Face-bow record without a third point of reference: Theoretical considerations and an alternative technique

Carlo Ercoli, DDS,a Gerald N. Graser, DDS, MS,b Ross H. Tallents, DDS,c and Daniel Galindo, DDSd Eastman Dental Center, University of Rochester, Rochester, N.Y.
Accurate mounting of dental casts is achieved by transferring the tridimensional spatial relationship of the maxillary arch to an articulator. A face-bow is used to transfer this relationship to the articulator, usually by relating the face-bow to a plane of reference. The most common reference plane is the Frankfort plane, which has been assumed to be horizontal when the patient is in the natural head position. The axis-orbitale plane has also been considered horizontal and used as reference. However, it has been shown that both planes are not horizontal, and mounting a maxillary cast according to these planes can result in an inaccurate mounting. This article describes an alternative procedure for face-bow transfer without a plane of reference, and uses the angular relationship between the occlusal plane and the condylar path to mount the maxillary cast on the articulator. The elimination of a reference plane, to which relate the functional determinants of occlusion, avoids an additional source of error during the mounting procedure. (J Prosthet Dent 1999;82:237-41.)

ccurate mounting of dental casts is achieved by transferring the tridimensional spatial relationship of the maxillary arch to an articulator, often by using a face-bow. This is traditionally done by using 3 reference points. The criteria used in the selection of these reference points have been ease of location, convenience, and reproducibility. Two points are located in the area of the temporomandibular joints (TMJ).1 A third point is selected, anterior to the TMJs, to define a plane of reference, which is oriented in the articulator so that the 3-dimensional position of the upper cast is reproduced as it is in the patient. Ellis2 suggested that proper mounting of the maxillary cast can be achieved when 2 relationships are established: (1) The distance of the maxillary arch from the intercondylar hinge axis. This relationship is recorded by locating the hinge axis.3-6 Once the axis of rotation is located, the distance of the maxillary arch from this axis is easily recorded with a face-bow. (2) The 3-dimensional relationship between the maxillary occlusal plane and the skull. This function is inherent with the use of a face-bow and is independent from the first one. Some investigators have suggested that the angular relationship between the condylar path and the occlusal plane also should be recorded.7-9 A plane of reference has been used to record this relationship,10 and the most common reference plane is the Frankfort plane (FP).11 The FP is established, in profile, by the lowest point in the margin of the left and right bony orbit
aAssistant

Fig. 1. A, Occlusal plane of maxillary cast. B, Trajectory of condylar inserts of articulator. C, Horizontal upper member of articulator when incisal pin is set at zero.

Professor, Division of Prosthodontics. Chief, and Program Director, Division of Prosthodontics. cProfessor and Program Director, Temporomandibular Joint Disorders Program. dResident, Division of Prosthodontics.
bProfessor,

Fig. 2. A, Occlusal plane of maxillary arch. B, Condylar trajectory. C, Hypothetical horizontal plane.
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Fig. 3. Patient was instructed to protrude his mandible in an edge-to-edge position. Right posterior teeth achieve greater disclusion than left ones.

Fig. 6. Upper cast is mounted in articulator with split cast technique. A, Cast. B, Compound. C, Mounting stone. D, Mounting ring.

Fig. 4. Silicone registration material is used to record protrusive position.

Fig. 7. pound Green heads,

Upper and lower casts secured together with comand nails; split cast mounting is open. A, Casts. B, compound. C, Nails. D, Mounting stone. Arrowsilicone registration material.

Fig. 5. Face-bow record is taken without paying attention to third point of reference. No attention is paid to patients posture.
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Fig. 8. Condylar mechanisms of articulator are loosened and split cast mounting is closed. A, Casts. B, Green compound. C, Nails. D, Mounting stone. Arrowheads, silicone registration material.
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(orbitale) and the highest point in the margin of the right or left bony auditory meatus (porion).11 Originally, this plane was defined parallel to the horizontal plane of reference (HPR) (the Frankfort Agreement).11,12 The HPR can be defined as a horizontal plane established on the face of the patient by 1 anterior reference point and 2 posterior reference points from which measurements of the posterior anatomic determinants of occlusion and mandibular motion are made.11 Thus, it is a true horizontal plane. The convention that the FP is parallel to a horizontal plane implied, by definition, that the former is also horizontal. In 1906, the International Agreement for the Unification of Craniometric and Cephalometric Measurement in Monaco further defined the FP as horizontal. This concept is so widely accepted that the Glossary of Prosthodontic Terms (GPT-7)11 also defines the FP as horizontal. Because the porion point is not reproducible on the articulator, manufacturers of articulators substituted the axis for porion. In this way the axis-orbitale plane (AOP) was assumed to coincide with the FP and by definition11 with the HPR.13 In this way, the misconception was created that parallelism exists between the FP, the AOP, the upper member of the articulator (when the incisal pin is set at zero) and the HPR. However, it has been demonstrated that (1) the FP is not parallel to the AOP14 and (2) when a subject is standing in the natural head position (NHP, also called esthetic reference position [ERP], defined as the position of the head when an individual is sitting or standing erect with the head level and eyes fixed on the horizon),13 the FP is not parallel to the HRP.13,15,16 The upper and lower members of the articulator are, in most articulators, parallel to each other, and to the horizontal plane. Functional components of an articulator are the condylar inserts and the incisal guide table. These elements are set at specific angular relationships with the upper member of the articulator. That the upper member of the articulator is horizontal (when the incisal guide pin is zeroed), is likely the reason why clinicians try to relate the spatial position of the maxillary arch and the inclination of the condylar path to an ideal horizontal plane in the patient. Figures 1 and 2 illustrate this concept. Plane A corresponds to the occlusal plane of the maxillary cast in the articulator and of the maxillary arch in the patient.11 Plane B corresponds to the trajectory of the condylar inserts in the articulator and of the condylar path in the patient. Plane C is the horizontal upper member of the articulator and the HPR when the subject is in the NHP.17 Clinicians have commonly attempted to record the occlusal plane (plane A) and condylar inclinations (plane B) relative to the HRP (plane C), and transfer such relationships to the upper member of the articulator. Planes A and B are easily recorded from a patient and are readily transferred to
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Fig. 9. Right and left mean condylar inclination are recorded for future reference. Right condylar inclination (R) is greater than left one (L) (black arrows). Compare this with greater disclusion noted on patients right side in Figure. 1. A, Upper member of articulator. B, Condylar inserts.

an articulator. Plane C is easy to locate on the articulator (it is represented by the upper member of the instrument when the incisal guide pin is set at zero). However, it is impossible to define it exactly in a patient because of the individual variability of the NHP.17 This article describes an alternative procedure for face-bow transfer that eliminates the need for a plane of reference and uses the angular relationship between the occlusal plane and the condylar path to mount the maxillary cast on the articulator.

PROCEDURE
1. Make impressions of the maxillary and mandibular arches for diagnostic casts. 2. Rehearse with the patient to protrude his mandible until the incisors are in an edge-to-edge position (Fig. 3). (Patients with poor neuromuscular control and/or altered proprioception can be guided in this position by the dentist. In partially or completely edentulous patients, wax rims are used to simulate the dental arches.) 3. Instruct the patient to hold this position and record it with the use of silicone registration material (Regisil PB, Dentsply Caulk, Milford, Del.) (Fig. 4). Make 3 records. 4. After setting, trim the excess material so that only the cusp tips are recorded. 5. Take a face-bow record without paying attention to a third point of reference and/or the posture of the patient (Fig. 5). 6. Mount the upper cast with a split cast technique3 (Fig. 6). 7. Mount the lower cast in maximal intercuspation and separate the upper cast from the split mounting. 8. Relate the upper cast to the lower one by using 1 of the protrusive records. Secure the 2 casts together with nails and compound material (Kerr Co, Romulus, Mich.) (Fig. 7).
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9. Loosen the condylar mechanisms of the articulator and adjust the right and left condylar inclinations to allow the split cast to close (Fig. 8). 10. Repeat steps 8 and 9 with the other 2 protrusive records. 11. Calculate the average values obtained with the 3 protrusive records and program the condylar settings of the articulator (Fig. 9).

DISCUSSION
Anecdotal information has been used to define the spatial relationship of the FP to the HPR.11 The term Frankfort horizontal plane is a misnomer and, as defined, the plane is not horizontal when a subject is in the NHP.13,15,16 The AOP has also been misused as parallel to the HPR; according to Pitchford,13 these 2 planes would form an angle of 13 degrees. The impossibility of locating a horizontal plane when the patient is in the NHP is inherent with the individual variability of this position.17 The concept of NHP was first described by Broca,18 who defined it as the position of a standing man when his visual axis is horizontal. Reproducibility of NHP has been the topic of research for decades with controversial results.17,19-22 As stated by Solow and Tallgren,19 the natural head position has been the subject of considerable interest in the anthropological as well as in the orthodontic literature. Widespread research has been made for a craniofacial reference plane, which in the natural head position, would exhibit a constant relationship to the true horizontal plane. In the anthropologic field, the interest have been motivated by a requirement for comparison of cranial structure in different populations.23-25 In the orthodontic literature, the NHP has been used for assessment of facial esthetics in orthodontic analysis and treatment planning.26-28 Definitions of the NHP have varied among different authors. Furthermore, methods used to help the patient achieve this position (mirror, light sources, or patient self-balance position) have also varied.19,20 In prosthodontics, the relationship of the occlusal plane with the other determinants of occlusion have been described by Hanau (Hanau Quint). 29 He described how the inclination of the occlusal plane, the condylar guidance, the incisal guidance, the cusp height, and the compensating curve relate to each other. Bergstrom1 further analyzed and discussed the occlusal and articular variables and their reproduction by articulators. This article describes a procedure that uses a interocclusal record technique to record the angular relationship of the occlusal plane to the condylar path for the purpose of accurately mounting the maxillary cast on an articulator. With this technique, no attempt is made to locate a plane of reference in the patient or in the articulator; the clinician records and transfers the
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relationship between the occlusal plane, and the condylar protrusive path regardless of the position of the upper member of the articulator. The incisal guide table can also be set with the same protrusive record.30 Any changes in the inclination of the maxillary cast (inclination of the occlusal plane) on the sagittal plane will not alter this ideal position, as far as the inclination of the condylar path is also modified for the same angle.7,29 Protrusive records have been extensively used to record the inclination of the condylar path.1,30-32 Comparative studies have demonstrated that interocclusal protrusive records do not differ from radiographic33 and pantographic34 records. However, some authors have criticized the use of interocclusal records to program the articulator.35,36 In particular, the reproducibility of protrusive records have been questioned. To minimize errors, the authors suggest to take 3 protrusive records and average them to program the articulator. It is our opinion that this technique simplifies the diagnostic procedures during patient evaluation by avoiding the location and transfer of planes of reference. The protrusive record, which is used to mount the cast, can also be used in the restorative phase, thus saving clinical time. Reference planes are not needed for a correct mounting of stone casts. The elimination of a reference plane, to which the functional determinants of occlusion are related, avoids an additional source of error during the mounting procedure.
REFERENCES
1. Beyron H. On the reproduction of dental articulation by means of articulators: a kinematic investigation. Acta Odontol Scand (Suppl)1950;9:3149. 2. Ellis E 3rd, Tharanon W, Gambrell K. Accuracy of face-bow transfer: effect on surgical prediction and postsurgical result. J Oral Maxillofac Surg 1992;50:562-7. 3. Lucia VO. Modern gnathological conceptsupdated. Chicago: Quintessence; 1983. p. 40-6, 49-53. 4. McCollum BB. The mandibular hinge axis and a method of locating it. J Prosthet Dent 1960;10:428-35. 5. Lauritzen AG, Wolford LW. Hinge axis location on an experimental basis. J Prosthet Dent 1961;11:1059-67. 6. Borgh O, Posselt U. Hinge axis registration: experiments on the articulator. J Prosthet Dent 1958;8:35-40. 7. Weinberg LA. An evaluation of the face-bow mounting. J Prosthet Dent 1961;11:32-42 8. Dos Santos Junior J, Nelson SJ, Nummikoski P. Geometric analysis of occlusal plane orientation using simulated ear-rod facebow transfer. J Prosthodont 1996;5:172-81. 9. Olsson A, Posselt U. Relationship of various skull reference lines. J Prosthet Dent 1961;11:1045-9. 10. Brandrup-Wognsen T. Face-bow, its significance and application. J Prosthet Dent 1953;3:618-30. 11. Academy of Prosthodontics. Glossary of Prosthodontic Terms. 7th ed. J Prosthet Dent 1999;81:41-112. 12. Krueger GE, Schneider RL. A plane of orientation with an extracranial anterior point of reference. J Prosthet Dent 1986;56:56-60. 13. Pitchford JH. A reevaluation of the axis-orbital plane and the use of orbitale in a facebow transfer record. J Prosthet Dent 1991;66:349-55. 14. Gonzales JB, Kingery RH. Evaluation of planes of reference for orienting maxillary casts on articulators. J Am Dent Assoc 1968;76:329-36.

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15. Bailey JO Jr, Nowlin TP. Evaluation of the third point of reference for mounting maxillary casts on the Hanau articulator. J Prosthet Dent 1984;51:199-201. 16. Lundstrom F, Lundstrom A. Natural head position as a basis for cephalometric analysis. Am J Orthod Dentofacial Orthop 1992;101:244-7. 17. Luyk NH, Whitfield PH, Ward-Booth RP, Williams ED. The reproducibility of the natural head position in lateral cephalometric radiographs. Br J Oral Maxillofac Surg 1986;24:357-66. 18. Broca M. Sur le Projections de la tete, et sur un nouveau procede de cephalometric. Bullettin de la Societ d Anthropologie de Paris 1862; 3:514. 19. Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand 1971;29:591-607. 20. Chiu CS, Clark RK. Reproducibility of natural head position. J Dent 1991;19:130-1. 21. Lundstrom A, Lundstrom F, Lebret LM, Moorrees CF. Natural head position and natural head orientation: basic considerations in cephalometric analysis and research. Eur J Orthod 1995;17:111-20. 22. Siersbaek-Nielsen S, Solow B. Intra- and interexaminer variability in head posture recorded by dental auxiliaries. Am J Orthod 1982;82:50-7. 23. Von Ihering H. Ueber das wesen der prognathie und ihr verhltniss zur schdelbasis. Arch Anthrop 1872;5:359-407. 24. Schmidt E. Die horizontalebene des menschlichen schdels. Arch Anthrop 1876;9:25-60. 25. Lthy A. Die vertikale gesichsprofilierung und das problem der schdelhorizontalen. Arch Anthrop 1912;11:1-87. 26. Downs WB. Analysis of the dentofacial profile. Angle Orthodont 1956;26:191-212. 27. Bjerin R. Comparison between the Frankfort horizontal and the sella turcica-nasion as reference planes in cephalometric analysis. Acta Odont Scand 1957;15:1-12. 28. Moorrees CFA, Kean MR. Natural head position, a basic consideration in the interpretation of cephalometric radiographs. Am J Physiol Anthrop 1958;16:213-34.

29. Hanau RL. Articulation defined, analyzed and formulated. J Am Dent Assoc 1926;13:1694-707. 30. Knap FJ, Ziebert GJ. Checkbite technique in major oral reconstruction. J Prosthet Dent 1969;21:458-65. 31. Pound E. Let /S/ be your guide. J Prosthet Dent 1977;38:482-9. 32. Halperin RA, Graser GN, Rogoff GS, Plekavich EJ. Mastering the art of complete dentures. Chicago: Quintessence; 1988. p. 116-7. 33. Freitas A de. A comparison of the radiographic and prosthetic measurement of the sagittal path movement of the mandibular condyle. J Oral Surg 1970;30:631-8. 34. Curtis DA. A comparison of protrusive interocclusal records to pantographic tracings. J Prosthet Dent 1989;62:154-6. 35. Craddock FW. Accuracy and practical value of records of condyle path inclination. J Am Dent Assoc 1949;38:697-710. 36. Owen EB. Condyle path: its limited value in occlusion. J Am Dent Assoc 1948;36:284-90.

Reprint requests to: DR CARLO ERCOLI UNIVERSITY OF ROCHESTER EASTMAN DENTAL CENTER DIVISION OF PROSTHODONTICS 625 ELMWOOD AVE ROCHESTER, NY 14620 FAX (716) 244-8772 E-MAIL: Carlo_ercoli@urmc.rochester.edu
Copyright 1999 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/99/$8.00 + 0. 10/1/99196

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