Hobos Philosophy

Full Mouth Rehabilitation
– Hobo’s Philosophy
Dr. Divya Mehra

Contents
 Introduction  Twin Table
 Terminologies  Twin Stage
 Definition – Full Mouth Rehabilitation  Conclusion
 Indications for Full Mouth  References
Rehabilitation
 Analysis of Occlusion
 Disocclusion
 Necessity For Disocclusion
 Classification of Occlusal
Rehabilitation
2
Introduction – Dr. Sumiya Hobo
 Dr. Hobo was one of the pioneers of modern dentistry in
Japan
 A graduate of Nihon University School of Dentistry in

1961.
 He attended graduate school at the Indiana University

School of Dentistry, specializing in Fixed Prosthodontics.
 In 1972, he returned to Japan to open his International

Dental Academy in Tokyo as well as one of the
outstanding Laboratory Technician Schools in the World.
3
 Dr. Hobo along with Peter K. Thomas introduced the concept of
Gnathology to Japan
 He authored the text “Fundamentals of Fixed Prostheses” for

Quintessence as well as the “Encyclopedia of Occlusion,”
 He retired from active teaching several years ago and passed away at the
age of 69
4
Introduction
 The goal of dentistry is to increase the life span of the functioning

dentition
 In striving to achieve its goal, dentistry uses its knowledge, skill and all
the resources at its command in both maintenance work and
rehabilitation
 The phrase full-mouth rehabilitation means different things to different

people.
5
Introduction
 Planning and executing the
restorative rehabilitation of a
decimated occlusion is probably
one of the most intellectually
and technically demanding tasks
facing a restorative dentist.
 The aim is to provide an

orderly pattern of occlusal
contact and articulation that
will optimize oral function,
occlusal stability and
esthetics. 6
Introduction
A better understanding of the scientific principles underlying

our techniques will inevitably improve those techniques,
since it focuses attention on the goal and thus provides a
criterion for evaluating our procedures
7
Terminologies
 Condylar Guidance :
 Mandibular guidance generated by the condyle and the articular disc
traversing the contours of the glenoid fossa
 Anterior Guidance :
 Incisal Guidance + Canine Guidance
• Incisal Guidance - During Protrusive movement
• Canine Guidance - During Lateral Guidance
 Incisal Guidance :
 The influence of the contacting surfaces of the mandibular and maxillary
anterior teeth on mandibular movements
Terminologies
 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
 Immediate mandibular lateral translation:

 The translatory portion of the lateral movement in which the non – working side
of the condyle moves essentially straight and medially as it leaves the centric
relation position
 Laterotrusion :
 Condylar movemnt on the working side in the horizontal plane
Full Mouth Rehabilitation - Definition
 Full mouth rehabilitation entails the performance of all the

procedures necessary to produce healthy, esthetic, well functioning,
and self maintaining masticatory mechanism.
10
INDICATIONS Full Mouth Rehabilitation
 The restoration of multiple teeth, which are

missing, worn, broken-down or decayed.
 To replace improperly designed and executed

crown and bridge work.
 Treatment of temporomandibular disorders may

also be considered an indication for
rehabilitation, but great caution is advisable in
such cases.
11
Goal ..
 The following goals should be achieved when planning for an occlusal

rehabilitation:
1. Static coordinated occlusal contact of the maximum number of teeth when the
condyle is in comfortable, reproducible position.
2. An anterior guidance that is in harmony with function in lateral eccentric position

on the working side.
3. Disclusion by the anterior guidance of all posterior teeth in eccentric movements.
4. Axial loading of teeth in centric relation, interproximation, and function.

Regardless of the clinical reason, the decision to carry out
any treatment should be based upon achieving
Oral Health, Function, Esthetics And Comfort,
and treatment should be planned around these rather than the

technical possibilities.
13
The First step is :
Analysis of the Occlusion

Analysis of Occlusion
 When undertaking relatively small amounts of

restorative treatment,
for example : up to 2 or 3 units of crown and
bridge work, it is often acceptable, and advisable
to adopt a confirmative approach - that is to
construct the restoration to conform to the
patient's existing intercuspal position
15
The alternative strategy is to re-organize the occlusion by establishing a new

occlusal scheme around a stable condylar position.
 The decision to re-organize a patient's occlusion may be made on the grounds

that :
 Either the existing IP is unacceptable and needs to be changed, or
 Where a very large amount of treatment is to be undertaken and the
operator has the opportunity to optimize patient's occlusion.
 The condylar position usually chosen is

termed 'centric relation' (CR).
16
The decision should be made after a detailed and careful

examination of the occlusion, preferably with the use of
accurate study casts mounted in a semi adjustable
articulator in the retruded arc of closure.
17
When 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 :

 Bruxism
 Lack of interocclusal space for restoration
 Unacceptable Function
 Unacceptable esthetics
18
 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.
19
 Bruxism :
An optimally constructed occlusion will better be able to deal with

the forces generated in parafunction.
20
 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.
21
 Unacceptable Function :
Poor tooth to tooth contact with tilting and supraeruption of teeth may
create problems with masticatory function, particularly when large
number of teeth have been lost.
22
 Unacceptable esthetics :
Alteration in the clinical crown height
may necessitate improving esthetics.
 This may be made possible by
constructing the restorations to a
reorganised occlusion, possibly at an
increased vertical dimension. 23
So Many Indications ….
24
Functional Analysis of Occlusion
 It includes :
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.
25
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.
26
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.
27
Check for Disocclusion
DISOCCLUSION
 It is the separation of opposing teeth during eccentric

movement of the mandible – GPT 8.
28
Necessity for Disocclusion
 Molar disocclusion during eccentric movements is
effective in eliminating harmful lateral occlusal
forces.
 Mechanically, the maxillary and mandibular teeth

should be in contact during eccentric movements
for optimal chewing efficiency.
 Maximal shear force is observed with a fully

balanced occlusion
29
 However, the condyle must follow one

orbit precisely during eccentric
movements for optimal function in a
fully balanced occlusion.
 If the condyle deviates slightly, it

directly influences the relation between
the teeth, resulting in occlusal
prematurities and deflective occlusal
contacts
30
 When the mandible is protruded, the only teeth

in contact should be the anterior teeth.
 This is so because when the mandible is

protruded the condyles are no longer braced.
 Since the amount of flexing of the mandible

depends on varying degrees of contraction of the
closing musculature, there is no way to
harmonize the posterior teeth to all the different
degrees of muscle force. 31
 The anterior teeth, being farthest from

the fulcrum and not nearly so subject to
the flexing, and are in the best position
to carry the load.
 Protrusive stresses on posterior teeth are

further compounded by the fact that
such forces are usually directed toward
inclines of the upper cusps as the wider
part or the lower arch moves forward
into the narrower part of the upper arch. 32
Because we do not need for
posterior teeth to touch
during incising
WHY
DISOCCLUSION
?????
Because it is impossible to Because posterior tooth

harmonize the posterior interferences in protrusion
occlusion to all degrees of are among the most
muscle force in protrusion damaging
33
Disocclusion
How Much Is Good Enough !!

AMOUNT
AMOUNT of Disocclusion
 There is minimal literature available regarding the proper amount

of disocclusion.
 Shooshan (1960) and Scot (1964) stated that during lateral,

movement, the molars should disocclude more than 0.5 mm
between maxillary and mandibular posterior teeth on the
nonworking side.
35
 Thomas (1967) stated when maxillary and mandibular

cuspid has tip to tip relation during lateral movement; the
molars should disocclude 1.0 mm.
36
 Hobo and Takayama (1985, 93) experimentally measured the amount of
disocclusion using various methods and they concluded that the amount
of disocclusion found, with various techniques was:
37
Factors Influencing Disocclusion
Incisal
Path
Cusp Angle
38
The Condylar Path
The Condylar Path
 The Condylar path is described by GPT

as :
Path traveled by the mandibular condyle in
the temporomandibular joint during
various mandibular movements.
 McCollum and Stuart described the

condylar path as a fixed entity in an adult.
40
Buffer space
 However recent studies show when repetitive
lateral movements were compared with the
respective condylar paths, no movement traced
the same line.
 The deviation in the condylar path during

eccentric movements was attributed to the shock-
absorbing nature of the articular disk.
 This study refers to this deviation in condylar

path as a "buffer space"
41
Buffer space
 Eg : Accurately Machined Gears
 Immobile when the gears are too

close and tight
Disc  A little spacing is needed to allow

the gears to function smoothly
Condyle  Buffer spacing is essential for the
condyle and the disc to function
smoothly
Buffer space
 The average buffer spaces are 0.2 mm in centric relation, 0.3 mm in

laterotrusion, and 0.8 mm along the protrusive and nonworking
sagittal condylar path.
 Molar disclusion should be greater than the buffer space to avoid

occlusal interferences during eccentric movements.
 When the average amount of disclusion is compared with buffer

space, the amounts closely match.
43
Buffer space
The amount of disclusion should be slightly more than the buffer

space to prevent deflective occlusal contacts providing separation
between the opposing posterior dentition, so that when the condyle
is displaced during articular disk compression, harmful occlusal
forces can be controlled. 44
The difference between
Eccentric and Returning Condylar Paths.
 In a study done by Hobo and Takayama, it was found that there was a difference between the between
eccentric and returning condylar paths
 It was seen that the returning condylar path always passed above the eccentric path graphically, when the
lines were drawn there was a difference of 13° with the protrusive path and 23° with lateral movement.
 The possible reasoning behind this deviation is that these paths are created by physiologic difference in
the opening and the closing muscles utilized.
45
Why did we have to know This ??
 In dentistry, the condylar path has been considered the standard reference for
occlusion.
 However, the above results showed the condylar path was not fixed but was
changeable.
50
Influence of the Condylar Path on
Disocclusion
 When condyle moved 3mm – the amount of disocclusion is 1mm.
 So, the influence of the condylar path on disocclusion is –
 During protrusive movement – 0.02mm / degree
 During lateral movement :

 0.015 mm / degree – non-working side
 0.002 mm / degree - on the working side.
51
Influence of the Condylar Path on Disocclusion
 Now, also there is deviation in the condylar paths caused by the difference between the
eccentric and returning paths.
 This difference is 13 degrees for protrusive and 23 degrees during lateral movement.
 So, this makes a total disocclusion, under the influence of the condylar path to be
 During protrusive - 0.26mm.
 During lateral - Working side- -0.05mm.
Non – working side – 0.35 mm.
 Based on this, it was concluded that although the deviation of the condylar path is large, its
influence on the amount disocclusion is small.
52
 So,
Condylar Path Cannot be the Sole Guiding Factor

in order to Establish Good Occlusion.
The Anterior Guidance
 Early gnathological concepts focussed

primarily on the condylar path
 They believed that the anterior guidance had

no influence on the condylar path
 And that both were independent factors.
55
 To verify – Studies were conducted to record

the condylar path under 2 test conditions:
 With tooth contact
 Without tooth contact – using a clutch
 Conclusion :
 Condylar path was affected by the anterior
guidance
 More on the working side condyle, min on the
non-working condyle.
56
 Hence :
Condylar Guidance and Incisal Guidance were
DEPENDENT and not Independent factors
57
 During No – Tooth contact :

 The working condyle showed a
tendency to move straight laterally
along the transverse horizontal
axis –LATEROTRUSION
 On an Average – in healthy TMJs,
condylar guidance is in accordance
with anterior guidance
58
 This Straight Axis on which the

condyle travelled was called as the
“Neutral Line”
 Hobo and Takayama conducted a
study with tooth contact during
lateral movement
59
 The study concluded that the working condyle deviated inferiorly- below the neutral
axis when the actual incisal path is steeper – DETRUSION
 The working condyle deviate superiorly – above the neutral axis when the actual
60
incisal path was flatter – SURTRUSION
Why did we have to know This ??
 The anterior guidance influences the condylar path, which infers the condylar path is
influenced by the patient's occlusion.
 Therefore, if patient has poor occlusion, his condylar path is affected by malocclusion.
 If such a condylar path is measured precisely, reproduced on an articulator, and used as a

reference for the fabrication of a restoration, the occlusion of the restoration can be
adversely affected by the poor condylar path
 The condylar path on an articulator should not be a copy of the condylar path in the
patient.
 To avoid a vicious cycle, set the condylar paths on an articulator to produce a

"good" occlusion. 61
Influence of the Incisal Path on Disocclusion
The influence of the incisal path on disocclusion is :
 During protrusive – 0.038 / degree
 During eccentric movement :

 0.042 mm / degree - on non-working side.
 0.039 mm / degree - on the working side.
62
Influence of the Incisal Path on Disocclusion
 Now, also there is deviation in the incisal path on protrusive and lateral movements. This
difference is 10 degrees for both
 So, this makes a total disooclusion, under the influence of the incisal path to be –
 During protrusive - 0.38 mm.
 During lateral - Working side - 0.38 mm.

Non – working side – 0.42 mm.
 Based on this, it was concluded that although the influence of incisal path on disocclusion
was larger than the condylar path influence but it still could not be used as the sole guiding
factor for occlusion.
63
Cusp Shape Factor
Cusp Shape Factor / Cuspal Angulation
 Cusp Angle is "The angle made by the average slope of a cusp with the
cusp plane measured mesiodistally or buccolingually"
 The Cusp Plane means : “the plane determined by the two buccal cusp
tips and the highest lingual cusp of a molar”.
 The angle formed by the average cusp slope and the horizontal reference
plane is called the Effective Cusp Angle
65
66
Cuspal Angulation
 The effective cusp angle during protrusive movement is referred to as the

Sagittal Protrusive Effective Cusp Angle.
 The effective cusp angle during lateral movement on the working and
nonworking side are referred to as the Frontal Lateral Effective Cusp Angle
On The Working And Nonworking Side
67
Cuspal Angulation
 For posterior disocclusion to occur – the slopes of the molar cusp must be
parallel to condylar path and the Anterior guidance must be steeper than the
condylar path
 If the posterior cusps are kept parallel to the anterior guidance – there will not
be posterior disocclusion – even if the anterior guidance is steeper.
68
Cusp Shape Factor
 The shape of the cusp has great

influence on the disocclusion of the
posterior teeth
 If a balanced occlusion is to be achieved –

it is necessary to make the cusp with a
straight edge – Greater cuspal inclination
 If disocclusion is to be achieved – make

cusps with a convex semicircular shape of
the slope – Cuspal Inclination decreases
Influence of the Cusp Angle on Disocclusion
 The studies proved that the cusp angle did not show any deviations as they
were seen in the case of the incisal and the condylar path.
 Amount of decrease in disocclusion

 During protrusive – 0.46 mm / degree increase
 During lateral :
 Working side - 0.041mm / degree increase.
 Non – working side – 0.46 mm / degree increase.
 All the above calculations proved that the influence of cusp angle is 40% -
44% of the total influence which is far greater than condylar path but
comparable to incisal path.
70
Influence on disocclusion
Influence
Condylar
Cusp angle Incisal path Condylar
Cusp angle Incisal path path
path
71
 Since the influence of the cusp angle is more reliable than the
other factors it was concluded that the new reference for
occlusion should be the cusp angle of newly erupted permanent
teeth not the condylar or incisal path
72
How disocclusion is achieved ???
 Using protrusive movement as an example the reasons

which necessitate disocclusion can be understood :
73
Scenario I
 When
 The sagittal condylar path inclination is 40 degrees,
 The cusp angle is parallel to the condylar path, and also
 The incisal path equal to the condylar path.
 Mandible only translates and does not rotate.

 Since the mandibular and maxillary molars slide in contact in
eccentric movement, there is No Disocclusion.
74
Cusp angle = Condylar path = Incisal path
75
Scenario II
 When
 The sagital condylar path inclination is 40 degrees,
 The cusp angle is parallel to the condylar path, but
 The incisal path is steeper than the condylar path.
 Mandible translates and ROTATES.
 Maxillary and mandibular molars DISOCCLUDE.
 referred as “Anterior Guide Component”

76
Condylar path = Cusp angle Incisal path 77
Scenario III
 When
 The sagittal inclination of the condyle is 40 degrees,
 The condyle and the incisal path are parallel, however
 The cusp angle is shallower than the condylar path.
 Mandible only translates.
 Since the cusp angle is shallower, the maxillary and mandibular

molars DISOCCLUDE
 Referred as “Cusp Shape Component” 78

Condylar path = Incisal path Cusp angle 79
Scenario IV
 When
 The sagittal inclination of the condyle is 40 degrees,
 The incisal path is steeper than the condylar path, and
 The cusp angle is shallower than the condylar path.
 Mandible translates and rotates.
 Disocclusion is wider and is seen in healthy individuals.
80
Cusp angle < Condylar path < Incisal path 81
Classification of Occlusal
Rehabilitation
82
Occlusal Rehabilitation
 There are four types of occlusal rehabilitation and

situations, and each requires a different type of treatment
83
Type I
The curve of Spee (occlusal curvature of the posterior teeth)

and the incisal guidance are acceptable as presented by
the patient, but
The Posterior Teeth Need Rehabilitation.
Restore the lower Then the upper
Step 2
Step 1
posterior teeth to the posterior teeth are

patient's curve of Spee, restored by the
as presented. functionally generated
path technique
84
Type II
The curve of Spee is irregular,
but the incisal guidance is acceptable.
Step 2
Then the upper posterior
Step 1
Restore the lower

teeth are restored by the
posterior teeth to a more
functionally generated
desirable curvature
path technique
85
Type III
The curve of Spee and the incisal guidance are both
unacceptable.
Step 1
Step 2
Step 3
The restoration
The correction of The restoration
of the upper
the incisal of the lower
posterior teeth
guidance by posterior teeth to
with the use of
restoring the a more desirable
the functionally
upper anterior occlusal
generated path
teeth curvature
technique.
86
The curve of Spee and the incisal guidance are not acceptable,
and
The Upper and Lower Anterior Teeth Need Rehabilitation.
Step 1
Step 3
Step 2
Step 4
The restoration
The restoration of of upper
The restoration of The restoration of
the lower posterior posterior teeth
the upper anterior
all the lower teeth to a more with the use of
teeth and the
acceptable the functionally
anterior teeth, incisal guidance,
occlusal curvature generated path
technique
87
Hobo’s Twin Table Technique
88
Concept Hobo’s Twin Table Technique
 Anterior guidance is crucial in human occlusion because it

influences molar disclusion that controls horizontal forces.
 Molar disclusion is determined by :
 A Cusp Shape Factor
 Angle of hinge rotation.
89
Angle of Hinge Rotation
 Posterior disocclusion occurs when anterior guidance is steeper
than the condylar path.
 Mandible
TRANSLATES
and
ROTATES.
This rotation of the condyle compensates for the difference in the

steepness of the anterior and the condylar path
This is referred to
as the
Angle Of Hinge
Rotation
Contribution to Disocclusion
 Posterior disocclusion during :
 Protrusion : 0.2 mm
 Lateral Movement
 Working/Non-working sides – 0.5 mm
Degree Of Disocclusion
Measured Value Angle of hinge Rotation Cusp Shape factor (mm)
Protrusive 1.1 0.2 0.9
Working 0.5 0.5 0
Non-Working 1.0 0.5 0.5
94
Concept Hobo’s Twin Table Technique
 This new technique develops anterior guidance to create a

predetermined, harmonious disclusion with the condylar path.
 One incisal table is used to incorporate a cusp-shape factor

and the other is used for the angle of hinge rotation.
 This method does not require special equipment and is an

uncomplicated procedure suitable for daily practice.
95
• The cusp-shape factor and the angle of hinge rotation are derived primarily from the
condylar path.
MEASUREMENT • To ensure an accurate measurement, a pantograph or interocclusal records can be
OF THE
CONDYLAR PATH used for this procedure
• The incisal table coincides three - dimensionally with the condylar path and molar
cusp shape.
INCISAL TABLE
WITHOUT • If this table is used to create anterior guidance, a full balanced occlusion will result
DISCLUSION
• This custom incisal table, called an incisal table with disclusion, incorporates a
INCISAL TABLE predetermined degree of disclusion.
WITH
DISCLUSION
96
Selection of the Articulator
 Two Types :
 Semi - adjustable
 Fully – adjustable
 Semi-adjustable creates only a straight condylar path
 Fully-adjustable develops a curvature
 Because a condylar path with a curve is more accurate and reflects

a reliable anterior guidance, Fully-adjustable is preferred.
 These articulators duplicate the working condylar path in different

ways :
 Semi-adjustable – Only develops a straight outward path

- Sagittal deviation cannot be adjusted
 Fully-adjustable – reproduces the sagittal deviation

 In Hobo’s Twin Table Technique – the working condyle is set on

the articulator tom move directly outward on the transverse
horizontal axis.
 Hence – a Semi-adjustable Arcon Articulator With A Box-Shaped

Fossa Element Is Sufficient
RECAP
Twin –Table Technique
Study Casts are made PROCEDURE
101
Face Bow Transfer and IOR made PROCEDURE
102
Study Casts with Removable Anterior Segment
Anterior segment
removed to
eliminate the
effects of existing
anterior guidance
103
Eccentric Movements
 Articulator is moved
through eccentric
movements to eliminate
interferences that impede
an even, gliding motion.
 This procedure
results in a cusp-shape
factor that harmonizes
with the condylar path.
104
Cusp Shape Factor Incorporated
 Areas where the tooth does not contact with the opposing occlusal surface – wax is added until
it contacts evenly.
 The missing teeth or tooth structure spaces are replaced with wax
 Once the maxillary and mandibular casts interdigitate evenly during eccentric movement, it
means the cusp is now parallel to the condylar path.
105
 The cusp shape factor has been harmoniously incorporated
Incisal Table without Disocclusion
106
Incisal Table without Disocclusion
If anterior guidance is organized according to this table –

fully balanced occlusion will result 107
Incisal Table with Disocclusion
One of the incisal tables without disclusion is placed on the articulator so that
the tip of the incisal pole contacts the incisal table in CR
Two 3 mm thick plastic inserts are prepared to approximate the Protrusive

Movement position
Inserted behind the right and the left condyles – max and mand casts placed
in 3 mm protrusion
Inserted behind the right and the left condyles – max and mand casts placed
in 3 mm protrusion
109
A vinyl sheet 1.1 mm thick – Mesiobuccal cusp tips of right and

left mand molars – predetermined disclusion
Tip of the incisal pin gets raised backward and upward on the
incisal table
Build chemical cured resin into a cone using brush between the
incisal pin and the table – creating the angle of hinge rotation for
protrusive movement.
Simulate lateral movement by placing 3 mm insert behind one condyle at a

time and 1 mm and 0.5 mm vinyl sheet on the non-working and working side
respt.
Build chemical cured resin into a cone using brush between the incisal pin
and the table – creating the angle of hinge rotation for Lateral movement.
Connect the 3 resin cones with chemical cure resin to build walls between the
cones and do eccentric movements of the articulator .
Incisal table with disclusion with incorporated predetermined degree of

disclusion
113
114
115
116
Tooth Preparation
Impressions made
An accurate final impression is made with a rubber base
impression material.
The maxillary working cast is again made with a removable

anterior segment using dowel pins.
A facebow is used to transfer the maxillary working cast
A centric relation record is used to articulate the mandibular

working cast
119
120
121
122
123
124
125
126
127
Advantages Hobo’s Twin Table Technique
 Can be used for a variety of prosthetic procedures

 Full mouth rehab
 Posterior quadrant restorations
 Anterior restorations
 Relatively uncomplicated
 Does not require any special equipment
 Final prosthesis results in a restoration with predictable posterior

disclusion and anterior guidance in harmony with condylar path
Hobo’s Twin STAGE Technique
129
Hobo’s Twin STAGE Technique
 Although condylar path has been regarded as the main determinant for occlusion, it has been
found to show deviations.
 Also, it has minimal influence on disocclusion
 Incisal Path – Less deviation than condylar path
 Influences disocclusion (at the 2nd molar) –

 Twice as much as that of condylar path during protrusive
 3 times on the Non-working side
 4 times on the Working side (Lateral Movement)
130
Influence
Cusp
Cusp Incisal
Incisal Condylar
Condylar
angle
angle path
path path
path
131
Standard Value of Cusp Angle
 Cusp Angle – Independent from both condylar path and incisal path.
 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 a reference for
occlusion, making a restoration following this guide should be ideal for the
patient
132
 To establish a new reference for occlusion , it is necessary to define a standard

value for cusp angle
 To obtain this – The measured amount of disocclusion was the only reliable
data available.
 Using this data – standard cusp angle values were calculated
133
ThereforethetheCalculated
Therefore CalculatedStandard
StandardCusp
CuspAngle
Angleisis: :
134
135
• These adjustment values are effective only when the Axis Plane is used
as reference and requires a facebow transfer.
• When a different horizontal reference plane is used, a new computation

is necessary to obtain different adjustment values.
136
Twin Stage Procedure
 In the Twin-Stage procedure, a standard cusp angle is created on a restoration.
 The incisal path (anterior guidance) for obtaining the standard amount of
disclusion is then computed based on the mathematical model of mandibular
movement.
 Thus, by using the standard cusp angle as the main determinant, it is
possible to establish the standard amount of disclusion. The anterior
guidance created in this manner may control the condylar path, since the
condylar path is influenced by the anterior guidance.
Basic Concept Hobo’s Twin Stage Technique
 To create a standard cusp angle on the restoration, on articulator is mandatory
 The adjustment value of the articulator used to create the standard cusp angle
was called "Condition 1."
 The adjustment value used to create anterior guidance was called "Condition
2."
 These articulator adjustment values were determined by computation.
138
In order to provide disocclusion, the cusp angle should be shallower than the
condylar path.
To eliminate the effect of the anterior teeth while waxing up the posterior to create
shallower cuspal angles – removable anterior segment is fabricated
 The cast with a removable anterior segment is fabricated. First, reproduce the
occlusal morphology of posterior teeth without the anterior segment and
produce a cusp angle coincident with the standard values of effective cusp
angle
(referred to as "Condition 1 ")
139
 Secondly, Reproduce anterior morphology with the anterior

segment and provide anterior guidance which produces a standard
amount of disocclusion
(referred to as "Condition 2")
 This is named the "twin-stage procedure."

140
Adjusting Values on the Articulator
 The standard value of sagittal protrusive effective cusp angle is 25°
 To obtain this cusp angle – Various combinations of Condylar path

angulation and anterior guide table are possible
141
 The SIMPLEST combination is – adjust

 Sagittal condylar path - 25°
 Anterior guide table - 25°
 Wax the occlusal morphology to produce a balanced articulation.

 This will result in a cusp angle of 25 °
142
 Other combinations :
 Sagittal condylar path - 10° (too shallow)
 Anterior guide table - 30° (too steep)
OR
 Sagittal condylar path - 40° (too steep)
 Anterior guide table - 20° (too shallow)
A 25 ° cusp angle can be obtained at the 1st molar

143
144
Articulator Adjustment To Achieve The Standard Cusp Angle
Whats Recommended ????
 If the adjustment values of the condylar path and the incisal guide table are not
kept the same – a 25- degree cusp angle will be obtained only at the 1st molar
 When both kept the same - 25- degree cusp angle created on each cusp of
posterior teeth
 Hence , recommended !!
 This is the adjustment value for the articulator to achieve Condition 1
145
146
Adjusting for Generating Disocclusion
 After waxing the cusp angle to standard value , the anterior guidance should be
established to produce the standard disocclusion
 Again, infinite combinations of condylar path and incisal guide table are
possible.
 Recommended combination :
 Condylar path – 40°
 Incisal Guide table - 45 °
147
 This combination will result in a

1. Standard amount of disocclusionon molars
2. A physiological Anterior Guidance
 This is the articulator adjustment for Condition 2
148
 Other Combinations :
150
Fabrication of Each Occlusal Scheme
 Since the standard cusp angles were used as the main determinant
of occlusion, the measurement of the Condylar path was not
necessary, and the tooth contact condition during eccentric
movements was controlled precisely by every selected occlusal
scheme.
151
 To reproduce the amount of disclusion for each occlusion scheme, different

adjustment values of an articulator were required.
 The different occlusal schemes include :

• Mutually Protected
• Group Function
• Balanced occlusion
152
 Mutually Protected Occlusal Scheme :

• Most suitable for natural dentition
Anterior
Condylar path guide table
Bennett Angle LateraL Wing
inclination sagittal
Inclination
Condition 1 25 15 25 10
Condition 2 40 15 45 20
153
 Group Function Occlusal Scheme :
• Indicated when canine guidance is absent as a result of the loss of a canine.
• To create group function, articulator adjustment values for "Condition 2" must be
modified.
• In group function, the amount of disclusion on the working side during lateral movement
must be zero.
• This can be achieved by changing the lateral wing angle of the anterior guide table tor
Condition 2 from 20 to 0 degrees.
• The amount of disclusion on the nonworking side becomes 0.5 mm

154
 Group Function Occlusal Scheme :

• To create group function, articulator adjustment values for "Condition 2" must be
modified.
• The amount of disclusion on the working side during lateral movement must be zero.
Anterior
Bennett Angle Lateral Wing
Inclination
Condition 1 25 15 25 10
Condition 2 40 15 45 0
155
 Balanced Occlusion :
• Recommended for complete dentures.
• To create this articulation Condition 1 should be used to produce both the cusp angle and anterior
guidance.
Anterior
Bennett Angle Lateral Wing
Inclination
Condition 1 25 15 25 10
Condition 2 25 15 25 10
156
Physiological Discrepancy
The sagittal
condylar path
distributes
+ 14 degrees
(SD) from the
mean value (40
degrees).
157
 If the sagittal condylar path of the patient is steeper than the articulator adjustment value
(40 degrees), this difference is harmless because the amount of disclusion increases.
 On the contrary, if the condylar path in the patient is shallower than 40 degrees, the
amount of disclusion decreases to some extent.
 The sagittal condylar path distributes + 14 degrees (SD) from the

mean value (40 degrees).
158
 Within this limit, the lowest value of an eccentric condylar path (26 degrees) is
almost equal to the mean of the returning condylar path , so the discrepancy must
be harmless.
 However, when the returning condylar path is much shallower than its mean, cuspal
interferences MAY occur
159
 When the condylar path of a patient is 16

degrees, there is no disocclusion, and
maxillary and mandibular cusps slide in
contact evenly.
 Accordingly, when the condylar path

becomes shallower than 16 degrees,
cuspal interferences WILL occur. 160
Facebow transfer Step-wise procedure
161
Mock Up
163
Tooth Preparation
164
Mounting of master casts with removable
anterior segment
165
166
Establish the Cusp Angle – Condition 1
167
168
Wax up the anterior teeth – Condition 2
169
170
Metal Try in
171
Ceramic Build-up
172
173
Completed Ceramic Build-up
174
Finished Restoration
175
Twin Stage vs Twin Table
 The Twin-Stage Procedure was developed as the advanced
version of the Twin-Table Technique.
 The Twin-Table Technique has several disadvantages compared to

the Twin-Stage Procedure.
 The Twin-Table technique – Disadvantages
 The cusp angle was fabricated parallel to the measured condylar path, and the cusp angle became too
steep.
 To obtain a standard amount of disocclusion with such a steep cusp angle, the incisal path had to be
set at an angle that was extremely steep.
 This made the patient uncomfortable.
 In addition an anterior guide table of an articulator was fabricated by means of resin moulding. It was
technique sensitive
 The Twin-Stage procedure – Advantages
1. Measurement of the condylar path not necessary, complicated instruments such as

the pantograph and fully adjustable articulator become unnecessary.
2. The guideline for optimum occlusion is shown clearly by the adjustment values of
an articulator (conditions 1 and 2), it is possible to diagnose eccentric occlusal
relations of the patient precisely and simply.
3. The procedure can be indicated for almost every phase of

restorative and prosthodontic work including the Single Crown,
FPD, Implants, Complete-mouth Reconstructions, and Complete
Dentures.
Presently, the twin-stage procedure is Contraindicated in the

following cases :
Abnormal curve of
Spee Abnormal curve of
Wilson
Abnormally rotated
tooth
Abnormally
inclined tooth
180
Variation Between The Two Techniques
Twin table technique Twin stage technique

Patients condylar inclination is recorded Fixed condylar guidance of 40 degree is followed.
and followed
Molar disclusion is determined by a cusp Molar disclusion is determined by a

shape factor and an angle of hinge standard cusp angle and the anterior
rotation guidance
Develops anterior guidance to create a Standard cusp angle is used as the main
predetermined, harmonious disclusion determinant of to establish the standard amount of
with the condylar path. disclusion.
The anterior guidance created in this manner helps
control the condylar path, since the condylar path
is influenced by anterior guidance.
181
One incisal table is used to incorporate a Condition 1 gives a standard cusp angle
cusp-shape factor and the other is used and condition 2 helps give anterior
for the angle of hinge rotation. guidance for predetermined disclusion
The anterior guidance and the patients The anterior guidance and the patients
condylar inclination are in harmony condylar inclination may or may not
be in harmony
The amount of disclusion determined in The amount of disclusion changes

the articulator and that seen in patients (increase or decreases) in patient’s mouth
mouth are same. as in this technique a fixed value of 40°
as the condylar inclination is followed.
The amount of
disclusion doesn’t change in patient’s So as the condylar inclination varies the
Mouth amount of disclusion also varies from the
predetermined value
182
Inter – occlusal bite records are required for the No such records are required as the
programming of the articulator to patient’s condylar inclination is pre determined to
condylar inclination 40
Generally followed only for full mouth Can be followed for both dentate (fixed
rehabilitation in dentate patients (fixed prosthesis) and edentulous patients (complete
prosthesis) dentures)
183
Conclusion
 Occlusal rehabilitation is a radical and

serious procedure. It should not be
undertaken merely because the
occlusal relationship existing does not
conform to preconceived concepts of
the normal or ideal.
 In the presence of functional adequacy

conservative treatment is indicated. 184
Conclusion
 Patients who have had full mouth rehabilitation commonly say that their mouth
feel “stronger”.
 The masticatory muscles have obviously not been strengthened by the therapy.
 What has happened is that the patient can exert greater force with comfort and
without anticipation of pain than they could before and that therefore they do
exert a greater force.
185
Conclusion
 The individual patient’s reaction bears witness to these

benefits and should inspire us, in terms of human satisfaction
as well as of scientific progress, to strive continuously for
improvement in the techniques of full mouth rehabilitation.
186
References..
 Sumaiya Hobo, Hisao Takayama : Oral Rehabilitation Clinical

Determnation of Occlusion.
 Twin table technique for occlusal rehabiliation :

Part I – Mechanism Of Anterior Guidance J Prosthet Dent
1991;66:299-303.
 Twin table technique for occlusal rehabiliation :

Part II– Clinical Procedure J Prosthet Dent 1991;66:471-7.
187
 Biologic laws governing functions of muscles that move
mandible. Part – I. J Prosthet Dent. 1977; 37:648-56.
 A practical approach to full mouth rehabilitation. J Prosthet Dent.

1987;57:261.
 Formula for adjusting the horizontal condylar path of the semi

adjustable articulator with interocclusal records. Part – I. J
Prosthet Dent. 1986;55:422-6.
Thank You…
189

Hobos Philosophy

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Hobos Philosophy

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Full Mouth Rehabilitation

Dr. Divya Mehra

 A graduate of Nihon University School of Dentistry in

 He attended graduate school at the Indiana University

 In 1972, he returned to Japan to open his International

 He authored the text “Fundamentals of Fixed Prostheses” for

 The goal of dentistry is to increase the life span of the functioning

 The phrase full-mouth rehabilitation means different things to different

 The aim is to provide an

A better understanding of the scientific principles underlying

 Immediate mandibular lateral translation:

 Full mouth rehabilitation entails the performance of all the

 The restoration of multiple teeth, which are

 To replace improperly designed and executed

 Treatment of temporomandibular disorders may

 The following goals should be achieved when planning for an occlusal

2. An anterior guidance that is in harmony with function in lateral eccentric position

3. Disclusion by the anterior guidance of all posterior teeth in eccentric movements.

4. Axial loading of teeth in centric relation, interproximation, and function.

Oral Health, Function, Esthetics And Comfort,

and treatment should be planned around these rather than the

Analysis of the Occlusion

 When undertaking relatively small amounts of

The alternative strategy is to re-organize the occlusion by establishing a new

 The decision to re-organize a patient's occlusion may be made on the grounds

 The condylar position usually chosen is

The decision should be made after a detailed and careful

 Reorganization may be considered when the existing intercuspal

 Repeated fracture or failure of teeth or restorations :

 Repeated fracture or failure of teeth or

Clinical experience suggests that persistently

An optimally constructed occlusion will better be able to deal with

 Lack of interocclusal space for restoration :

Re-organising the occlusion to eliminate a large horizontal component

1. The determination of the proper vertical height by utilizing the

2. An examination and study of the path of closure from rest

3. The effects of the occlusal pattern upon

4. A study of the temporomandibular joint

 It is the separation of opposing teeth during eccentric

 Mechanically, the maxillary and mandibular teeth

 Maximal shear force is observed with a fully

 However, the condyle must follow one

 If the condyle deviates slightly, it

 When the mandible is protruded, the only teeth

 This is so because when the mandible is

 Since the amount of flexing of the mandible

 The anterior teeth, being farthest from

 Protrusive stresses on posterior teeth are

Because it is impossible to Because posterior tooth

How Much Is Good Enough !!

 There is minimal literature available regarding the proper amount

 Shooshan (1960) and Scot (1964) stated that during lateral,

 Thomas (1967) stated when maxillary and mandibular

 The Condylar path is described by GPT

 McCollum and Stuart described the

 The deviation in the condylar path during

 This study refers to this deviation in condylar

 Eg : Accurately Machined Gears

 Immobile when the gears are too

Disc  A little spacing is needed to allow

 The average buffer spaces are 0.2 mm in centric relation, 0.3 mm in

 Molar disclusion should be greater than the buffer space to avoid