the PM instrument (based on the Monson articulator) to establish the functional occlusal plane on mandibular teeth.
The philosophy is built on three core principles:
- Existence of a physiologic rest position of the mandible (constant)
- Recognition of a variable vertical dimension of occlusion (VDO)
- Acceptance of a dynamic, functional centric occlusion
The Four Steps of PMS Philosophy
| Step | Action |
|---|---|
| 1 | Proper examination, diagnosis, and treatment planning |
| 2 | Determination of anterior incisal guidance (for aesthetics, phonetics, function, comfort) - developed intraorally with acrylic resin |
| 3 | Selection of acceptable occlusal plane (Broadrick's Flag analysis); restoration of mandibular posterior teeth in harmony with anterior guidance without interfering with condylar guidance |
| 4 | Maxillary posterior occlusal surfaces developed using Functionally Generated Path (FGP) technique after completion of mandibular restorations |
Occlusal Principles of PMS
- Freedom in centric occlusion (long centric incorporated in lingual surfaces of maxillary incisors)
- Group function on the working side
- Absence of non-working side (balancing) contacts - balancing contacts considered deleterious in natural dentition
- Maxillary cuspids in good functional contact
- Incisal guidance is the predominating factor for selecting posterior guiding tooth inclines (over condylar guidance)
- Antero-posterior freedom of movement incorporated in restorations
Schuyler's Contribution (Freedom in Centric Concept)
Schuyler specifically advocated:
- Balancing contacts are deleterious and must be avoided in natural dentition
- Incisal guidance should be established first as the initial step of occlusal rehabilitation
- Antero-posterior freedom (long centric) must be incorporated
- Cusp-to-surface (rather than cusp-to-fossa) relationship - though this limits chewing efficiency (the main limitation of Schuyler's concept)
INDICATIONS for PMS-Based FMR
| Category | Specific Indication |
|---|---|
| Occlusal wear | Generalized tooth wear / attrition (especially Turner & Missirlian Category 1 - where anterior guidance is disturbed and must be restored first) |
| Collapsed bite / reduced VDO | Loss of vertical dimension with available freeway space for restoration |
| Anterior guidance loss | Loss of anterior guidance due to wear on anterior teeth |
| Genetic/developmental disorders | Amelogenesis imperfecta (AGI), dentinogenesis imperfecta |
| Multiple missing teeth | Partial edentulism with worn residual dentition |
| Aesthetic + functional deficit | Discolored, worn teeth with compromised chewing efficiency |
| Healthy TMJ | Patient with well-coordinated, symmetrical TMJ movement (without pain/crepitus) |
| Stable occlusion goal | When maximum tooth contacts in centric relation are desired |
| Turner & Missirlian Cat. 1 & 2 | Most commonly treated - 12 category 1 and 3 category 2 cases in systematic review literature |
PMS is the most widely used FMR philosophy - 57.69% of all FMR cases (15 out of 26) in a major systematic review were treated with PMS (PMC8061435).
CONTRAINDICATIONS for PMS-Based FMR
| Category | Contraindication |
|---|---|
| TMJ pathology | Active TMD, TMJ dysfunction, pain or crepitus - harmonious anterior-condylar guidance cannot be established |
| Poor periodontal support | Generalized severe periodontitis - teeth cannot serve as stable abutments |
| Uncontrolled parafunction | Severe bruxism/clenching without splint therapy first |
| Inadequate freeway space | No available inter-occlusal space to increase VDO |
| Malocclusion | Severely maloccluded teeth - PMS cannot be easily adapted (unlike Hobo's twin stage which also has this limitation) |
| Non-arcon articulator dependency | PMS was developed on a non-arcon articulator and may not accept interocclusal records at increased VDO well |
| Systemic/medical contraindications | Uncontrolled diabetes, immunosuppression, bleeding disorders, bisphosphonate use |
| Insufficient bone support | If implants are needed but inadequate bone exists |
| Patient compliance issues | Non-cooperative patients who cannot maintain oral hygiene |
| Financial/time constraints | PMS is a multi-stage, technique-sensitive philosophy requiring significant clinical time |
Limitations of PMS Technique
- Cusp-to-fossae/marginal ridge contacts may complicate occlusal design
- Use of wax FGP techniques can cause errors (wax distortion)
- The PM instrument was based on the non-arcon Monson articulator - may not accurately record eccentric movements at increased VDO
- In practice, the PM instrument itself is rarely used in clinical case reports (none of the 15 cases in the systematic review actually used it)
PMS Suitability for COMBINATION CASES: Natural Teeth + Implant-Supported FMR
This is one of the most clinically relevant aspects of PMS philosophy, and it is well-suited for combination cases for the following reasons:
Why PMS Works Well in Combination (Tooth + Implant) FMR
1. Anterior Guidance First (Step 2) - Universal Applicability
PMS establishes anterior guidance on natural anterior teeth first (or implant-supported anteriors), before the posterior teeth are restored. Whether the posterior teeth are natural or implant-supported, the framework is the same - posterior occlusion must be in harmony with the established anterior guidance.
2. Functionally Generated Path (FGP) - Compatible with Implant Prosthetics
The FGP technique used in Step 4 (maxillary posterior restorations) can be applied to both implant-supported crowns/bridges and natural tooth restorations. The occlusal contacts are generated in harmony with the patient's actual functional movements.
3. Broadrick Flag Analysis - Works for Any Arch Configuration
The occlusal plane is selected based on anatomical landmarks (curve of Monson), not tooth type. Whether teeth are natural or implant-supported, the same occlusal plane analysis applies.
4. Occlusal Load Distribution
In a combination case:
- Natural teeth have a periodontal ligament (PDL) with proprioceptive feedback and some mobility (50-200 micrometers)
- Implants are ankylosed (osseointegrated) with no PDL and negligible mobility (3-5 micrometers)
PMS's group function concept and freedom in centric (long centric) help buffer the occlusal load differences. The long centric principle absorbs minor discrepancies in centric stops between natural and implant-supported units.
5. Quadrant-by-Quadrant Approach
PMS rehabilitates in phases (mandibular anterior → maxillary anterior → mandibular posterior → maxillary posterior). This phased approach is ideal for combination cases where some quadrants have implants and others have natural teeth - each can be treated sequentially.
Key Clinical Modifications for Implant Cases within PMS
| Consideration | Clinical Modification |
|---|---|
| No PDL on implants | Slightly reduced occlusal contacts on implants in centric (use shimstock, not shim foil); implant crowns brought into occlusion slightly lighter than natural teeth |
| Anterior guidance | Preferably on natural anterior teeth if present; if on implant-supported anteriors, ensure light, well-distributed contacts |
| Group function | Distribute lateral contacts across both natural and implant teeth to prevent overload of any single implant |
| FGP on implant sites | Generate functional path carefully; implants have no proprioceptive feedback, so lateral contacts must be verified with articulating paper at multiple excursions |
| Splinting of implants | Multiple adjacent implants in combination cases may be splinted together before FGP, mirroring PMS's cross-arch stabilization concept |
Summary Comparison: PMS vs Schuyler's Contribution
| Feature | Pankey-Mann | Schuyler |
|---|---|---|
| Instrument | PM Instrument (Monson-based) | No specific instrument; occlusal equilibration |
| Occlusal contact | Group function working side | Cusp-to-surface (less efficient) |
| Centric freedom | Long centric | Antero-posterior freedom in centric |
| Starting point | Anterior guidance first | Anterior guidance first |
| Balancing contacts | Absent | Deleterious, must be avoided |
| Key technique | FGP + Broadrick Flag | Equilibration of existing occlusion |
Evidence Base
The most current systematic review (Philosophies of FMR - PMC8061435) confirms:
- PMS is the most widely applied FMR philosophy (57.69% of cases)
- Primary indication: Turner & Missirlian Category 1 (anterior guidance disturbed)
- Age range of treated patients: 18-75 years (broad applicability)
- Recent 2025 case report (IJOHD, Kumar et al.) demonstrates PMS success in partial edentulism with severe wear
- Implant + tooth-supported FMR using PMS philosophy is an established contemporary practice, integrating centric relation, anterior guidance, and harmonious posterior disclusion
indications and contraindiation for hobo
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Hobo's Twin Table Technique & Twin Stage Procedure - FMR Philosophy
Background
Developed by Sumiya Hobo (1991), with the Twin Stage procedure later advanced by Hobo and Takayama, this philosophy is the second most widely used approach to full mouth rehabilitation (FMR) after PMS. It is used in 34.61% of FMR case reports in systematic review literature, compared to only 7.69% for the original Twin Table alone.
The core premise is that incisal guidance and condylar path are interdependent factors - neither can be established in isolation from the other.
The Two Techniques: Key Distinction
| Twin Table Technique (Hobo, 1991) | Twin Stage Procedure (Hobo & Takayama) | |
|---|---|---|
| Tables used | Two separate incisal tables | One incisal table adjusted for two conditions |
| Table 1 / Condition 1 | Posterior restorations fabricated WITHOUT anterior disocclusion (standard cusp angle, no guidance) | Posterior wax-ups with removable anterior segment - cusp angle aligned with condylar path (25° sagittal protrusive) |
| Table 2 / Condition 2 | Second table WITH anterior disocclusion to achieve incisal guidance + posterior disclusion | Anterior restorations added to provide anterior guidance + posterior disclusion |
| Focus | Interplay of condylar path + anterior guidance | Cusp angle as the primary determinant |
| Articulator | Requires custom programming | Semi-adjustable articulator (Bennett angle fixed at 15°) |
| Complexity | More technique-sensitive | Simpler, more reproducible |
| Current use | Largely superseded | Widely adopted, CAD/CAM compatible |
Occlusal Principles of Hobo's Philosophy
- Mutually protected occlusion - anteriors protect posteriors in excursions; posteriors protect anteriors in centric
- Posterior disocclusion during all eccentric mandibular movements (lateral, protrusive) - this is the hallmark
- Precise anterior guidance established before posterior restorations
- Condylar path and incisal guidance are dependent variables - changing one affects the other
- Bennett angle: fixed at 15° (simplified, does not need to reproduce the Fisher angle)
- Immediate mandibular translation (Bennett movement) does not need to be produced
- Anterior guide table: triangular gutter shape, adjustable for both sagittal inclination and lateral wing angles
INDICATIONS for Hobo's Twin Table / Twin Stage FMR
| Category | Specific Indication |
|---|---|
| Severe tooth wear | Generalized attrition, abrasion, erosion with reduced VDO |
| Turner & Missirlian Classification | Applicable to T&M Category 1, 2, and 3 (broader range than PMS alone) |
| Occlusal disharmony | Loss of anterior guidance requiring complete re-establishment |
| TMJ disorders | Following successful occlusal splint therapy (TMJ stabilized before FMR) |
| Need for posterior disocclusion | Cases where posterior teeth must be protected from lateral forces |
| Fixed prosthodontics | Multiple crown/bridge restorations requiring harmonious occlusal morphology |
| Implant-supported restorations | Applicable to implant cases - posterior disocclusion protects osseointegrated implants from harmful lateral forces |
| Complete dentures | Applicable as an occlusal scheme for removable prostheses |
| Digital workflow / CAD/CAM cases | Twin Stage is particularly suitable for virtual articulator and digital wax-up workflows |
| Maloccluded cases | Twin Stage is more adaptable than PMS for cases with some degree of malocclusion |
| Cases where PMS is limited | When the PM instrument-based approach is not feasible or non-arcon articulator is unsuitable |
CONTRAINDICATIONS for Hobo's Philosophy
| Category | Contraindication |
|---|---|
| Abnormal posterior tooth inclinations | Severe Curve of Spee, extreme Curve of Wilson - the cusp angle calculations become unreliable |
| Severely rotated posterior teeth | Rotation distorts the cusp angle relationship; standard values cannot be applied accurately |
| Uncontrolled TMD | Active TMJ pathology - must be resolved with splint therapy FIRST before initiating FMR |
| Severely maloccluded teeth (Twin Stage) | Hobo's twin stage cannot be used for maloccluded teeth (this is why PMS may be preferred in such cases) |
| Poor periodontal support | Insufficient periodontal/bony support for abutment teeth |
| Uncontrolled parafunctional habits | Severe bruxism without prior splint management |
| Inadequate operator skill | Requires precise articulator programming and wax-up; errors arise without adequate training |
| Non-compliant patients | Multi-phase treatment requires patient cooperation |
| Systemic contraindications | Same as all FMR: uncontrolled systemic disease, bleeding disorders, immunosuppression, bisphosphonate therapy |
Advantages of Hobo's Approach
- Posterior disocclusion minimizes harmful lateral forces on restorations, TMJ, and periodontal tissues
- Applicable to FPD, implants, and dentures - versatile
- Evidence-based - grounded in research on the interdependence of anterior guidance and condylar path
- Semi-adjustable articulator suffices - no need for fully adjustable articulator (unlike gnathological approach)
- Twin Stage is CAD/CAM and digital workflow compatible - a major advantage in modern prosthodontics
- Easier to learn than full gnathological techniques; simpler than PMS for certain case types
- Bennett angle standardized at 15° reduces operator-dependent variability
Limitations
- Not suitable for cases with abnormal posterior tooth inclinations (extreme Curve of Spee/Wilson, rotation)
- Limited long-term studies on posterior disocclusion reproducibility
- Less widely used than PMS in classical literature (7.69% Twin Table; 34.61% Twin Stage)
- Wax-up technique demands operator skill for accurate articulator programming
- Cusp-to-fossa occlusal scheme requires careful execution
Comparison: Hobo vs PMS at a Glance
| Feature | PMS | Hobo Twin Stage |
|---|---|---|
| Occlusal protection | Group function | Mutually protected occlusion |
| Working side | Group function contacts | Anterior/canine guidance (posterior disclusion) |
| Balancing side | No contacts | No contacts (posterior disclusion) |
| Starting step | Anterior guidance first | Posterior (Condition 1) then anterior (Condition 2) |
| Instrument | PM instrument + Broadrick Flag | Two incisal tables / single adjustable table |
| Articulator | Non-arcon (Monson based) | Semi-adjustable arcon |
| Malocclusion | Limited adaptability | Also limited (Twin Stage cannot handle maloccluded teeth) |
| Most used for T&M | Category 1 (12/15 cases) | Category 1, 2, and 3 |
| CAD/CAM | Less adapted | Twin Stage: highly compatible |
| Implant suitability | Good (posterior disclusion via long centric) | Excellent (built-in posterior disocclusion) |
Summary
Hobo's Twin Stage is the more modern and preferred of the two Hobo techniques, particularly in digital/CAD/CAM-driven practices. Its hallmark is posterior disocclusion protecting both restorations and the TMJ. The key contraindication to remember is abnormal posterior tooth inclinations (extreme curve of Spee/Wilson, rotation) and uncontrolled TMD, which must be resolved first. For implant cases, the built-in posterior disocclusion makes Hobo's approach particularly protective of osseointegrated implants from destructive lateral occlusal forces.
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