SRM Journal of Research in Dental Sciences | Vol.

4 | Issue 1 | January-March 2013

29
Prosthodontic management of generalized severe
dental fluorosis using simultaneous arch technique and
Hobo twin-stage concept of full mouth rehabilitation
Vijay Kumar, Harpreet Singh, Sophia Sharma
1
Department of Prosthodontcs, M.N DAV Dental College and Hospital, Tatul, Solan, Himachal Pradesh,
1
Department of Dental Surgery,
PHU Paldi, Mahilpur, Hoshiarpur, Punjab, India
INTRODUCTION
Dental fluorosis is a developmental disturbance of enamel
caused by successive exposures to high concentrations of
fluoride during tooth development.
[1]
Severely fluorosed
teeth may undergo post eruptive surface breakdown and dark
brown to black staining.
[2]
The enamel is often affected
and may vary from areas of flecking to diffuse opacious
mottling, while the color of the enamel ranges from chalky
white to a dark brown/black. Brown/black discoloration may
be posteruptive and probably caused by the internalization
of extrinsic stain into the pitted enamel.
[3]
Appearance of
teeth may also resemble line shading in pencil sketch,
[4]

which indicates dental fluorosis. This case is not common
because of severe degree of damage to enamel both because
of fluorosis and extensive carious lesions thus rendering
it weak and fragile. Usually generalized carious lesions to
such an extent are not seen in cases of generalized dental
fluorosis. This necessitates extensive removal of enamel
which is brittle, soft or decayed via. teeth preparation
followed by extensive extracoronal restorations. Treatment
of severe generalized dental fluorosis to acceptable aesthetic
and mastication especially in young age remains a great
challenge.
CASE REPORT
A 22 years old male patient presented to us with
generalized brown-black discoloration of teeth with
multiple structural defects [Figures 1 and 2]. The patient
seems to be depressed, underconfident and appear to be
undernourished. Upon examination, it was also found that
anterior teeth showed multiple wear facets [Figure 1].
Multiple carious lesions, pulp involvement, and chipping
of enamel on applying moderate force with dental explorer
were found.
ABSTRACT
Treatment of severe generalized dental fuorosis with surface defects to rehabilitate
esthetics, phonetics, and mastication require removal of unsupported and pitted enamel
and/or dentine, reestablishment of centric relation with or without reestablishing vertical
dimension of occlusion and fabrication of full mouth crown and bridge work. In this case full
occlusal reconstruction was done using simultaneous arch technique and Hobo twinstage
procedure following reorganizing approach as generalized fuorosis led to severe structural
defects, oblique facets because of anterior traumatic occlusion and multiple dental car
ies, which were otherwise not possible to be treated by direct restorations alone. Centric
relation was also recorded at reestablished vertical dimension.
Key words: Centric relation, dental fuorosis, Hobo twinstage procedure, removable
anterior segment, simultaneous arch technique
Case Report
Address for correspondence:
Dr. Vijay Kumar,
Khanpur, Mahilpur, Hoshiarpur, Punjab - 146 105, India.
E-mail: dr_kumarvijay2007@yahoo.co.in
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DOI:
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Kumar, et al.: Prosthodontic management of generalized dental flurosis using Hobo twin stage concept of full mouth rehabilitation
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
30
The patients dental history dated back to 12 years when he
first noticed discoloration of his newly erupted upper and lower
front teeth followed by involvement of subsequent erupting
permanent teeth. Since then the discoloration increased
to current status. There was no history of discoloration of
deciduous teeth. There was positive family history of similar
discoloration in his siblings as well. But there was no relevant
medical history. All wisdom teeth showed irregular GAPS
on cusp [Figures 3 and 4], which is an indication of dental
fluorosis,
[4]
with staining in the central fossa instead of gross
structural defect. Patient was diagnosed as having generalized
mottling/fluorosis of teeth with brown-black staining and post
eruptive dental caries. Multiple dental caries, which is not a
common finding in dental fluorosis, could be a consequence
of food lodgment in areas of gross enamel defects. Reverse
overjet was found on left canine and premolar region. There
was history of extraction of 27 and 46, nearly 7 and 1 years
back, respectively, because of carious decay. Left maxillary
third molar (28) probably had closed the space formed by
missing 27. On extra oral examination, lower facial height was
found to be normal. Lip seal was found to be incompetent.
Figure 1: Preoperative intraoral view
Procedure
After making diagnostic impression, two sets of diagnostic
casts were made. Although extraoral appearance was not
indicative of loss in vertical dimension but on intraoral
evaluation based on phonetic, multiple carious decay leading
to unstable and poor posterior occlusal contacts and anterior
traumatic occlusion, a definitive loss in vertical dimension
was found. Incompetent lip seal was probably because of
short upper lip. Full mouth charting of carious teeth, missing
teeth, and any alteration in occlusal plane level was done by
mounting the diagnostic casts in existing centric occlusion
on WhipMix articulator after making orientation record with
Quickmount face bow. Maxillary cast was sectioned before
mounting to get removable anterior segment. Endodontic
treatment was carried out in 16, 26, 36, and 47.
Diagnostic wax-up was done on articulated diagnostic casts
with removable anterior segment [Figure 5] to foresee the
proposed teeth size and shape in final restorations, horizontal
and vertical overlap in anterior and posterior teeth, occlusal
plane and also to access modifications in teeth preparation,
which were required to rectify mild rotations of teeth and
reverse posterior overjet.
Figure 2: Preoperative extraoral view
Figure 3: Mandibular Occlusal view Figure 4: Maxillary occlusal view
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Kumar, et al.: Prosthodontic management of generalized dental flurosis using Hobo twin stage concept of full mouth rehabilitation
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
31
Teeth preparation of both the arches was done [Figure 6]
utilizing information gained by diagnostic waxup, using
simultaneous arch technique. Special consideration was
given to 22, 24 and 36, 37 and 47 while preparation because of
presence of rotation and reverse overjet relation, respectively,
to bring them in class 1 relation with acceptable esthetics in
final restorations within limitations. 45 and 47 were prepared
to get a common path of placement for proposed porcelain
fused to metal (PFM) bridge. Retraction cord was placed
and impression of both arches was made using putty-wash
technique. Die pins were secured to final impressions and
final casts were obtained. Dies were cut to get final casts
with removable dies.
Face bow record was again made using Quickmount
facebow [Figure 7]. Maxillary final cast with full mouth
teeth preparation was mounted on the Whip Mix
articulator using Quickmount face bow. Cotton rolls were
used to deprogram the masticatory muscle engrams.
[5]

Recording of centric relation requires incisal separation
by 1-3 mm when the occlusal prematurities are barely
separated.
[6]
As occlusal prematurities were present in this
case centric relation needed to be recorded at reestablished
vertical dimension. In addition to this neuromuscular
relaxation is an integral part of physiologically sound
and scientific centric relation recording method.
[5]

Centric relation was recorded at raised vertical dimension
(approximately 23 mm) by bilateral manipulation of jaws
using Anterior stop technique.
[5]
Low fusing compound was
used to make anterior jig
[6]
and Addition silicone regular
body (Reprosil) was used to secure the position of maxillary
and mandibular posterior teeth bilaterally to complete
the centric relation record
[6,7]
[Figure 8]. Anterior jig and
two posterior records were used as tripod for relating the
mandibular cast against already mounted maxillary cast to
complete the articulation. Articulator values were adjusted
to the average values
[8]
as advocated by Hobo for twin-stage
procedure [Table 1].
This was done for reproduction of standard cusp angles
and standard amount of disocclusion for Condition 1.
Here posterior occlusion was developed to get balanced
articulation fearlessly without considering anterior
teeth as anterior segment of maxillary cast was already
removed. Later anterior segment was placed back on
articulator and articulator setting was changed as per
Condition 2 [Table 1]. As sagittal condylar inclination
Figure 5: Diagnostic wax-up with separable anterior segment
Figure 6: Teeth preparation with retraction cord in place
Figure 7: Face bow record Figure 8: Centric relation record with anterior jig in place
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Kumar, et al.: Prosthodontic management of generalized dental flurosis using Hobo twin stage concept of full mouth rehabilitation
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
32
Condition 2 [Table 1]. Bisque trial was done in patients
mouth and verified for maximum intercuspation in centric
relation and mutually protected occlusion in eccentric
relations. Final restorations were cemented [Figures 13-16]
with glass ionomer luting cement. Care was taken to
maintain opposite occlusal contact relationship. Flash was
removed after every cementation using dental explorer and
dental floss.
DISCUSSION
Severe generalized dental fluorosis requires removal of
defective and unsupported enamel, rehabilitation of
mastication, phonetics, and esthetics. This becomes
difficult in young patients where almost all teeth are
involved to such an extent that they require some kind
of extracoronal restoration for their long term survival.
In addition to this, reestablishing centric relation with
accuracy, when occlusal support is less in quality of
quantity pose a great challenge. Moreover selection of
occlusal scheme and its effective execution add to existing
challenge.
Commonly used method for treatment of mild to
moderate generalized dental fluorosis is microabrasion

and
in-office bleaching with or without composite veneering.
Microabrasion
[9]
or composite veneering was not possible
for this case because of severity of damage to teeth. The
final decision for selection of treatment depends upon the
severity of intrinsic stains and structural defect of enamel.
for condylar path and sagittal inclination and lateral wing
angle values for anterior guide table were adjusted as per
Condition 2, it provides disocclusion in posterior teeth on
protrusive and lateral excursions thus allowed us to develop
anterior teeth occlusion without considering for amount
of disocclusion produced in posterior teeth in eccentric
mandibular movements.
Provisional restorations were fabricated at reestablished
vertical dimension and occlusal contact relations, esthetics,
and phonetics were verified in patients mouth [Figure 9].
Provisional restorations were cemented using Temp Bond
temporary luting cement. Patient was recalled after 2 weeks
and examined for any discomfort in temporomandibular
joints, difficulty in eating or drinking, and phonetics. Patient
was found to be symptom free and he seems to regain
confidence.
Castings were made with Ni-Cr alloy (Bego) and metal
try in was done to access the complete seating, margin
adaptation and occlusal clearance. Posterior PFM
crown-bridge restorations were fabricated to develop
bilateral balance occlusion without maxillary anterior
teeth on articulator [Figure 10] with articulator settings
for Condition 1 [Table 1]. Later anterior PFM crowns
were fabricated to develop canine guidance occlusion
on the articulator [Figures 11 and 12]. 36, 37, and 47
were fabricated to have cross bite relationship keeping in
view their original position in dental arch. Later anterior
occlusion was developed with articulator values for
Table 1: Articulator adjustment values for Hobo twin-stage procedure
Condition Condylar path Anterior guide table
Sagittal condylar inclination Bennet angle Sagittal inclination Lateral wing angle
Condition 1
Without anterior teeth
25 15 25 10
Condition 2
With anterior teeth
40 15 40 20
Figure 9: Provisional restorations in place Figure 10: Posterior fnal restorations on articulator
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Kumar, et al.: Prosthodontic management of generalized dental flurosis using Hobo twin stage concept of full mouth rehabilitation
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
33
The reason for undertaking occlusal rehabilitation may
include the restoration of multiple teeth, which are missing,
worn, broken down or decayed.
[10]
This case was treated with full mouth crown and bridge
work using simultaneous arch technique as it provide us
the flexibility to simultaneously restore both the arches,
develop occlusal plane, occlusal scheme, crown contours,
and embrasures. Reestablishing vertical dimension also
Figure 13: Postoperative intraoral frontal view
Figure 15: Left lateral intraoral view showing canine guidance
Figure 14: Right lateral intraoral view showing canine guidance
Figure 16: Postoperative extraoral view
Figure 11: Anterior segment repositioned on articulator and all
fnal restorations in place
Figure 12: Canine guided occlusion on articulator
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Kumar, et al.: Prosthodontic management of generalized dental flurosis using Hobo twin stage concept of full mouth rehabilitation
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
34
provides additional space for restorative material
[11]
and
esthetics result of treatment is more uniform too. Segmental
technique could not be used as segmental rehabilitation
of arch does not favor reestablishment of the vertical
dimension. Compound anterior jig was used to exert upward
and posterior guidance during mandibular closure
[10]
to
reestablish the vertical dimension and recording centric
jaw relation.
It was decided to develop occlusal scheme using Hobo
twin-stage concept because all maxillary and mandibular
anterior teeth and molars need crown-bridge work thus
anterior guidance and cuspal angle can be established
precisely without concern about the remaining natural teeth.
Moreover, there was no abnormal curve of Spee, no severe
rotations, or inclined teeth,
[8]
which cannot be straightened
during the course of treatment. Twin stage procedure is
based on the principles of disocclusion in lateral excursions.
Here maxillary cast was cut distal to canines bilaterally,
to make the anterior segment detachable. It dictates that
cusp angle should be shallower than condylar path and also
incisal guidance be kept steeper than condylar inclination
to provide disocclusion. This provides us with a mutually
protected occlusion.
CONCLUSION
The use of simultaneous arch technique of full mouth
rehabilitation with Hobo twin-stage procedure for occlusal
development has been described. Removable anterior segment
of upper cast help develop occlusion of anterior and posterior
teeth independent of each other. Diagnostic waxup provided
vital information that helped in teeth preparation using
simultaneous arch technique. Centric relation was reestablished
and vertical dimension of occlusion was increased to avoid
posterior occlusal prematurities and provide a comfortable
position of mandible from where all functional mandibular
movements could be made. For the patient described, sequence
of treatment followed, appear to be effective.
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How to cite this article: Kumar V, Singh H, Sharma S. Prosthodontic
management of generalized severe dental fuorosis using simultaneous
arch technique and Hobo twin-stage concept of full mouth rehabilitation.
SRM J Res Dent Sci 2013;4:29-34.
Source of Support: Nil, Confict of Interest: None declared
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