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HOBO
FULL MOUTH REHABILITATION
ANISH AMIN
HOBO’S PHILOSOPHY AND
TECHNIQUES.
Contents
 Definitions
 Introduction
 Theoretical background
 Disocclusion
 Articulators
 Occlusal adjustments
 Twin stage procedure
 Twin table technique
 Full mouth constructions
 Rationale for twin stage procedure
TERMINOLOGIES
(as per GPT – 8)
Condylar Guidance : Mandibular guidance generated by the
condyle and the articular disc traversing the contours of the
glenoid fossae.
Condylar Guidance : The mechanical form located in the upper
posterior region of an articulator that controls the movement
of it’s mobile member.
 Incisal Guidance : The influence of the contacting surfaces of
the mandibular and maxillary anterior teeth on mandibular
movements.
 Incisal Guidance : The influences of the contacting surfaces of
the guide pin and the guide table on articular movement.
 Bennet Angle : The angle formed between the sagittal plane and
the average path of the advancing condyle as viewed in the
horizontal plane during lateral mandibular movements
 Mandibular Lateral Translation : The translatory portion of
lateral movement in which the non working side of condyle
moves essentially straight and medially as it leaves the centric
relation position.
 Physiologic Rest Position : the mandibular position assumed
when the head is in an upright position and the involved
muscles, particularly the elevators and the depressor groups,
are in tonic contraction and the condyles are in a neutral
unstrained position.
 Laterotrusion : Condylar movement on the working side in the
horizontal plane
 Mandibular Translation : The translatory movement ( medio-
lateral) movement of the mandible when viewed in the frontal
plane.
 Fischer’s Angle : The angle formed by the intersection of the
protrusive and non working side condylar path as viewed in
sagittal plane.
Functional analysis of occlusion
A functional analysis of occlusion is pertinent to the
formulation of a proper plan of treatment for complete mouth
rehabilitation. It must include:
(1) The determination of the proper vertical height by utilizing
the physiologic rest position of the mandible as a guide, and
'noting the existing functional freeway space.
(2) An examination and study of the path of closure from rest
position to the physical contact position of the teeth, noting
whether condyle displacement occurs.
3)The effects of the occlusal pattern upon the periodontal
structures.
(4) A study of the temporomandibular joint positions relative to
the occlusal pattern by means of roentgenographic evaluation.
WHY DO WE NEED TO
REORGANIZE
OCCLUSION ?
Reorganization may be considered when the existing intercuspal
position is considered unsatisfactory for any of the following
reasons:
 Repeated fracture or failure of teeth or restorations : Clinical
experience suggests that persistently failing restorations (for
example crown and bridge debonding) are very commonly
attributed to unfavorable occlusal loading which may be
improved by reorganization.
 Lack of interocclusal space for restoration :
Re organising the occlusion to eliminate a large horizontal
component of slide between CR and IP can create a valuable
interocclusal space for the restoration of worn anterior teeth.
Alternatively, the occlusion may be re organised at an
increased vertical dimension necessitating occlusal coverage
for at least one arch.
 Bruxism : An optimally constructed occlusion will
better be able to deal with the forces generated in
parafunction.
 Trauma from occlusion : This may be soft tissue trauma
(due to teeth impinging on the cheek or alveolar ridge) or
periodontal trauma due to occlusal trauma.
 Unacceptable Function : Poor tooth to tooth contact with
tilting and overeruption of teeth may create problems with
masticatory function, particularly when large number of teeth
have been lost.
 Unacceptable esthetics : Alteration in the clinical crown height
may be necessary to improve esthetics, and this may be made
possible by constructing the restorations to a reorganised
occlusion, possibly at an increased vertical dimension.
Theoretical background
 Main aim of the dentist ?
 Occlusal schemes ?
 Development of articulator?
 Influence of condylar guidance ,incisal guidance and
cuspal angle on full mouth reconstruction ?
Occlusal schemes
 The occlusal schemes for eccentric movements are
classified according to the contact condition between
upper and lower posterior teeth.
 Balanced articulation, group function and mutually
protected articulation.
Balanced Occlusion/ Balanced Articulation:
 The bilateral, simultaneous, anterior and posterior
occlusion contact of teeth in centric and eccentric
positions.
 Group function, as established by Schuyler (1959) was
intended to distribute occlusal forces uniformly to all
the teeth of the working side, also referred to as
unilateral balanced articulation, which occurred only in
8% of natural dentition.
 So the definition was changed to multiple contact
relationships of the posterior teeth of the lateral
movements of the working side in 1987
 D’Amico in 1958 conducted a study and stated that
cuspid protected articulation and disocclusion were
natural adaptations for preventing destructive
occlusion.
 According to GPT, cuspid protected articulation is
defined as mutually protected articulation in which the
vertical and horizontal overlap of the cuspid teeth
dis engages the posterior teeth in excursive movements
of the mandible
Necessity For Disocclusion
 1.”security insurance “ to protect the teeht from harmful
effects due to a cuspal interference.an interference could
occur due to a difference between the eccentric and
returning condylar path.
 2. a redundant need to protect the teeth from harmful
effects due to any cuspal interference since anterior
guidance varies among individuals .
Disocclusion
 Amount of disocclusion
 Nearly miss the teeth while mastication?
 Shooshan and Scott (1964) at non working molar should
be more than .5mm
 Thomas 1.0mm
 Hobo and Takayama 1993 measured in experimental
level to be for protrusive 1.06 mm ,non working side
1mm and working side 0.47mm
Mechanism 1
Mechanism 2
Mechanism 3
Mechanism 2 +3= 4
Influences on amount of
disocclusion .
 Condylar path ?
 Deviation in the path ?
 OLIVA ,HOBO,TAKAYAMA observed a deviation
width of 0.4mm average ,0.8mm maximum on the non
working condyle
Buffer spacing
 Hobo et al 1989 concluded that buffer spacing exists in
glenoid fossa, functions of which are:
 Control mechanical stresses which TMJ is subjected to
 Allow condylar mobility
 Prevent force transmission on to articular disc
 If buffer space is absent, it may lead to:
 Damage such as disk displacement, disc perforation.
Anterior
guidance
influences
condylar path
Condylar path
is influenced
by patient’s
occlusion
Patient’s poor
occlusion
Incisal
guidance
cuspal
angle
Good
occlusion
 Influence of incisal path in full-mouth restoration:
 The deviation of the incisal path in each individual is
less than that of the condylar path.
 The incisal path influences disocclusion at 2nd molar
twice as that of condylar path , during protrusive
movement, three times on non-working side and 4 times
on working side.
 Standard value of the cusp angle:
 Cusp angle was considered as the most reliable reference
for occlusion.
 Since there are minimal variations in cusp morphology
of permanent teeth immediately after eruption, and if
the value of the cusp angle at the time of eruption is
used as the reference for occlusion, making restoration
following this guide should be ideal for the patient.
 However, there are no standard references of the cuspal
angles. So only disocclusion to be obtained in the
rehabilitation process would be useful.
 The cusp path can be determined from the measured
values of the condylar path and incisal path based on
the mathematical model of the mandibular movement.
When the cusp path is obtained in this manner, the value
of the cusp angle is estimated using trignometry.
 Standard values of effective cusp angles on molars
Cusp angle Cusp angle on
molars(degrees)
Sagittal protrusive effective
cusp angle
Frontal lateral effective cusp
angle(working side)
Frontal lateral effective cusp
angle(non- working side)
25
15
20
The articulator ????
 Sagital condylar path:
Fisher’s angle
 The angle formed by intersection of the protrusive and
non-working side condylar paths as viewed in sagittal
plane.
 electronic studies indicate that sagittal inclination of
the condylar path when measured at the centre of the
condyle, showed 40 degree to the axis plane, during both
protrusive and lateral movements.Thus, the mean Fisher
angle was nearly zero.
Reasons why not to reproduce it in the articulator:
 There are large deviations in the condylar path and
fisher’s angle deviates less than the deviation of the
condylar paths.
 The influence of condylar path on the amount of
disocclusion is less than that of incisal path.
 So, the correction can be corrected to zero in
articulators.
Bennet angle
 Bennet angle measured with a pantograph in non-tooth
contact condition was 50 degrees maximum.(Hobo,1982)
 Measured with tooth contact, maximum was found to be
24 degrees.(Nakano,1975)
 Standard deviation under tooth contact condition is 17
degrees.
 But articulator calibration better done in 15 degrees.
Anterior guide assembly.
 Studies by Hobo and Takayama showed that influence
of anterior guidance was found to be 2 times greater on
2nd molars and 3 times greater on 1st molar in
comparison of condylar guidance.
Incisal path
 Using an electronic mandibular movement measuring
system, arrow head tracing is observed both sagittally
and frontally.
 The line is almost straight within 2-3mm from
maximum intercuspation
 Accordingly, if the tip of anterior guide pin is pin-point,
the envelope of motion will form an arrow shape, which
includes a straight line.
Anterior guide table.
 Anterior guide table of an articulator reproduces convex
pyramid cone at the upper limit of the envelope of
motion. This cone appears 2-3mm anterior to maximum
intercuspation.
 Triangular shaped gutter is formed by turning a
triangular pyramid upside down to simulate the
anterior guide table.
Criterion for selection of an
articulator
 Must have straight sagittal condylar path
 Reproduces either one of the sagittal protrusive and
non-working side lateral condylar path inclination but
not necessarily reproduce Fisher angle.
 Immediate mandibular translation need not be produced
 Bennett angle fixed at 15 degrees
 Need not have curved anterior guide table
 Anterior guide table should be shaped like triangular
gutter and be adjustable for both sagittal inclination
and lateral wing angles.
Twin stage procedure :
 Basic concept of twin stage procedure:
 The cast with a removable anterior segment is
fabricated. First, reproduce the occlusal morphology of
the posterior teeth without the anterior segment and
produce a cusp angle coincident with the standard
values referred to as Condition I
 Adjusting articulator for condition I :
condition condylar
path
Anterior
Guide table
Sagittal
condylar
path
inclination
Bennett
angle
Sagittal
inclination
Lateral
wing
angle
Condition
I
25 15 25 10
 Secondly, reproduce anterior morphology with the
anterior segment and provide anterior guidance which
produces a standard amount of disocclusion referred to
as condition II
 The application of the two conditions described to
fabricate cusp angle and anterior guidance is termed as
twin stage procedure.
Adjustment values for generating
disocclusion
 If the incisal path is more than 5 degrees steeper than the
condylar path, then the patient complains of
discomfort(McHorris 1979).
 If the incisal path is shallower than the condylar path,
condyle rotates in a reverse direction- different from the
ordinary direction- during protrusive movements that is
not a physiological movement.
condition condylar
path
Anterior
Guide table
Sagittal
condylar
path
inclination
Bennett
angle
Sagittal
inclination
Lateral
wing angle
Condition
II
40 15 45 20
 In this manner, the standard amount of disocclusion can
be obtained on the molars
 A physiological anterior guidance will be fabricated.
For group function.
condition condylar
path
Anterior
Guide table
Sagittal
condylar
path
inclunation
Bennett
angle
Sagittal
inclination
Lateral
wing angle
Condition
II
40 15 45 0
Adjusting values for complete
denture prosthesis
 Since Gysi, it has been widely recognized that balanced
articulation is most suitable for complete denture
prosthesis.
 In order to make a balanced articulation, occlusal
surfaces of denture teeth are adjusted to establish a
standard cusp angle under condition I
After endodontic therapy and post
and core restoration
Tooth preparation and impressions
Cementation of copings for mandibular
overdenture, secondary impression made.
Re-establishment of vertical dimension
Die preparations
Selection of articulator and facebow transfer
Centric inter occlusal registration
Hobo’s stage I condition: Articulator programming
25º
15º
25º
10º
Establishment of Curve of Spee using the Broadrick’s
principle of occlusal plane analyzer and arrangement
of mandibular teeth
Wax up for maxillary crowns and establishing
the balanced occlusion
Metal try-in in articulator
Metal try-in in patient mouth
PFM restorations in articulator with bilateral
balanced occlusion
Processing of mandibular complete overdenture
prosthesis and laboratory remounting
Fit-in of twin prosthesis, maxillary fixed prosthesis
and mandibular removable complete prosthesis
Checking for bilateral balanced articulation
Before restoration
After restoration
Contra indications
 Abnormal curve of spee
 Abnormal curve of wilson
 Abnormally rotated tooth
 Abnormally inclined tooth
Occlusion diagnosis and
correction.
 Guide for intra-oral adjustment:
Steps to fabricate occlusal reduction guide:
Impression of the occlusal surfaces of study cast
Completing the working cast
Block out of the cast except occlusal surfaces
Box the cast and pour mixed clear resin
Trim and smooth occusal reduction guide
Mark the adjusted areas of the study cast in black
Reduce the surface of guide with the bur to expose the
portion in black
Full mouth reconstruction
HOBO’S TWIN TABLE
TECHNIQUE
Pre-op intra-oral view
Maxillary arch Mandibular arch
Maxillary And Mandibular Diagnostic Cast
Mounted diagnostic cast
Face bow transfer
Orientation relation was
recorded using a face-bow
and the articulator
programmed using
protrusive and lateral
records
Study cast were made
with a removable
anterior segment
After removing the anterior segment move
the articulator through eccentric
movement to eliminate interference which
prevent an even gliding motion (fully
balanced occlusion).
Interference were marked by articulating paper
and were eliminated. Wax was added to produce
proper shape where ever insufficient tooth
structure was present.
Using a flat incisal
table, chemically
cured acrylic resin
was molded by
moving the incisal pin
through eccentric
INCISAL TABLE
WITHOUT DISCLUSION
The incisal table without disclusion is made
without anterior guidance and with no disclusion
OCCLUSAL PLANE ANALYSIS
Occlusal plane analysis was
done using modified broadrick
analyser and a template was
made to determine the
preparation line
Tooth preparation
Tooth preparation was
done for porcelain fused
to metal with ceramic
facing restorations
Impression
Impressions were made with rubber
base material using custom trays
with 2mm spacer
Jaw relation
Centric relation record was made using
intra-oral tracer and inter-occlusal record
made with zinc-oxide eugenol and secured
on to a semi-adjustable articulator
Provisionals were made with chemically cured poly
methyl methacrylate resin and cemented with non-
Provisional restorations
Impressions were poured in type IV die stone.
A die-lock tray was used and spliting and
ditching of the die was done. Two coats of Ney
die spacer was applied.
WORKING CAST
Posterior wax up was done using the
‘INCISAL TABLE WITHOUT DISCLUSION’
WAX
UP
One 3mm thick spacer is
placed behind one
condylar element to
simulate a lateral position
A spacer measuring
the same as the pre
determined
disclusion is placed
on the mesio-buccal
cusp tip of the
mandibular first
molar. This simulates
a lateral movement
The tip of the incisal pin
is lifted upward and to
the side. A resin cone
was made with pattern
resin
Repeat the same
procedure for the
other side
A 3mm spacer was placed behind the right and left
condyle to stimulate a protrusive movement.
The three resin cone
represent the right and left
lateral movement and
protrusive movement with
disclusion while the
condyle moves 3mm from
centric.
Connect three cones with
resin to form walls and add
resin into the wall and then
move the articulator
Incisal table
with disclusion
It is critical to form the resin cones toward the outer edge of the path.
Use the incisal table with
disclusion and reposition
the anterior segment on
the maxillary cast.
Complete the anterior wax
up by moving the
articulator through
eccentric movement
Completed wax up
Metal try in
Stable anterior centric
stops were evaluated
Finished prosthesis
Post cementation view in centric occlusion
Disclusion during eccentric movements
Pre-op view
Post-op view
To Summarize…
Hobo’s twin table technique can be used for a variety
of prosthetic procedures including
 Full mouth occlusal rehabilitation,
 Posterior quadrant restorations,
 Anterior restorations.
Rationale for using hobos
technique
 Using mathematical analysis, influence of the condylar
path on disocclusion was found to be less than
previously thought.
 So use of condylar path as a major reference for
occlusion ?
 William McHorris reported sagittal inclination of
incisal path should be no more than 5 degrees steeper.
 This suggestion was tested in twin stage procedure.
 However, 5 degree difference of incisal path produced
only 0.2mm of disocclusion which is 20% of standard
disocclusion required.
 The last element to be considered was Cusp Angle.
 The author concluded that cusp angle was most suitable
reference for occlusion and new prosthetic procedures
were established based on this concept.
 Hobo et al studied the effects of twin stage procedure in
vitro and in vivo. It was found that disocclusion
occurred evenly within 0.1mm accuracy in both the tests.
REFERENCES
 Oral rehabilitation ,clinical determination of occlusion
Sumiya Hobo, Hisao Takayama quintessence
publication 1997.
 Twin tables technique for occlusal rehabilitation :part2
–clinical procedures J Prosthet Dent 1991 ;66 :471-7
 Twin tables technique for occlusal rehabilitation :part1
J Prosthet Dent 1991 ;66 :299-301

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Full mouth hobo

  • 3. Contents  Definitions  Introduction  Theoretical background  Disocclusion  Articulators  Occlusal adjustments  Twin stage procedure  Twin table technique  Full mouth constructions  Rationale for twin stage procedure
  • 4. TERMINOLOGIES (as per GPT – 8) Condylar Guidance : Mandibular guidance generated by the condyle and the articular disc traversing the contours of the glenoid fossae. Condylar Guidance : The mechanical form located in the upper posterior region of an articulator that controls the movement of it’s mobile member.
  • 5.  Incisal Guidance : The influence of the contacting surfaces of the mandibular and maxillary anterior teeth on mandibular movements.  Incisal Guidance : The influences of the contacting surfaces of the guide pin and the guide table on articular movement.  Bennet Angle : The angle formed between the sagittal plane and the average path of the advancing condyle as viewed in the horizontal plane during lateral mandibular movements
  • 6.  Mandibular Lateral Translation : The translatory portion of lateral movement in which the non working side of condyle moves essentially straight and medially as it leaves the centric relation position.  Physiologic Rest Position : the mandibular position assumed when the head is in an upright position and the involved muscles, particularly the elevators and the depressor groups, are in tonic contraction and the condyles are in a neutral unstrained position.
  • 7.  Laterotrusion : Condylar movement on the working side in the horizontal plane  Mandibular Translation : The translatory movement ( medio- lateral) movement of the mandible when viewed in the frontal plane.  Fischer’s Angle : The angle formed by the intersection of the protrusive and non working side condylar path as viewed in sagittal plane.
  • 8. Functional analysis of occlusion A functional analysis of occlusion is pertinent to the formulation of a proper plan of treatment for complete mouth rehabilitation. It must include: (1) The determination of the proper vertical height by utilizing the physiologic rest position of the mandible as a guide, and 'noting the existing functional freeway space. (2) An examination and study of the path of closure from rest position to the physical contact position of the teeth, noting whether condyle displacement occurs.
  • 9. 3)The effects of the occlusal pattern upon the periodontal structures. (4) A study of the temporomandibular joint positions relative to the occlusal pattern by means of roentgenographic evaluation.
  • 10. WHY DO WE NEED TO REORGANIZE OCCLUSION ?
  • 11. Reorganization may be considered when the existing intercuspal position is considered unsatisfactory for any of the following reasons:  Repeated fracture or failure of teeth or restorations : Clinical experience suggests that persistently failing restorations (for example crown and bridge debonding) are very commonly attributed to unfavorable occlusal loading which may be improved by reorganization.
  • 12.  Lack of interocclusal space for restoration : Re organising the occlusion to eliminate a large horizontal component of slide between CR and IP can create a valuable interocclusal space for the restoration of worn anterior teeth. Alternatively, the occlusion may be re organised at an increased vertical dimension necessitating occlusal coverage for at least one arch.
  • 13.  Bruxism : An optimally constructed occlusion will better be able to deal with the forces generated in parafunction.  Trauma from occlusion : This may be soft tissue trauma (due to teeth impinging on the cheek or alveolar ridge) or periodontal trauma due to occlusal trauma.
  • 14.  Unacceptable Function : Poor tooth to tooth contact with tilting and overeruption of teeth may create problems with masticatory function, particularly when large number of teeth have been lost.  Unacceptable esthetics : Alteration in the clinical crown height may be necessary to improve esthetics, and this may be made possible by constructing the restorations to a reorganised occlusion, possibly at an increased vertical dimension.
  • 15. Theoretical background  Main aim of the dentist ?  Occlusal schemes ?  Development of articulator?  Influence of condylar guidance ,incisal guidance and cuspal angle on full mouth reconstruction ?
  • 16. Occlusal schemes  The occlusal schemes for eccentric movements are classified according to the contact condition between upper and lower posterior teeth.  Balanced articulation, group function and mutually protected articulation.
  • 17. Balanced Occlusion/ Balanced Articulation:  The bilateral, simultaneous, anterior and posterior occlusion contact of teeth in centric and eccentric positions.
  • 18.  Group function, as established by Schuyler (1959) was intended to distribute occlusal forces uniformly to all the teeth of the working side, also referred to as unilateral balanced articulation, which occurred only in 8% of natural dentition.  So the definition was changed to multiple contact relationships of the posterior teeth of the lateral movements of the working side in 1987
  • 19.  D’Amico in 1958 conducted a study and stated that cuspid protected articulation and disocclusion were natural adaptations for preventing destructive occlusion.  According to GPT, cuspid protected articulation is defined as mutually protected articulation in which the vertical and horizontal overlap of the cuspid teeth dis engages the posterior teeth in excursive movements of the mandible
  • 20. Necessity For Disocclusion  1.”security insurance “ to protect the teeht from harmful effects due to a cuspal interference.an interference could occur due to a difference between the eccentric and returning condylar path.  2. a redundant need to protect the teeth from harmful effects due to any cuspal interference since anterior guidance varies among individuals .
  • 21. Disocclusion  Amount of disocclusion  Nearly miss the teeth while mastication?  Shooshan and Scott (1964) at non working molar should be more than .5mm  Thomas 1.0mm  Hobo and Takayama 1993 measured in experimental level to be for protrusive 1.06 mm ,non working side 1mm and working side 0.47mm
  • 26. Influences on amount of disocclusion .  Condylar path ?  Deviation in the path ?  OLIVA ,HOBO,TAKAYAMA observed a deviation width of 0.4mm average ,0.8mm maximum on the non working condyle
  • 27. Buffer spacing  Hobo et al 1989 concluded that buffer spacing exists in glenoid fossa, functions of which are:  Control mechanical stresses which TMJ is subjected to  Allow condylar mobility  Prevent force transmission on to articular disc  If buffer space is absent, it may lead to:  Damage such as disk displacement, disc perforation.
  • 28. Anterior guidance influences condylar path Condylar path is influenced by patient’s occlusion Patient’s poor occlusion
  • 30.  Influence of incisal path in full-mouth restoration:  The deviation of the incisal path in each individual is less than that of the condylar path.  The incisal path influences disocclusion at 2nd molar twice as that of condylar path , during protrusive movement, three times on non-working side and 4 times on working side.
  • 31.  Standard value of the cusp angle:  Cusp angle was considered as the most reliable reference for occlusion.  Since there are minimal variations in cusp morphology of permanent teeth immediately after eruption, and if the value of the cusp angle at the time of eruption is used as the reference for occlusion, making restoration following this guide should be ideal for the patient.
  • 32.  However, there are no standard references of the cuspal angles. So only disocclusion to be obtained in the rehabilitation process would be useful.  The cusp path can be determined from the measured values of the condylar path and incisal path based on the mathematical model of the mandibular movement. When the cusp path is obtained in this manner, the value of the cusp angle is estimated using trignometry.
  • 33.  Standard values of effective cusp angles on molars Cusp angle Cusp angle on molars(degrees) Sagittal protrusive effective cusp angle Frontal lateral effective cusp angle(working side) Frontal lateral effective cusp angle(non- working side) 25 15 20
  • 36. Fisher’s angle  The angle formed by intersection of the protrusive and non-working side condylar paths as viewed in sagittal plane.  electronic studies indicate that sagittal inclination of the condylar path when measured at the centre of the condyle, showed 40 degree to the axis plane, during both protrusive and lateral movements.Thus, the mean Fisher angle was nearly zero.
  • 37. Reasons why not to reproduce it in the articulator:  There are large deviations in the condylar path and fisher’s angle deviates less than the deviation of the condylar paths.  The influence of condylar path on the amount of disocclusion is less than that of incisal path.  So, the correction can be corrected to zero in articulators.
  • 38. Bennet angle  Bennet angle measured with a pantograph in non-tooth contact condition was 50 degrees maximum.(Hobo,1982)  Measured with tooth contact, maximum was found to be 24 degrees.(Nakano,1975)  Standard deviation under tooth contact condition is 17 degrees.  But articulator calibration better done in 15 degrees.
  • 39. Anterior guide assembly.  Studies by Hobo and Takayama showed that influence of anterior guidance was found to be 2 times greater on 2nd molars and 3 times greater on 1st molar in comparison of condylar guidance.
  • 40. Incisal path  Using an electronic mandibular movement measuring system, arrow head tracing is observed both sagittally and frontally.  The line is almost straight within 2-3mm from maximum intercuspation  Accordingly, if the tip of anterior guide pin is pin-point, the envelope of motion will form an arrow shape, which includes a straight line.
  • 41. Anterior guide table.  Anterior guide table of an articulator reproduces convex pyramid cone at the upper limit of the envelope of motion. This cone appears 2-3mm anterior to maximum intercuspation.  Triangular shaped gutter is formed by turning a triangular pyramid upside down to simulate the anterior guide table.
  • 42. Criterion for selection of an articulator  Must have straight sagittal condylar path  Reproduces either one of the sagittal protrusive and non-working side lateral condylar path inclination but not necessarily reproduce Fisher angle.  Immediate mandibular translation need not be produced  Bennett angle fixed at 15 degrees  Need not have curved anterior guide table  Anterior guide table should be shaped like triangular gutter and be adjustable for both sagittal inclination and lateral wing angles.
  • 43. Twin stage procedure :  Basic concept of twin stage procedure:  The cast with a removable anterior segment is fabricated. First, reproduce the occlusal morphology of the posterior teeth without the anterior segment and produce a cusp angle coincident with the standard values referred to as Condition I
  • 44.  Adjusting articulator for condition I : condition condylar path Anterior Guide table Sagittal condylar path inclination Bennett angle Sagittal inclination Lateral wing angle Condition I 25 15 25 10
  • 45.  Secondly, reproduce anterior morphology with the anterior segment and provide anterior guidance which produces a standard amount of disocclusion referred to as condition II  The application of the two conditions described to fabricate cusp angle and anterior guidance is termed as twin stage procedure.
  • 46. Adjustment values for generating disocclusion  If the incisal path is more than 5 degrees steeper than the condylar path, then the patient complains of discomfort(McHorris 1979).  If the incisal path is shallower than the condylar path, condyle rotates in a reverse direction- different from the ordinary direction- during protrusive movements that is not a physiological movement.
  • 48.  In this manner, the standard amount of disocclusion can be obtained on the molars  A physiological anterior guidance will be fabricated.
  • 49. For group function. condition condylar path Anterior Guide table Sagittal condylar path inclunation Bennett angle Sagittal inclination Lateral wing angle Condition II 40 15 45 0
  • 50. Adjusting values for complete denture prosthesis  Since Gysi, it has been widely recognized that balanced articulation is most suitable for complete denture prosthesis.  In order to make a balanced articulation, occlusal surfaces of denture teeth are adjusted to establish a standard cusp angle under condition I
  • 51.
  • 52. After endodontic therapy and post and core restoration
  • 53. Tooth preparation and impressions
  • 54. Cementation of copings for mandibular overdenture, secondary impression made.
  • 57. Selection of articulator and facebow transfer
  • 58. Centric inter occlusal registration
  • 59. Hobo’s stage I condition: Articulator programming 25º 15º 25º 10º
  • 60. Establishment of Curve of Spee using the Broadrick’s principle of occlusal plane analyzer and arrangement of mandibular teeth
  • 61. Wax up for maxillary crowns and establishing the balanced occlusion
  • 62. Metal try-in in articulator
  • 63. Metal try-in in patient mouth
  • 64. PFM restorations in articulator with bilateral balanced occlusion
  • 65. Processing of mandibular complete overdenture prosthesis and laboratory remounting
  • 66. Fit-in of twin prosthesis, maxillary fixed prosthesis and mandibular removable complete prosthesis
  • 67. Checking for bilateral balanced articulation
  • 69. Contra indications  Abnormal curve of spee  Abnormal curve of wilson  Abnormally rotated tooth  Abnormally inclined tooth
  • 70. Occlusion diagnosis and correction.  Guide for intra-oral adjustment: Steps to fabricate occlusal reduction guide: Impression of the occlusal surfaces of study cast Completing the working cast Block out of the cast except occlusal surfaces Box the cast and pour mixed clear resin Trim and smooth occusal reduction guide Mark the adjusted areas of the study cast in black Reduce the surface of guide with the bur to expose the portion in black
  • 72.
  • 73.
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  • 78.
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  • 86.
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  • 88.
  • 90. Pre-op intra-oral view Maxillary arch Mandibular arch
  • 91. Maxillary And Mandibular Diagnostic Cast Mounted diagnostic cast
  • 92. Face bow transfer Orientation relation was recorded using a face-bow and the articulator programmed using protrusive and lateral records
  • 93. Study cast were made with a removable anterior segment
  • 94. After removing the anterior segment move the articulator through eccentric movement to eliminate interference which prevent an even gliding motion (fully balanced occlusion).
  • 95. Interference were marked by articulating paper and were eliminated. Wax was added to produce proper shape where ever insufficient tooth structure was present.
  • 96. Using a flat incisal table, chemically cured acrylic resin was molded by moving the incisal pin through eccentric
  • 97. INCISAL TABLE WITHOUT DISCLUSION The incisal table without disclusion is made without anterior guidance and with no disclusion
  • 98. OCCLUSAL PLANE ANALYSIS Occlusal plane analysis was done using modified broadrick analyser and a template was made to determine the preparation line
  • 99. Tooth preparation Tooth preparation was done for porcelain fused to metal with ceramic facing restorations
  • 100. Impression Impressions were made with rubber base material using custom trays with 2mm spacer
  • 101. Jaw relation Centric relation record was made using intra-oral tracer and inter-occlusal record made with zinc-oxide eugenol and secured on to a semi-adjustable articulator
  • 102. Provisionals were made with chemically cured poly methyl methacrylate resin and cemented with non- Provisional restorations
  • 103. Impressions were poured in type IV die stone. A die-lock tray was used and spliting and ditching of the die was done. Two coats of Ney die spacer was applied. WORKING CAST
  • 104. Posterior wax up was done using the ‘INCISAL TABLE WITHOUT DISCLUSION’ WAX UP
  • 105. One 3mm thick spacer is placed behind one condylar element to simulate a lateral position A spacer measuring the same as the pre determined disclusion is placed on the mesio-buccal cusp tip of the mandibular first molar. This simulates a lateral movement
  • 106. The tip of the incisal pin is lifted upward and to the side. A resin cone was made with pattern resin
  • 107. Repeat the same procedure for the other side
  • 108.
  • 109. A 3mm spacer was placed behind the right and left condyle to stimulate a protrusive movement.
  • 110. The three resin cone represent the right and left lateral movement and protrusive movement with disclusion while the condyle moves 3mm from centric.
  • 111. Connect three cones with resin to form walls and add resin into the wall and then move the articulator Incisal table with disclusion
  • 112. It is critical to form the resin cones toward the outer edge of the path.
  • 113. Use the incisal table with disclusion and reposition the anterior segment on the maxillary cast. Complete the anterior wax up by moving the articulator through eccentric movement Completed wax up
  • 114. Metal try in Stable anterior centric stops were evaluated
  • 116. Post cementation view in centric occlusion
  • 119. To Summarize… Hobo’s twin table technique can be used for a variety of prosthetic procedures including  Full mouth occlusal rehabilitation,  Posterior quadrant restorations,  Anterior restorations.
  • 120. Rationale for using hobos technique  Using mathematical analysis, influence of the condylar path on disocclusion was found to be less than previously thought.  So use of condylar path as a major reference for occlusion ?
  • 121.  William McHorris reported sagittal inclination of incisal path should be no more than 5 degrees steeper.  This suggestion was tested in twin stage procedure.  However, 5 degree difference of incisal path produced only 0.2mm of disocclusion which is 20% of standard disocclusion required.
  • 122.  The last element to be considered was Cusp Angle.  The author concluded that cusp angle was most suitable reference for occlusion and new prosthetic procedures were established based on this concept.  Hobo et al studied the effects of twin stage procedure in vitro and in vivo. It was found that disocclusion occurred evenly within 0.1mm accuracy in both the tests.
  • 123. REFERENCES  Oral rehabilitation ,clinical determination of occlusion Sumiya Hobo, Hisao Takayama quintessence publication 1997.  Twin tables technique for occlusal rehabilitation :part2 –clinical procedures J Prosthet Dent 1991 ;66 :471-7  Twin tables technique for occlusal rehabilitation :part1 J Prosthet Dent 1991 ;66 :299-301

Editor's Notes

  1. forces) the latter may have an accelerating effect on periodontal disease although the evidence is conflicting. Reorganisation of the occlusion to direct forces axially and eliminate interferences and premature contacts can reduce tooth mobility. However, the overall gain in periodontal attachment is marginal and should be considered as no more than adjunct to periodontal management.
  2. To prevent harmful horizontal forces caused by mandibular eccentric moments. Guichet 1977 stated that condylar path was unchangeable in a living body but the anterior guidance can be changed freely by the dentist. The mandible can be analogous to an inverted tripod
  3. Group func : Change in def of it .. 3 legged table
  4. Mc horris 1979
  5. Cusp shape component
  6. This buffer spacing is mainly attributed to the soft tisuues of the tmj.