RAAB ET AL

adherent plaque. The SEM examination in this study con- Shannon IL, McCrary BR, Starcke EW. Removal of salivary deposits by
firms previous reports that the ultrasonic method is the commercial denture cleaners. Gen Dent 1976:24:30-A~7.

Myers HM, Krol AJ. Effectiveness of a sonic-action denture cleaning

most effective technique for cleaning the denture program. J PROSTHET DENT 1974;32:613-8.
surface.6*7 Ultrasonically cleaned samples achieved supe- Budtz-Jorgensen E. Materials and methods for cleaning dentures.J
PROSTHET DENT 1979;42:619-23.
rior results in the removal of plaque, debris, and stains in
Gwinnett AJ, Caputo L. The effectiveness of ultrasonic denture clean-
most samples tested. ing: a scanning electron microscope study. J PROSTHET DENT 1983;
Many handicapped patients, such as those who are de- 50~20-5.
bilitated by strokes, lack the physical dexte$ty to clean 6 Dills SS, Olshan AM, Goldner S, Brogdon C. Comparison of the anti-
microbial capability of an abrasive paste and chemical-soak denture
their dentures properly. The ultrasonic cleaning technique cleaners. J PROSTHET DENT 1988;60:467-70.
offers a rapid, inexpensive, effortless method of cleaning 7. Palenik CJ, Miller CH. In vitro testing of three denture-cleaning sys-
tems. J PROSTHET DENT 1984;51:751-4.
dentures for the handicapped patient. Whether ultrasonic
cleaning methods can be more favorably used by all den- Reprint requests to:
ture wearers needs to be verified by a more comprehensive DR. FRANK RAAB
161 MCCARRON ST. 811
clinical investigation. ROSEVILLE, MN 55113

REFERENCES
1. Lindquist L, Andrup B, Hedegard B. Proteshygien II. Klinisk vadering
av ett hygienprogram for patienter med protessto mutitt. Tandlakar-
tidningen 1975;61:872.

Cephalometrically predicted occlusal plane: Implications in

removable prosthodontics
Hercules C. Karkazis, D.D.S., Dr. Dent.,* and Gregory L. Polyzois, D.D.S.,
Dr. Dent., M.Sc.D.*
University of Athens, School of Dentistry, Athens, Greece

Although the determination of the occlusal plane is crucial in clinical removable

prosthodontics, none of the existing methods gives su5cient guidelines for that
purpose. The aim of this investigation was to check the hypothesis that the
angulation of the occlusal plane is generally related to the skeletal base of the
maxillae. Statistical analysis revealed (1) no strong linear correlation (p->O.OS)
between the following variables: (a) the length of Cook’s plane to Cook’s occlusal
plane angle, (b) the length of the maxillary plane to the maxillary occlusal plane
angle, and (c) the PO Na AN6 angle to the occlusal Frankfort plane angle; (2) no
parallelism between the occlusal and HIP plane with a mean angle of 4.57 degrees,
SD 2.57 degrees, and range of 0 to 9.5 degrees; and (3) no correlation between the
predicted and clinically determined occlusal planes (r0.267, t1.797, p 70.05). (J
PROSTHET DENT 1991;65:258-64.

T he function and esthetics of removable prostheses
are dependent on the correct orientation of the occlusal
plane. Many theories and methods have been proposed
over the years to facilitate correlation of the artificial
occlusal plane to the natural 0ne.l
Lateral cephalometric radiography has been used for the
study of the relationships between the natural occlusal
Presented at the European Prosthodontic Association meeting,
Oslo, Norway.
*Assistant Professor, Department of Prosthodontics.
10/l/22689
plane and other cranial landmarks2 and recently for
prediction of the occlusal plane orientation in complete and
partial denture fabrication.3-5 However, none of these
methods provides evidence for widespread clinical appli-
cation.
The objective of this investigation was to check the hy-
pothesis that the angulation of the occlusal plane is gener-
ally related to the skeletal base of the maxillae.
An attempt was made to:
1. Study the relationship between the length of Cook’s
plane running from the anterior nasal spine (ANS) to the
hamular notch (HN) and the angulation of the occlusal
plane relative to Cook’s plane;
2. Explore the possible correlation between the length of

258 FEBRUARY lBB1 VOLUME 66 NUMBER 2

CEPHALOMETRICALLY PREDICTED OCCLUSAL PLANE

Fig. 1. Landmarks (AN&, anterior nasal spine [anterior tip of sharp bony process at
lower margin of anterior nasal opening]; HN, hamular notch; IT, mesioincisal angle of up-
per central incisor [incisai tip]; UMT, mesiolingual cusp of maxillary first molar [upper
molar tip]; Cook’s plane, line extending from ANS to HN; occlusal plane, line extending
from IT to UMT) and measurements (Cook’s plane to occlusal plane [degrees]; ANS-HN
[mm] for dentulous sample.

Fig. 2. Landmarks (AN&, anterior nasal spine; PNS, posterior nasal spine; IT, incisal tip;
UMT, upper molar tip; maxillary plane, line extending from ANS to PNS; occlusal plane,
line extending from IT to UMT) and measurement (maxillary plane to occlusal plane [de-
grees]) for dentulous sample.

the maxillae (ANS-PNS) and the angle formed by the in-
tersection of the occlusal and maxillary planes;
3. Repeat Monteith’s measurement,3 which is the rela-
tionship between the superior border of the external audi-
tory meatus (PO)-Nasion (Na)-ANS angle and the angle
formed by the intersection of the occlusal-Frankfort hor-
izontal planes;
4. Check the observation that the occlusal plane tends to
parallel the hamular notch-incisive papilla (HIP) plane;6
and,

THE JOURNAL OF PROSTHETIC DENTISTRY 259

 KARKAZIS AND POLYZOIS

Frankfort Horizontal

Or

Fig. 3. Landmarks (AN&, anterior nasal spine [point on lower contour of anterior nasal
spine where vertical thickness is 3 mm]; Na, nasion; PO, superior border of external audi-
tory meatus [by means of ear rods of cephalostat]; Or, orbitale; IT, incisal tip; UMT, up-
per molar tip; Frankfort horizontal plane, line extending between Or and PO;occlusal plane,
line extending between IT and UMT) and measurements (PoNaANS [degrees] and
occlusal plane to Frankfort plane [degrees]) for dentulous sample.

5. Verify Monteith’s proposed formula3-5 by checking
the cephalometrically predicted occlusal plane against
the clinically determined one on a sample of denture
wearers.
MATERIAL AND METHOD
Young, dentate subjects were chosen consisting of IO
men and 12 women with 28 to 32 teeth present in an
acceptable arch form, with an Angle’s class I relationship,
and with no history of orthodontic treatment. In addition,
22 men and 22 women who wore complete dentures were
included in this investigation.
Lateral cephalometric radiographs were made with the
mandible in the rest position for all subjects by using stan-
dard techniques.l
Landmarks and measurements
The landmarks and measurements used in this investi-
gation were as follows: dentate sample (Cook’s plane,
ANS-PNS, PO Na ANS, and HIP) (Figs. 1 through 4) and
edentulous sample (Fig. 5).
The clinical determination of the anteroposterior incli-
nation of the artificial occlusal plane was made according
to the alatragus line running from the lower border of the
alae of the nose to the middle of the tragus of the ear.
On the dentate subjects, the points of reference of the
occlusal plane were identified on the radiographs by metal
pellets attached to the incisal tip (IT) and upper molar tip
(UMT) with sticky wax.
The superior border of the external auditory meatus (PO)
was located on the radiographs by means of the metal rods
of the ear-fixation pins.8 A line perpendicular to the
occlusal plane was drawn 10 mm distal to the IT. The point
of intersection between this line and the lower border of the
hard palate in this region was identified as the landmark
incisive papilla (IP) (Fig. 4). Tracings were made on acetate
paper from all of the radiographs. Linear and angular
measurements were recorded to the nearest 0.5 mm.
Data of the dentulous sample were analyzed by use of
regression and correlation analyses whereas Student’s
t-test was applied to the edentulous sample. A level of 0.05
probability was accepted as statistically significant.
RESULTS
The results are presented in Table I. Statistical analyses
revealed the following:
1. No strong linear correlation (p >0.05) existed between
the following variables: (a) the length of Cook’s plane to
Cook’s occlusal plane angle, (b) the length of maxillary
plane to the maxillary occlusal plane angle, and (c) the PO
Na ANS occlusal angle to the Frankfort plane angle.
2. No parallelism was found between the occlusal and
HIP planes with a mean angle of 4.57 degrees, SD 2.57 de-
grees, and a range of 0 to 9.5 degrees.
3. No correlation was found between predicted and clin-
ically determined occlusal planes (r = 0.267, t = 1.797, p
>0.05).
The difference of their values follows a normal distribu-

260 FEBRUARY 1891 VOLUME 66 NUMBER 2

CEPHALOMETRICALLY PREDICTED OCCLUSAL PLANE

Fig. 4. Landmarks (IP, incisive papilla [see text for identification]; HN, hamular notch;
IT, incisal tip; UMT, upper molar tip; HIP plane, line extending between HN and IF, oc-
clusal plane, line extending between IT UMT) and measurement (HIP plane to occlusal
plane [degrees]) for dentulous sample.

Fig. 5. Landmarks (AN&, anterior nasal spine [point on lower contour of anterior nasal
spine where vertical thickness is 3 mm]; Na, nasion; PO, superior border of external audi-
tory meatus [by means of ear rods of cephalostat]; Or, orbitale; IT, incisal tip; UMT, up-
per molar tip; Frankfort horizontal plane, line extending between Or and PO;occlusal plane,
line extending between IT and UMT) and measurements (PONo ANS [degrees] and oc-
ciusal plane to Frankfort plane [degrees]) for edentuious sample.

tion (x2 = 3.648, df = 3, p >0.05) with a mean of 1.65 of 4.38 degrees. The means of the two variables (predicted
degrees, standard deviation k5.28 degrees, median 1.65 and clinically determined) proved to have no significant
degrees, maximum 13.3 degrees, skewness 0.0072, and kur- difference although the t value was marginal (t = 1.923,
tosis -0.391, although the absolute differences have a mean df = 43, p = 0.0586).

THE JOURNAL OF PROSTHETIC DENTISTRY 261

 KARKAZIS AND POLYZOIS

Table I. Measurements on dentulous and edentulous sample

Dentulous

ANS - HN Plane - HN.ANS ANS - PNS Occlusal - Maxillary PO - Nn.ANS Occlusal - Frankfort HIP - Occlusal
Occl (mm) (degrees) (mm) (degrees) (degrees) (degrees) (degrees)

61 9.5 56 4.5 69.5 8.5 8.5

60.5 14.5 57 5 70 16.5 7.5
65 13 67.5 5 71 10.5 3
55.5 14 53.5 6 68 11 6.5
64.5 11 62 6.5 78 10 9.5
65 17.5 58.5 7.5 65.5 19 6
61.5 16.5 60.5 8.5 71.5 10 3.5
65 8.5 60 1 73 7 8
63.5 18.5 58.5 8 76 14 1.5
57 16.5 52.5 6 67 9.5 6
58.5 12.5 55.5 6.5 72 12 4.5
53 13.5 52.5 8 77 8 4
55 14 48.5 4 72 10.5 5
59 20.5 58 15.5 76 17.5 2
59.5 18.5 55.5 13.5 74 17.5 3
60 18.5 55 9 70 12 1.5
55.5 20 53 12 71 13 4
58.5 19.5 53 10.5 75.5 9 3
56 17.5 52.5 10.5 73.5 7 5
55.5 16.5 51.5 10 83.5 8.5 7
49.5 20.5 48 11.5 69.5 17.5 1.5
54.5 19.5 52 11 73 13 0

n = 22 n = 22 n = 22 n = 22
I = -0.4085 r = -0.2879 r = -0.2977 ii = 4.57
p > 0.05 p > 0.05 p > 0.05 SD = 2.57
p > 0.05

*Through Monteith’s formula y = 77.3484 - (0.9098 x).

In 1985, Monteith,314 on the basis of investigations by

DISCUSSION
In 1953, Sloane and Cook9 conducted a study of 26 dry
skulls and found that the plane of occlusion is strongly re-
lated to the length of the line connecting the ANS and the
hamular notch, which also represents the skeletal base of
the maxillae.
Eighteen years later, L’Estrange and Vig,‘O using a
cephalometric method, found that the angulation of the
occlusal plane to the maxillary one is related to the height
and length of the maxillomandibular space.
However, our first result indicated no such correlation (p
>0.05). This discrepancy was probably due to the different
determination of the occlusal plane and the totally differ-
ent methodology. Instead of using the hamular notch,
which is difficult to identify on radiographs, it was decided
to use an equivalent bony landmark (the PNS) and repeat
the measurements. The ANS-PNS line represents the
skeletal base of the maxillae as well. The results again
showed no correlation (p >0.05).
Sloan and Cook9 and L’Estrange and Vig,i” reported that
the PO Na ANS angle is inversely related to the occlusal-
Frankfort planes angle. He subjected his results to a
regression and correlation analysis and found a strong cor-
relation (r2 = 76%) p <0.005) between the two angles. He
finally developed a formula for the determination of the
occlusal plane angulation relatively to the Frankfort plane.
In a later application of his measurements on a sample of
white men and on a sexually mixed sample of 40 Tsawana-
speaking black persons, he reported a coefficient of deter-
mination r2 of 80% and 78% respective1y.l’
Chow et all2 in 1986 repeated Monteith’s measurements
on a sample of 32 Cantonese men and reported a low coef-
ficient of determination r2 = 26%, “a value that is essen-
tially useless in a predictive application.”
These measurements were repeated on our denture sub-
jects by use of exactly the same landmarks and methodol-
ogy. However, no significant correlation was found (r2 =
8.87 % ,p >0.05). According to our results, none of the three

FEBRUARY 1991 VOLUME 136 NUMBER 2

CEPHALOMETRICALLY PREDICTED OCCLUSAL PLANE

on a sample of 10 white edentulous subjects, concluded that

his proposed method was promising in accuracy and
Edentulous
esthetic quality.
Predicted occlusal* Clinically determined As a second part of the present investigation, the com-
plane (degrees) occlusal plane, (degrees)
puted occlusal plane according to Monteith’s formula was
Men Women Men Women checked against the clinically determined one on a sample
of 44 edentulous subjects. The clinical determination of the
12.3 12.7 3.5 10.5 artificial occlusal plane by use of various intraoral and ex-
9.1 11.4 -2 19.5 traoral landmarks, such as Camper’s line and retromolar
10.9 14.6 10 15 pads, is a well-established and widespread method usually
9.6 10.9 11 8.5
leading to accepted esthetic and functional results.
13.20 10.0 8 10
Although Monteith’s proposed formula is still a contro-
10.93 15.9 12 12.5
15.02 15.0 8 15.5
versial issue, its application to our denture wearers sample
16.4 6.4 7.5 0 might be of clinical interest. According to our results,
21.8 18.7 8.5 12 Monteith’s formula cannot determine the actual occlusal
14.6 7.3 9.5 4.5 plane but is close to a clinically determined plane.
15.5 11.8 11.5 10.5 Certain factors such as polymerization shrinkage of
10.9 8.6 13 6.5 acrylic resin and distortion from the relieving of internal
10.0 13.7 15 13 strains produce a combined effect leading to a spatial
11.4 6.4 9 0 movement of artificial teeth and the occlusal plane.13l’4
17.7 6.8 6.5 9.5
The nature of this movement is characterized by a drop-
8.2 17.7 15.5 15.5
ping of the occlusal plane at the posterior region, thus
10.9 11.4 19 19
10.5 8.6 7.5 16.5
bringing the resultant plane in closer agreement with the
18.2 5.9 18.5 7.5 computed one.
12.3 8.2 10 12
CONCLUSIONS AND CLINICAL
9.1 16.8 7 9.5
9.6 6.4 8.5 11
IMPLICATIONS
1. No evidence was found that any of the three studied
n = 44 parameters (Cook’s plane, ANS-PNS, and PO Na ANS)
t = 1.923 could be used as a reliable guideline for determination of
the occlusal plane through a regression formula.
p > 0.05
2. The HIP plane tends to parallel the occlusal plane,
giving one more guideline for its determination, although
further clinical application is necessary.
3. Monteith’s formula cannot determine the occlusal
plane in edentulous subjects, although it provides occlusal
mentioned parameters (Cook’s plane, ANS-PNS, and PO planes closely oriented to the clinically determined ones.
Na ANS) could be used for the determination of the When used properly, cephalometrics is a useful tool for
occlusal plane angulation through a regression formula. removable prosthodontics research and clinical practice.
Rich6 used simple instrumentation on 32 maxillary casts On the basis of these results and previous similar
of worn dentitions and observed a relationship between the studies,15yl6 the authors believe that cephalometrics is
occlusal plane and the hamular notch-incisive papilla valuable in studying the vertical dimension of occlusion
(HIP) plane. The divergence between HIP plane and the maxillomandibular relationship or alveolar bone loss, but
attritional occlusal plane was 4.31 degrees, with a range of seems to be of limited value for the prediction of the
4 to 8 degrees. For the same measurement, this study found occlusal plane. Well-established procedures in the hands of
a mean value of 4.57 (t = 0.34, p <0.05) with a range of 0 experienced dentists still offer successful, convenient, and
to 9.5 degrees. The discrepancy was probably due to the prompt results.
different methodology. The HIP plane also has been used
for the mounting of maxillary edentulous casts in a special
REFERENCES
articulator designed for the Triad (Dentsply Int. Inc., York,
Pa.) denture system. 1. Williams DR. Occlusal plane orientation in complete denture construc-
tion. J Dent 1982;10:311-6.
Our results confirmed Rich’s observation that the HIP 2. Karkazis HC, Polyzois GL, Zissis AJ. Relationship between ala traeus
plane tends to parallel the occlusal plane, which gives an- line and natural occlusal plane. Implications in denture prosthodontics.
other guideline for the occlusal plane determination. Fur- Quintessence Int 1986;17:253-5.
3. Monteith BD. A cephalometric method to determine the angulation of
ther clinical application is needed to establish this concept. the occlusal plane in edentulous patients. J PROSTHET DENT 1985;
Monteith,5 in a further clinical evaluation of his concept 54:81-T

THE JOURNAL OF PROSTHETIC DENTISTRY 263

 KARKAZIS AND POLYZOIS

4. Monteith BD. A cephalometrically programmed adjustable plane: a new
concept in occlusal plane orientation for complete denture patient. J
PROSTHET DENT 1985;54:388-94.
5. Monteith BD. Evaluation of a cephalometric method of occlusal plane
orientation for complete dentures. J PROSTHET DENT 1986;55:64-9.
6. Rich H. Evaluation and registration of the HIP plane of occlusion. Aust
Dent J 1982;27:162-8.
7. Broadbent BH. A new x-ray technique and ita application to orthodon-
tia. Angle Orthod 1931;1:45-66.
8. Ricketts RM. Perspectives in the clinical application of eephalometrics.
Angle Orthod 1981;51:115-50.
9. Sloane RB, Cook J. A guide to the orientation of the plane of occlusion.
J PROSTHET DENT 1953;3:53-65.
10. L’Estrange PR, Vig PS. A comparative study of the occlusal plane in
dentulous and edentulous subjects. J PROSTHET DENT 1975;33:495-503.
ll. Monteith BD. Letter to the editor. J PROSTHET DENT 1986;55:663-4.
:X2. Chow TW, Clark RKF, Darvell BW. Letter to the editor. J PROSTHS~
DENT 1986;55:662-3.
13. Karkaais HC, Polyzois GL. A study of the occlusal plane orientation in
complete denture construction. J Oral Rehabil 1987;14:399-404.
14. Polyzois GL, Zissis AJ, Karkazis HC, Demetriou PP. Changes of verti-
cal occlusal relationships in fast-boiled denture base resins: a compar-
ative study. Quintessence Dent Technol 1986;10:441-5.
15. Chaconas SJ, Gonidis D. A cephalometric technique for prosthodontic
diagnosis and treatment planning. J PROSTHET DENT 1986;56:567-74.
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space in edentulous patients: a cephalometric approach. J Oral Rehabil
1983;1Oz283-93.
Reprint requests to:
DR. HERCULFL? C. KARKAWS
SCHOOL OF DENTISTRY
UNIVERSITY OF ATHENS
2 THNON Sm, GOUDI 11527
ATHENS, GREECE

264 FEBRUARY 1991 VOLUME 66 NUMBER 2