ARCHITECTINGTHEOCCLUSALPLANE

ClaytonA.Chan,D.D.S.,M.I.C.C.M.O DirectorofNeuromuscularDentalStudies,LasVegasInstituteforAdvancedDentalStudies

Itisknownthatdentalocclusionisinfluencedbychangesinthecantoftheocclusalplane. Studieshavedefinedthegeometricandmathematicalrelationshipsbetweendentalocclusionand rotationsoftheocclusalplaneinthesagittalview.Asageneralclinicalguide,eachdegreeof rotationoftheocclusalplanewillresultinahalfmillimeterchangeinthedentalocclusal relationship.Thisisofimportance,becausechangesinthecantoftheocclusalplaneare sometimesunintentional,aswellasintentional,duringocclusal therapy.Earlierstudieshavealso documentedthattheocclusalplanerotatesnaturallyupwardandforwardapproximately6 degreesduringgrowthanddevelopment.ThisphenomenontendstodevelopaClassIIdental relationandthereforehasimportantimplicationsforthedevelopingdentition.<1> Establishingapropermaxillarymountedstudy castiscriticalin designingtheaestheticsmile profile. Clinicalexperienceandmany studieshaveshownthatthemannerinwhichthe maxillarycastismountedandorientedtoahorizontalocclusal planewill affecttheappearance ofthesmileabroadtoothylookorasoftgentlesmile. Newtrendsinrestorativedentistry indicatethatdentistandtechniciansareusinghorizontalreferencetablesandlevelingplanes ratherthantraditionalearbowtransferstorelatethemaxillarycastfordiagnosticwaxupsand smiledesigning. UsinganyFoxOcclusalPlaneplate(Dentsply,International)allowsforverysimple
transmittingoffacialandfunctionalinformationtothearticulator.

AnteriorUpPitch

NormalizedOcclusalPlane

FlatOcclusalPlane
NormalizedOcclusalPlane

A.

B.

Group A:Showbroadtoothysmiles.Maxillarycastsweremountedtosofttissuehamularnotch incisivepapilla(HIP)landmarks. Notetheocclusalplaneisflatandanteriorly pitchedupward. GroupB:Showssoftergentlesmiles.MaxillarycastsalsomountedtoHIP,showsadownward occlusalplaneslant physiologicocclusalplaneorientation.

RelatingtheMaxillaryArchtotheCranium Therearemanyreferenceplanestherestorativeandorthodonticclinicianusesintheassessment ofthemaxillaryarchtothecranialbase.Thefollowingisapartiallist: SNPlaneAlinefromsellatonasion consideredtorepresentthecranialbase. FrankfurtHorizontalPlanePoriontoOrbitale(Bony) CampersPlaneAcanthionexternalauditorymeatusplane(Bony) OPPMIPlaneOdontoidProcessPterygomaxillaryFissureIncisiveForamen (Bony) HIPLineHamularNotch IncisivePapilla(SoftTissue)TransitLinePlane AlaTragusLineAlaofnosetotragusofear(SoftTissue) Manyothers Allthesereferenceschangeovertimebasedonresearch.

Nasion

Sella Sella Porion Orbitale Nasion Porion OPPMI Orbitale

OPPMI

OCCLUSALPLANE

PhysiologicOcclusalPlane Figure1

FrontalView

PathologicOcclusalPlane

Inclinationof theOcclusalPlane(IOP) ThemostcommonplaneusedisFrankfurtplane(porionorbitale).Itwasfirstconceivedforthe orientationofskullsinanthropologyinthelatenineteenthcentury. Ferrario(1994), in previous studieshaveshownthatin naturalheadposture(NHP),theFrankfurtplaneisextended,withthe orbitalehigherthanthetragusortransversehorizontalaxis. Menshowedan upwardtendency andfemalesshowedadownward tendency.Thisstudyimpliedanoverlysteepangulationofthe occlusalplanewiththeincisaledgesofthemaxillaryanteriorsplacedinferiorlywhencompared toNHP. <1> ItwasconcludedthatthetwoFrankfurtplaneswerenevercoincidentinall subjectsthetraguswasalwayslowerandmoreanteriorthantheporion. Onaverage,theangletragusorbitaleporionwasabout6. Ciancaglini (2003)whencomparing14healthyversus14TMDyoungadultswithnormal occlusionreported:

 Nosignificantdeviationfromthehorizontalwasobservedfortheinterpupillaryaxisand occlusalplane. Inlateralview,theFrankfurtplanewasupwardorientatedrelativetothetruehorizontal inTMDgroup(meanangulardeviation2.8degrees,95%CI,1.04.6degrees). TheocclusalandCamperplanesweredownwardorientatedinbothgroups(P<0.0001) InclinationofocclusalplanetendedtobesmallerinTMDsubjects(meandifference betweengroups, 3.8degrees,95%CI, 7.60.1degrees). Furthermore,datasuggests,withinthispopulation,TMDmightbemainlyassociatedwith headpostureratherthanwithcraniofacialmorphology.<2> SeeFigure1. TheJournalofProsthodonticDentistry hasreportedCampersPlane(Acanthionexternal auditorymeatusplane,boney)isfrequentlyusedforthepurposeofestablishingthealatragus plane. Ideally,thealatragusplaneisconsideredtobeparalleltotheocclusalplane. The occlusalplaneisatanangleofapproximately10degreesrelativetotheFrankforthorizontal plane.<3> TheJournalofProsthodonticsalsoreported: 1. Theinclinationoftheocclusalplane(IOP)isoneofthekeyfactorsgoverningocclusal balance. 2. DeterminationofIOPisanimportantstepbeforeequilibratingcompletedentures, comprehensiverestorativedentistryandorthodonticprocedures.<4> Chan (2002,2005)demonstratedbycomputerizedmandibularscanning(CMS),EMGsignaling beforeandafterTENSandwithICATradiographicimagingthatasthemandiblemovesanterior alongan optimizedisotonicpathofclosuretheheadtiltsdownward,thuschangingthe orientationoftheocclusalplanefromaflatterocclusalplane(pathologic)asreferencedfroma horizontallevelbaselinetoamoreangled(6degrees)occlusalplane(physiologic). EyePosture,HeadPosture&MaxillaryMandibular Positioning Dentalliteraturehasoftenusedthehorizontallevelasareferenceforanalysisoftheocclusal planebothinthefrontalandsagittal/lateralviews,bipupilarplane,oticplane,aswellashead posture. Theorientationofthemaxillarycastshouldbeaccurately reproducedclinically and transferredto thelaboratorytechniciansocclusalanalyzingtableatthebench bothreferencedto horizontallevel. Visionplaysasignificantroleinbalance.Approximatelytwentypercentofthenervefibersfrom theeyesinteractwiththevestibularsystem. Theinterpupillaryorientationoftheeyesshouldbe centeredwithin theorbitsofthecraniumwhenthecervicalneckandheadpostureisnormalized. Theeyesarekeysenseorganstoassistincoordinatedbalancecontrolandspatialrelationships maintenanceofthehumanbody. Inanefforttoadjusttotheverticalmisalignmentoftheeyes,thepersonwillfrequentlytiptheir headtomechanicallyhelpaligntheeyes.Thismayoftenbearesultof aposteriormalalignment ofthemandibletothecranium (seefigure2).Thisinturncancauseatiltingupoftheheadand

posteriorizingofthemandible.Earcongestionfeelings,resultantdizzinessandbalancedisorders canresult.

Figure2 Oticplanerelatestothesenseofbalanceandequilibriumbecauseitrelatestothesemicircular canals. Thissenseofequilibriumallowsustoknowthepositionoftheheadinspaceandtothe restofthebody.Mechanoreceptorsinthecervicalspineandmandiblewillreacttochangesin thecranial,cervicalandmandibularpostureinanattempttokeepthesehorizontalrelationships intact. OcclusalPlaneDetermination Traditionallymostrestorativeaestheticclinicianshavepaidmoreattentiontothefrontal horizontalplaneaxis(interpupillary,oticandfrontal occlusal)astheyrelatedtothelongaxisof theface.Theuseoftheclassicstickbitesandsymmetrybiteshavebeenusedtocapturethese twodimensionalrelationshipstoregisterthefrontalhorizontallevelnessoftheirpatients maxillaryarches. Thisvisualsubjectiveassessmentbythedentisthasbeenusedasastandard referencechecktodeterminethemaxillaryarchlevelnessfrontally foryearswhen communicatingwiththelaboratorytechnician. Although thismayhelpaidthetechniciantomountthemaxillarycastinthefrontalhorizontal planes,itfailstogiveanaccuraterelationshipinthesagittalorlateral axis,especiallywhen realizingthatitistheposterior occlusalplaneslant(pitchaxis)thatiscriticalwhendesigningthe curvatureandangleofthesmileline(bicuspidstomolars)asreferencedtothesurroundinglip bordersoftheoralcavity.

Figure3: Notetheleftandrightocclusalplaneslantoftheabovepatientwhenseenfromthe lateralview(referencedtohorizontallevel).

Mostlaboratorytechnicianshavefoundthatwhenusingthesedevicesthatthemaxillary mountingsoftendidnotmatchtheaccompanyingfrontalsmilephotographs. Withyearsof laboratorymountingexperience,thetechnician customarilysetthestickbiteasideandmounted themaxillarycasttomatchthephotographinthefrontalplaneby theirtrainedeyes. Further,it leftinquestiontheangleorslantoftheposteriorocclusalplane(pitchaxis)asitrelatedtothe sagittalhorizontalplanerelativetoaleveltable. Oneofthemostimportantobjectivesinmaxillarymountingistoreplicatethemaxillary teeth orientationasitisseensagittally/laterallyfromthesideviewofthepatient. Thissideviewofthe occlusalplanecanbeeasilyobservedwhenaskingthepatienttosmilewiththeirheadat horizontallevelwiththepupilsoftheeyescenteredoftheorbitslookingatthehorizon(straight ahead)andpronouncingtheletterE. Thisocclusal planeangleiscriticalforoptimalsmiledesigningandmustbeaccuratelycaptured tocorrectlymountthemaxillarycast,referencingit tothehorizontalocclusalanalyzingtablefor properocclusalplaneanalysis. Diagnosingthe MaxillaryCastMountings Themaxillarycastmountingscanbeverydiagnosticastoindicatewhetherthereexists unresolvedcranialtomandibularmuscularimbalances. Whentheheadpositionandeye orientationwithintheorbitsareinapathologicpositionanaccommodativeresponsewillresult inaforwardheadposture(effectingthecervicalspinerelationshipkyphosis)withan accompanyabnormalmandibularjawclosurepattern(G.Wolford).Theheadtiltwillbe upwardcontributingthecervicalneckachesandpainwithananatomicallyflattertoanupward anteriorslantingocclusalplaneasreferencedfromhorizontallevel (Figure1). ICAT radiographicscanswillconfirmthattheboneyreferencefromtheodontoidprocessthroughthe pterygomaxillaryfissureandanteriortotheincisiveforamenwillbeabnormallylevel.Thus, whenmountingthemaxillarycastviathecomparablehamularincisivepapilla(HIP)softtissue referencesitwillpresentasaveryflattoanteriorlyupwardpitchedocclusalplane(57.6%). <5> Patientswhoareneuromuscularlystabilizedandcraniomandibularcervicallybalancedwill presentwithamorenormalizeheadposture(headtiltdownward),effectingthecervicalspine relationshiplordosis,withanaccompanyingisotonicjawclosurepattern.ICATradiographic imagingclearlydemonstrates(alinethroughtheodontoidprocess,pterygomaxillaryfissureand anteriortotheincisiveforamen)adownwardslant(87.5%). <5> Theocclusalplanewillalsobe moreparalleltotheseboneyreferencesconfirmingtheHIPreferencealsoslantsdownwardin relationshiptohorizontallevel.Thisphysiologicocclusalrelationshipmustbeaccurately recordedandrepresentedinthelaboratorymaxillarymountingif anoptimalsmilelineistobe designedtomatchnaturesocclusalplane.Occlusalcervical,craniomandibularrelationships andtoothwidthlength proportionscanbeachieved tonaturesdesignviavisualanalysisofthe variouslevelingplanes. Thetrainedandexperiencedlaboratorytechniciansrealizethesefacts.

HIPPlaneBeforeDiagnosticWaxUP

Figure4: MaxillarycastwasmountedtoclassicHIPsofttissuelandmarks.Theflatocclusal planereferencedtoahorizontalleveltablewouldbeindicativeofapathologicforwardhead orientationwithunderlyingunresolvedmusculoskeletalcraniumtomandibularocclusalposture. OPI(FoxPlane)BeforeDiagnosticWaxUp

Figure5: MaxillarycastmountedusingtheOPI(OcclusalPlaneIndex/FoxPlane).Noticethe occlusalplaneslantsdownward(6degrees)asreferencedtothehorizontaltable,indicativeofa morenormalizedheadposturesupportedbyanoptimizedmandibularposition.

Figure6:
BeforeTreatmentOcclusalPlaneatCO (Flat) LevelHIP AfterTreatmentOcclusalPlaneatMyocentric (Angled)DownwardslantHIP

A.

B.

A:ICATscanshowsalevel/flatocclusalplaneparalleltotheboneyodontoidincisiveforamen (HIP)beforeneuromuscularstabilization(pathologicocclusalplaneorientation).Patientis unposed,atthehabitualcentricocclusalmandibularposture. B:ICATscanshowsamorenormalizeddownwardslantboneyodontoidincisiveforamen(HIP) occlusalplaneafterneuromuscularorthotictreatment(physiologicocclusalplaneorientation),at an optimizedmyocentricocclusalmandibularposture.

Figure7

MoreTooth Reduction

A:HIPPlaneMountandDiagnosticWaxUpNotetheshorter upperposteriorteethwithbuiltincurveofSpee.Centralincisorsare waxedofftheleveltabletocompensatetocreateapropertoothlength andwidth.Emergenceprofileofmaxillary centralincisorwillbemore pronounced.

LessTooth Reduction

B:OPI(FoxPlane)MountandDiagnosticWaxUpNoteamore normalizedposteriorcrownlengthalsowithabuiltincurveofSpee.Maxillary centralincisorrootangulationismoreidealized.Thecentralincisorlengthand widthisreferencedfromtheocclusalanalyzingtableandwaxedasindicated withoutcompensatingtheanteriorincisorwaxupfromtheleveltable.

RecordingtheOcclusalPlaneAnglewiththeOPIUsingAFoxPlane AsimpleandreasonableclinicaltechniqueusingthewellknownFoxPlane(Dentsply,Trubyte) canbeusedtorecordthemaxillaryarchwiththepatientsheadathorizontallevel (Figure8).

A Figure8

A Figure9 ClinicalTechniqueThisIsHowIDoIt

1. Firstwiththepatientstandingstraightandtheheadpositionedwith eyeslookingstraight aheadlookingatthehorizon,makesurethesagittalheadtiltiswiththeeyesinthecenterof theorbits. (Natureslevelingbubbles). Thiswill assistingettingtheheadcorrectlyoriented tolevel.Subjectivelyassessthelongaxisoftheface. Theinterpupillaryeyesshouldnotbe usedalonetoreferencetofrontalhorizontallevel,sincesomepatientseyesmaybedifferent fromonesidetotheother.Earlevelness,eyebrowheights,noseorientationsandcornerof thelipsmaynotalwaysbereliablereferencesforfacialsymmetry. 2. Syringeanyfastsetpolyvinyl(30secondbiteregistrationmaterial)ontheFoxPlanebite forkandinsertitintothemouthupwardagainstthemaxillary anterior teeth. Donotpressthe posteriorregionofthebiteforkupontheupperposteriorocclusalsurfaces! Itisimportant tohavethepatientkeeptheirheadlevelwhenopeningthelowerjawandtheeyeslooking straightahead. Checktoconfirmthepupilsarecenteredoftheeyesockets/orbits). See Figure9A. 3. OrienttheFoxPlanetolevelandperpendiculartothelongaxisofthefaceaswellaslevel sagittally/laterallevel totheground(Figure9B). 4.Allowthepolyvinylmaterialtosetfirm whileholdingFoxPlanewithlightfingerpressure anteriorly. Takeamomenttoconfirmfrontalandsagittallevelnesstotheground. Ifthe recordingdoesnotlookrightrepeattheabovestepsuntil correctlyleveledandrecorded. AfterthePVmaterialhardens,removetheFoxPlaneandocclusalplaneindex(OPI)from themouth. 5.PealawaythePVocclusalplaneindex(OPI)fromtheFoxPlanebiteforkandplacetheOPI onany levelmountingtableandorienteditto thecenter/midline. (OrientingtheFoxPlane withtheOPIdirectlyontheanalyzingtableformountingcanalsobedone). Placetheupper dentalcastintotheindexregistrationandmounttheuppercast.

6.AftertheuppercastissetandmountedremovetheOPIfromthemountingtableandevaluate theocclusaltableslantorangulation(pitch)asitrelatestothehorizontaltable. 7.MountthelowercasttotheupperviatheMyocentricbiteregistration. Nowyouhavetheupperandlowercastsmountedphysiologically andaccurately,relatingthe patientsmaxillaandmandibleonanyarticulatingmodelholder. OcclusalPlaneIndex(OPI)/LevelFoxPlane

Figure10A

Figure10B: Note pretreatmentdiagnosticcastsindicatea56degreeocclusal planeangle.

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OPIgivesthelaboratory an easystartingreferencetobuildthecrownswith 610degree occlusalplanewithlittlepreoperativestonemodelocclusal reduction.Alteringthelevel occlusaltableatthebenchisnolongernecessarytocreatetheproperposteriorcrownlength.

Figure11

A. B. A. A six degreeslantoftheocclusalplanereferencedfromhorizontallevel iseasilywaxedwith curveofSpeeandcurveofWilsontoartisticallycreateasoftsmileline.B.Noteamoreeven distributionoftheupperandlowercrownlengthintheposteriorregionduetoproperocclusal planedeterminationandrecordingwiththeOPI(FoxPlane). Figure12

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Figure13:Asoftgentlesmilelineiscreatedbasedonanoptimizedmandibularposition andaproperlymountedmaxillarycastmountviatheOPI(FoxPlane)technique(notbased onasofttissueHIPmount/flat,seeFigure6beforeandafterICAT).

Figure14: Left:Beforetreatmentsmile:Notethemaxillaryfrontalplanedownwardleft cant. Right:Maxillaryfinishedrestorations.Notethecorrectedocclusalsmileline.

BeforeTreatment

AfterTreatment

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Finishedmaxillaryrestorations Thepatientselectedshade110,040,030fromIvoclarsChromoscopeshadeguide.Heavy translucencyattheincisalthirdalongwithagradualtransitiontothegingivalandproximal.The naturalsurfacetextureiscreatedtogiverealismalonewithinternalsculpteddentinallobes.

Conclusion TheOcclusalPlaneIndex(OPI)/FoxPlaneisasimpletechniquetoeffectively recordthe maxillary occlusalplaneangle(slant)foramoreaccuratediagnosticmountandevaluation when referencedtoanyhorizontalocclusaltableanalyzer. Kois,Leary,Jankelson,andothershave usedversionsoftheFoxPlanetoalignthemaxillaryarchsuccessfullyforyears.Thistechnique isdesignedtobetterassessthemaxillaryocclusalcants,asymmetriesandocclusaldiscrepancies whenreferencedtothehorizontalgroundwhen thepatientsheadiscorrectlyorientedlookingat alevel horizontalposition.Itassistsboththedentistandlaboratory technician tobetter communicateamorerepresentativeocclusalplaneorientationforocclusalwaxingandsmile design.Itisasimpleandinexpensivetechniquetouse,allowinganeasyaccurate transfertoany occlusalanalyzingtableviatheOPI.Itminimizesguessingandaneedtoalter theocclual pitch orangleoftheocclusalplaneinthelaboratory.Itallowsforamoreproportionaldistributionand crownlengthratiobetweentheupperandlowerposteriorcrownsandpreventstheneedto excessivelyreducethemaxillaryposteriorocclusionduringcrown preparation.

Dr.ClaytonA.Chan isdedicatedtosharehispassionandteachestheneuromuscular principlesthathaveworkedforhim.Heisaneducatortothousandsofdentistallaroundthe world,inspiringthemtotaketheirpracticestoanotherlevel.Heisconsideredbymanyan authorityonNeuromuscularDentistryandOcclusion.HepracticesinLasVegas,Nevada wherehefocusesonAestheticDentalOrthopedics, orthodonticsandTMJ,implementingboththe gnathologicalandneuromuscularprinciples. HeisDirectorofNeuromuscularDentistryatthe LasVegasInstituteforAdvancedDentalStudies.

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References: 1. BraunS,Legan,HL:Changesinocclusionrelatedtothecantoftheocclusalplane.AmJ OrthodDentofacialOrthop.1997Nov112(5):17A20A. 2. VirgilioF.Ferrario,MD,ChiarellaSforza,MD,DomenicaGerman,MD,LucaL. Dalloca,DMD,AlessandroMianiJr.,MD:Headpostureandcephalometricanalyses:An integratedphotographic/radiographictechnique,TheJournalofProstheticDentistry, Volume106,Number3,September1994. 3. CiancagliniR,ColomboBollaG,GherloneEF,RadaelliG.:Orientationofcraniofacial planesandtemporomandibulardisorderinyoungadultswithnormalocclusion. JOral Rehabil. 2003Sep30(9):87886. 4. TheGlossary ofProsthodonticTerms,SeventhEdition(GPT7), TheJournalof ProsthodonticDentistry,Volume81,Number1,January1999. 5. TheInclinationoftheOcclusal Plane,J.Prosth.Dent.,Volume87,Number2,February 2002. 6. InvestigativeClinicalResearchforNeuromuscularDentalTechnology:HIPResearch InvestigativeStudy,FourstudiesMarch2004,October2004,May2005andJune2005. 82participatingdentallaboratorytechnicians,154maxillarymodelcasts,LasVegas InstituteforAdvancedDentalStudies,LasVegas,Nevada.

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