Journal of Oral Rehabilitation 2005 32; 895900

A study of the proximity of the Broadrick ideal occlusal curve to the existing occlusal curve in dentate patients
H . L . C R A D D O C K * , C . D . L Y N C H , P . F R A N K L I N * , C . C . Y O U N G S O N A N D M . M A N O G U E * *Division of Restorative Dentistry, Leeds Dental Institute, Leeds, UK, Cork University Dental School and Hospital,
Cork, Ireland and

Department of Restorative Dentistry, Liverpool Dental School, Liverpool, UK

SUMMARY Increasingly, clinicians are called upon to restore dentitions, which have become mutilated because of tooth loss, wear, trauma and disease. In many cases, restoration of the occlusal plane may be required. A simple tool, which provides the laboratory technician with an approximation of the patients original occlusal curve may be useful. The purpose of this study is to determine the accuracy of the occlusal curve designed using the Broadrick ag. A total of 100 patients with intact dental arches were examined, and deviations from the Broadrick curve were measured on scanned study models using a software package. Simple descriptive

statistics were used to investigate the data, and intra-examiner reliability was examined using a Bland Altman plot. The results demonstrated little deviation from the Broadrick curve in natural adult dentitions, mean deviation 01262 mm, 95% condence interval )032 to 02844. Good intra-examiner reliability was achieved. It can be concluded that the Broadrick ag method may be of use in determining an appropriate occlusal curve for dentate individuals with deranged occlusal planes. KEYWORDS: Broadrick ag, occlusal curve, restoration Accepted for publication March 7 2005

Introduction
It is becoming apparent that more patients will remain at least partially dentate for their entire life. It is important to understand the overall effects of loss of teeth on patients and the rationale behind the maintenance and replacement of teeth. A Finnish study (1) carried out in 19771978 and repeated in 1989, showed that there were improvements in the number of remaining teeth in the 3039 age group, but the middle aged and elderly patients still had a reduced dentition, generating a need for some form of prosthetic replacement for many years to come. In 2000, Steele et al. (2) found that in the UK, the proportion of edentulous adults had fallen to 13%. This paper also demonstrated that most individuals will retain some natural teeth, but this will only be of benet if enough are retained to maintain adequate function. When investigating the numbers of antagonistic pairs of teeth remaining, Battistuzzi et al. (3) found that the
2005 Blackwell Publishing Ltd

most commonly missing posterior tooth was the rst permanent molar. Marcus et al. (4) had similar ndings, and Meskin and Brown (5), reported that mandibular posterior teeth were more likely to be missing than maxillary. Both Craddock and Youngson (6) and Killiaridis et al. (7), detected overeruption in a high proportion of cases with unopposed posterior teeth. Drifting and tipping of teeth adjacent to an extraction site is a commonly reported phenomenon. Teeth commonly drift or tip unless restrained by contact with adjacent teeth or occlusal contacts in the opposing arch, and the direction of tip or drift will also be under these inuences. Papandreas et al. (8), using cephalometric analysis, measured space closure following extraction of rst premolars in the mandible of adolescent subjects. The authors found that the crowns of the lower rst molars moved mesially more than the apices resulting in tipping or a combination of tipping and mesial drift.

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Fig. 1. Determination of the curve of Spee.

These movements play a part in the derangement of the patients occlusal scheme following posterior tooth loss, and may result in difculties in redening the curve for occlusal reconstruction. In classical descriptions of an intact normal natural dentition (9), an anteroposterior curve exists, which passes through the cusp tip of the mandibular canine and the buccal cusp tips of the mandibular premolar and molar teeth and extends posteriorally to pass through the anterior point of the mandibular condyle. (Fig. 1) The radius of this curve is 4 ins, and is best viewed from the lateral aspect. It is referred to as the Curve of Spee after the German anatomist who rst described it in 1890. Arrangement of the posterior teeth to follow this curve permits posterior tooth disclusion on mandibular protrusion given proper anterior tooth guidance. The natural arrangement of the posterior occlusal scheme may be disturbed by rotation, tipping and overeruption of posterior teeth, most commonly occurring following posterior tooth loss. Provision of a restoration within such a disturbed posterior occlusal scheme, may result in the introduction of a posterior protrusive interference (10). The challenge to the restorative dentist when restoring posterior dentitions is to design an occlusal scheme in harmony with the patients incisal and condylar guidance, and permitting total posterior disclusion on mandibular protrusion. In 1963, Dr Lawson Broadrick developed an instrument to provide a guide to the most suitable position and orientation of the posterior occlusal scheme where the natural Curve of Spee has been deranged (Brown and Lewis, Pers. comm., June 2004 ). This instrument is

Fig. 2. Broadrick anterior survey point.

commercially marketed as the Broadrick Occlusal Plane Analyser*, often referred to as the Broadrick ag. This instrument includes a laminated piece of cardboard that is attached to the superior aspect of the upper member of a semi-adjustable articulator. Its purpose is to permit reconstruction of the Curve of Spee in harmony with anterior and condylar guidance (10). It requires that articulated casts of the patients dentition be mounted in the articulator following facebow transfer. As the Curve of Spee is an arc of circle that passes through the cusp tip of the mandibular teeth and mandibular condyle, it is possible to locate the centre of the Curve on the Broadrick ag using a compass. Lynch and McConnell (11) described the use of teeth for both the anterior and posterior survey points for determination of the occlusal curve. In their study, the mandibular canine was selected as the Anterior Survey Point from which an arc of 4 ins was drawn using the compass on the Broadrick ag (Fig. 2). The distal incline of the disto-buccal cusp of the most distal molar was selected as the Posterior Survey Point (PSP) from which a corresponding arc of 4 ins was drawn onto the laminated plastic card. Should the position of the distal molar be unsuitable, then the most anterior point of the condylar element on the articulator may be selected, as originally described by Broadrick. The point of the compass should then be placed at
*Teledyne Water Pik, Fort Collins, CO, USA.

2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 895900

BROADRICK IDEAL OCCLUSAL CURVE IN DENTATE PATIENTS

The mean age was 5026 years, with a standard deviation of 1305. The 50% of the subjects had the curve assessed on the right side of the arch and 50% on the left. Allocation to each group was random. Alginate impressions were taken of the upper and lower dentition. Following disinfection, these were cast immediately. A snap removal of the impression was performed to minimize distortion of the material on removal from the mouth. The models were then trimmed in a seven-sided conguration, so that the buccal plane would lie parallel to the scanner surface when the models were placed on it. Each pair of study models was placed on the scanning bed of a Black widow 9636 USB three dimensional scanner. They were scanned with a millimetre scale rule included in each image at a resolution of 1401 DPI at 50% scale in full colour. The images were stored in Microsoft Picture it format to retain the three dimensional quality of the image. Using the Broadrick ag method described by Lynch and McConnell (11), the ideal occlusal plane was created using the scanned images. The software used was QuickCAD Millennium edition. This method of estimating an ideal occlusal curve uses anterior and posterior points in order to determine its radius, and thereby allow the curve to be scribed on study models. The Anterior Survey Point was taken as half way down the distal facing slope of the lower canine tip, and the PSP was the mid point of the posterior slope of the disto-buccal cusp of the mandibular second molar. The intercept of these arcs was used to determine the survey centre, which was drawn to pass through the points on the lower canine and second molar already described (Fig. 4). The maximum deviation was measured in the long axis of the tooth with the greatest deviation form the Broadrick curve. The distance from the most deviated cusp tip to the scribed curve was measured. For class 2 incisal relationships, the initial arc radius was 375 in and class 3 relationships a 5-in arc was used. When the deviation was outside the existing curve, a positive notation was given to the value of the deviation. If the deviation was inside the curve, a negative notation was given. When no deviation was detected, a value of zero was given. The incisal relationship was determined by the overjet measurement and classied as follows: 13 mm overjet class l (48% of subjects); >3 mm

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Fig. 3. Drawing occlusal curve.

the intersection of arcs on the ag. A curve can then be drawn through the lower teeth to demonstrate the ideal position of the mandibular cusp tips (Fig. 3). Teeth (or portions of teeth) that are overerupted, infra-occluded, rotated or tipped can then be identied (11). The position of these teeth can then be modied when restoring the posterior dentition. While the Broadrick ag has been commercially available for over 40 years, there is no published work to support the contention that the curve it produces exists in the natural dentition.

Aim of the study

The aim of this study is to investigate whether the Broadrick ag method of determining the appropriate occlusal curve for individual patients has any basis in natural dentitions.

Method
A total of 100 dentate individuals with no missing posterior teeth were recruited. Consecutive patients in the Undergraduate Restorative Clinic, with intact upper and lower arches (all teeth present with the exception of third molars), were invited to participate in the study. All patients were over 18 years of age. The sample consisted of 50 female and 50 male patients. The age range of the sample was 2079 years.

Devcom Ltd, Sterling, UK.

2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 895900

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The intra-examination reliability was therefore calculated.

Results
The mean deviation from the Broadrick generated occlusal curve was 01262 mm, standard deviation 0797, 95% condence interval )032 to 02844. (Table 1). The extent of the deviation ranged from )169 mm to 25 mm. 55% of the subjects investigated had no teeth deviating from the generated curve. Of those with a measurable deviation, three subjects had a maximum deviation between 001 and 05 mm, 15 had a maximum deviation between 051 and 1 mm, 18 had a maximum deviation between 101 and 15 mm, and nine had a measurable deviation >15 mm (Table 2, Fig. 5). When a single examiner is used, it is important to determine intra-examiner reliability. The Bland Altman plot, showing all plots lying within two standard deviations of the mean, demonstrates good intraexaminer reliability. (Chart 2). Correlation coefcients showed no statistically signicant correlation between the deviation from the Broadrick curve and age, sex and overjet. (Table 3).

Fig. 4. Broadrick occlusal plane drawn on image of scanned study models.

overjet class ll (45% of subjects); <1 mm or reverse overjet class lll (7% of subjects). Ten of the subjects already examined, approximately 10% of the total sample, were re-examined to determine intra-examiner reliability. The re-examination group were chosen at random, and were examined at an existing scheduled dental appointment between three and six months after their initial examination.

Discussion
The sample contained a wide age range of adult patients of both sexes, mean age 5026, standard deviation 1305. As the patients were chosen from a combined care Clinic of Leeds Dental Institute, it is believed that they are representative of a population of similar age likely to be encountered in General Dental Practice, and may be of a comparable age range to patients having

Distribution of deviation from Broadrick curve

Number of subjects
70 60 50 40 30 20 10 0 15125 05115 05 to05 05115 15125
Fig. 5. Chart 1: normal distribution of deviations from the Broadrick Occlusal Curve.

Deviation from Broadrick curve

2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 895900

BROADRICK IDEAL OCCLUSAL CURVE IN DENTATE PATIENTS

Table 1. Mean, range and standard deviation of deviation from Broadrick curve
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Bland altman plot of deviation from ideal curve

016

Difference in measurements

Minimum Maximum Mean SD Deviation from Broadrick )169 curve in millimetres 25 0126 0797

014 012 010 008 006 004 002 000 002 004 006 008 15 10 05 00 05 10 15 20

lost posterior teeth (5) and suffered derangement of the occlusal curve. This method of model measurement has previously been described by Craddock and Youngson (6), and has been found to be reliable. The use of widely available equipment and user friendly software for model measurement mean this method could have a wide range of applications. When assessing the accuracy of the Broadrick ag method of determining the orientation of an individuals occlusal curve, it is important to appreciate exactly what is being measured in this investigation. The only measurement recorded for each individual was the maximum deviation from the Broadrick Curve for an individual tooth, and that therefore it is likely that the majority of teeth along the curve are likely to be a closer t. Deviation for an individual tooth may be due to several factors, including tooth fracture, tooth wear, poorly contoured restorations, tooth tipping and drifting and failure of complete eruption, and may not be representative of the t of the curve for the remainder of the quadrant. Overjet measurement is useful for determining the incisal classication, however, in order to determine the relative anterior projection of the dental bases for determination of the skeletal classication, cephalometric analysis for each individual would have been necessary. Bearing in mind the radiation dosage for this type of radiograph, it would not have been ethically appropriate to expose patients for the purpose of our research, and incisal classication was used in this study, whilst appreciating the limitations of this method. The Broadrick ag was designed as an instrument to provide a guide to the location of the centre of the Curve of Spee. The results from this study support its use as a scientic instrument. However, there are
Table 2. Extent of deviation from the Broadrick Curve

Mean of measurement

Fig. 6. Chart 2: Bland Altman plot of intra-examiner reliability. Table 3. Correlation of deviation with sex, age and overjet Correlation of deviation with: Sex Age Overjet (mm) Correlation coefcient 0036 )0064 0056

certain aesthetic and functional scenarios that require the centre of the curve located to be modied slightly. In patients with a class II skeletal pattern, the use of a 4in curve would result in mandibular posterior teeth that are too low. These modications were incorporated into this study. If this had not been the case, a situation could arise, which could introduce posterior interferences and overeruption of the opposing maxillary teeth. Conversely, in a patient with a prognathic mandible, a 4-in radius would result in a curve that is too steep, again leading to posterior occlusal interferences (11). The number of class lll patients was relatively low and further study of this subgroup may be appropriate. However, for the remaining two incisal classication groups, there was no correlation between overjet and deviation from the occlusal curve, somewhat reinforcing the use of a different arc radius for class ll incisal relationships. Extension of the occlusal curve through the mandibular condyle is considered essential when designing proper posterior disclusion (12). The anterior point of

No deviation Deviation within 05 mm Deviation 051 mm 1 mm Deviation 011 mm 15 mm Deviation >15 mm No. of subjects 55 3 15 18 9

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the condylar element is a useful choice for the PSP when the position of the distal mandibular molar is unsuitable. It will be appreciated that the bucco-lingual position of the posterior teeth should also be considered when providing posterior restorations. When viewed from the anterior aspect, the mandibular molars have a slight lingual inclination and the buccal cusps of these teeth are higher than the lingual. This arrangement is referred to as the Curve of Wilson, the purpose of which is to permit lateral mandibular excursions free from posterior interferences (13). The Curves of Spee and Wilson were combined by George Monson, who in 1920 (14, 15) proposed that the mandibular teeth should be arranged to close around a sphere of 4-in radius, with the mandibular incisal edges and cusp tips touching the sphere. It will be appreciated that when posterior restorations are being designed, these should permit posterior disclusion in an anteroposterior and lateral direction. The aims of restorative treatment are usually: to prevent and treat dental and periodontal disease, to restore form, to restore function and to maintain and restore aesthetics. Many of these aims are interrelated, and the restoration of occlusal form may have effects on all the other aims. To have a tool, which accurately predicts occlusal form for an individual, which had been validated on non-restored patients, allows the clinician to make evidence based decisions when restoring occlusal schemes. The results of this study indicate that the use of the Broadrick ag method provides a good approximation of the natural occlusal curve for a wide range of patients, with no correlation between deviation for this curve and age or sex of the patients, or the incisal classication.

References
1. Hiidenkari T, Parvinen T, Helenius H. Missing teeth and lost teeth of adults aged 30 years and over in South-western Finland. Comm Dent Health 1996;13:215222. 2. Steele JG, Treasure E, Pitts NB, Morris J, Bradnock G. Total tooth loss in the United Kingdom in 1998 and implications for the future. Br Dent J. 2000;189:598603. 3. Battistuzzi P, Kayser A, Peer P. Tooth loss and remaining occlusion in a Dutch Population. J Oral Rehabil. 1987;14:541 547. 4. Marcus SE, Drury TF, Brown LJ, Zion GR. Tooth retention and tooth loss in the permanent dentition of adults: United States, 19881991. J Dent Res. 1996;75:684695. 5. Meskin LH, Brown LJ. Prevalence and patterns of tooth loss in US employed adult and senior populations, 19858 J. Dent Educ. 1988;52:686691. 6. Craddock HL, Youngson CC. A study of the incidence of overeruption and occlusal interferences in unopposed posterior teeth. Br Dent J 2004;196:341348. 7. Kiliaridis S, Lyka I, Friede H, Carlsson GE, Ahlqwist M. Vertical position, rotation, and tipping of molars without antagonists. Int J Prosthodont. 2000;13:480486. 8. Papandreas SG, Buschang PH, Alexander RG, Kennedy DB, Koyama I. Physiologic drift of the mandibular dentition following rst premolar extractions. Angle Orthodont. 1993;63:127134. 9. Spee FG, Biedenbach MA, Hotz M, Hitchcock HP. The gliding path of the mandible along the skull. J Am Dent Assoc 1980;100:670675. 10. Bowley JF, Stockstill JW, Attansio R. A preliminary diagnostic and treatment protocol. Dent Clin North Am 1992;36:551 568. 11. Lynch CD, McConnell RJ. Prosthodontic management of the curve of Spee: Use of the Broadrick Flag. J Prosthet Dent 2002;87:593597. 12. Needles JW. Practical uses of the Curve of Spee. J Am Dent Assoc 1923;10:918927. 13. Wilson GH. A Manual of Dental Prosthetics. Philadelphia: Lea & Febiger; 1911:2237. 14. Monson GS. Occlusion as applied to crown and bridgework. J Nat Dent Assoc 1920;7:399413. 15. Monson GS. Applied mechanics to the theory of mandibular movements. Dent Cosmos 1932;74:10391053.

Conclusion
The use of the Broadrick ag can determine an acceptable occlusal curve for individual dentate patients.
Correspondence: H. L. Craddock, Room 6129, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK. E-mail: h.l.craddock@leeds.ac.uk

2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 895900