Dr.

Divya Mehra
 Introduction  Twin Table
 Terminologies  Twin Stage
 Definition – Full Mouth  Conclusion
Rehabilitation  References
 Indications for Full
Mouth Rehabilitation
 Analysis of Occlusion
 Disocclusion
 Necessity For
Disocclusion
 Classification of Occlusal
Rehabilitation

3
 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.
4
 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

5
 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.

6
  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.
7
 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

8
 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
 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 entails the
performance of all the procedures
necessary to produce healthy, esthetic, well
functioning, and self maintaining
masticatory mechanism.

11
 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.
12
  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.

14
The First step is :
 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

16
 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). 17
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.

18
 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

19
 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.

20
 Bruxism :

An optimally constructed occlusion will

better be able to deal with the forces
generated in parafunction.

21
 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.

22
 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.

23
 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.
24
25
 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.

26
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.

27
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.

28
DISOCCLUSION

 It is the separation of opposing teeth during

eccentric movement of the mandible – GPT 8.

29
 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
30
 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

31
 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.
32
 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.
33
 Because we do not
need for posterior
teeth to touch during
incising

WHY
DISOCCLUSION
?????

Because it is impossible
Because posterior
to harmonize the
tooth interferences in
posterior occlusion to
protrusion are among
all degrees of muscle
the most damaging
force in protrusion

34
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.

36
 Thomas (1967) stated when maxillary and
mandibular cuspid has tip to tip relation
during lateral movement; the molars should
disocclude 1.0 mm.

37
 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:

38
 Condylar
path

Incisal
Path

Cusp Angle

39
 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.
41
 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.
42
 Eg : Accurately Machined
Gears
 Immobile when the gears
are too close and tight
 A little spacing is needed
to allow the gears to
function smoothly
 Buffer spacing is
essential for the condyle
and the disc to function
smoothly
 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.
44
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
45
 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.
46
 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.

51
 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.
52
 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.

53
 So,

Condylar Path Cannot be the Sole

Guiding Factor in order to
Establish Good Occlusion.
 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.
56
 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.
57
The Anterior Guidance

 Hence :
Condylar Guidance and Incisal
Guidance were DEPENDENT and not
Independent factors

58
The Anterior Guidance

 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

59
The Anterior Guidance

 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

60
 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 incisal path was flatter –
61
 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. 62
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.

63
 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.

64
Cusp Shape Factor
 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

66
67
 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

68
 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.

69
 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
 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. 71
 Influence

Cusp Incisal Condylar

angle path path

72
 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

73
 Using protrusive movement as an example
the reasons which necessitate disocclusion
can be understood :

74
 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.
75
76
 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”

77
78
 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”

79
80
 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.

81
82
83
 There are four types of occlusal rehabilitation
and situations, and each requires a different
type of treatment

84
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 1

Step 2
posterior teeth to posterior teeth are
the patient's curve restored by the
of Spee, as functionally
presented. generated path
technique
85
 The curve of Spee is irregular,
but the incisal guidance is acceptable.

Then the upper

Restore the
posterior teeth

Step 2
Step 1

lower posterior
are restored by
teeth to a more
the functionally
desirable
generated path
curvature
technique
86
The curve of Spee and the incisal guidance are
both unacceptable.
The
restoration
The
of the
correction
upper
of the
posterior
incisal
teeth with
guidance by
the use of
restoring
the
the upper
functionally
anterior 87
 The curve of Spee and the incisal guidance
are not acceptable,
and
The Upper and Lower Anterior
The
The Teeth Need
TheRehabilitation.
restoration The

Step 4
Step 1

Step 2

Step 3
restoration restoration of the lower restoration
of upper
of the upper posterior posterior
of all the
anterior teeth to a teeth with
lower teeth and more the use of
the
the incisal acceptable
anterior functionall
guidance, occlusal y
teeth, curvature generated
path 88
89
 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.

90
 Posterior disocclusion occurs when anterior
guidance is steeper than the condylar path.

 Mandible
TRANSLATE
S 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
 Posterior disocclusion during :

◦ Protrusion : 0.2 mm
◦ Lateral Movement
 Working/Non-working sides – 0.5 mm
 Measured Value Angle of hinge Cusp Shape
Rotation factor (mm)

Protrusive 1.1 0.2 0.9

Working 0.5 0.5 0

Non-Working 1.0 0.5 0.5

95
 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.

96
 •The cusp-shape factor and the angle of hinge rotation are derived primarily
MEASUREMENT
from the condylar path.
OF THE
•To ensure an accurate measurement, a pantograph or interocclusal records
CONDYLAR
can be used for this procedure
PATH

•The incisal table coincides three - dimensionally with the condylar path and
molar cusp shape.
INCISAL TABLE
•If this table is used to create anterior guidance, a full balanced occlusion will
WITHOUT
result
DISCLUSION

•This custom incisal table, called an incisal table with disclusion, incorporates
INCISAL TABLE
a predetermined degree of disclusion.
WITH
DISCLUSION

97
 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
Twin –Table Technique
10
2
10
3
Anterior
segment
removed to
eliminate the
effects of
existing
anterior
guidance

10
4
 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.

10
5
 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. 10
6
10
7
 If anterior guidance is organized
according to this table –fully balanced 10
occlusion will result 8
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
11
0
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
11
4
11
5
11
6
11
7
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
12
0
12
1
12
2
12
3
12
4
12
5
12
6
12
7
12
8
 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
13
0
 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)

13
1
 Influence

Cusp Incisal Condylar

angle path path

13
2
 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

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3
 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

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4
 Therefore the Calculated Standard Cusp
Angle is :

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5
13
6
• 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.

13
7
 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.
 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.

13
9
 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 ")

14
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 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."

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1
 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

14
2
 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 °

14
3
 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

14
4
Articulator Adjustment To Achieve The Standard Cusp Angle
14
5
 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

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6
14
7
 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 °

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8
 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

14
9
 Other Combinations :
15
1
 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.

15
2
 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

15
3
 Mutually Protected Occlusal Scheme :
Condylar
• Most suitable for natural dentition path Bennett
inclinatio Angle
n

Condition
25 15
1

Condition
40 15
2

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4
 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

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5
 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
Condylar guide
path Bennett table Lateral
inclinatio Angle sagittal Wing
n Inclinatio
n
Condition
25 15 25 10
1

Condition
40 15 45 0
2 15
6
 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
Condylar guide
path Bennett table Lateral
inclinatio Angle sagittal Wing
n Inclinatio
n
Condition
25 15 25 10
1

Condition
25 15 25 10
2 15
7
The
sagittal
condylar
path
distributes
+ 14
degrees
(SD) from
the mean
value (40
degrees). 15
8
 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).
15
9
 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

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0
 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.
16
1
16
2
164
165
16
6
167
16
8
169
17
0
17
1
17
2
17
3
17
4
17
5
17
6
 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

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1
Twin table technique Twin stage technique
Patients condylar inclination is Fixed condylar guidance of 40
recorded degree is followed.
and followed

Molar disclusion is determined by Molar disclusion is determined by

a cusp a
shape factor and an angle of standard cusp angle and the
hinge anterior
rotation guidance
Develops anterior guidance to Standard cusp angle is used as
create a the main
predetermined, harmonious determinant of to establish the
disclusion standard amount of disclusion.
with the condylar path. The anterior guidance created in
this manner helps control the 18
2
condylar path, since the condylar
One incisal table is used to Condition 1 gives a standard cusp
incorporate a angle
cusp-shape factor and the other is and condition 2 helps give anterior
used guidance for predetermined
for the angle of hinge rotation. disclusion
The anterior guidance and the The anterior guidance and the
patients patients
condylar inclination are in harmony condylar inclination may or may not
be in harmony
The amount of disclusion determined The amount of disclusion changes
in (increase or decreases) in patient’s
the articulator and that seen in mouth
patients as in this technique a fixed value of
mouth are same. 40°
as the condylar inclination is
The amount of followed.
disclusion doesn’t change in
18
patient’s So as the condylar inclination varies 3
Inter – occlusal bite records are No such records are required as
required for the programming the
of the articulator to patient’s condylar inclination is pre
condylar inclination determined to
40

Generally followed only for full Can be followed for both

mouth dentate (fixed prosthesis) and
rehabilitation in dentate edentulous patients (complete
patients (fixed prosthesis) dentures)

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4
 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.
18
5
 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.

18
6
 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.

18
7
 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
18
8
 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 –
19
0