REMOVABLE PROSTHODONTICS

The anterior point of reference

Noel D. Wilkie, D.D.S.*
Naval Regional Dental Center, Pearl Harbor, Hawaii
I- ositioning the maxillary cast in an articulator is
an essential part of many techniques in dentistry.
Two major objectives are restoration of the occlusion
and control of the form and the position of the teeth.
The degree of knowledge that the dentist and the
auxiliaries have, coupled with their ability to apply
this knowledge, will determine how well these objec-
tives are satisfied.
The dentist should thoroughly understand the
concept of the anterior point of reference and how it
should be chosen to accomplish the treatment objec-
tives. The student of prosthodontics should give
concentrated thought to the anterior point of refer-
ence and be acquainted with several concepts as
alternatives to be used in treating the difficult
patient. Both dentist and student should be thor-
oughly familiar with the difficulties that arise if the
choice and the use of the anterior reference point are
not well coordinated with all individuals taking part
in fabricating the prosthesis.
To do less means that the maxillary cast will be
positioned in the articulator arbitrarily. Such uncon-
scious or purposeful neglect by the dentist may result
in additional and unnecessary record making, an
unnatural appearance in the final prosthesis, and
even damage to the supporting tissues. To delegate
the positioning of the maxillary cast in the articula-
tor to someone who is not fully knowledgeable and
who is unaware of the consequences of an arbitrary
mounting can result in extra expense and unnecessa-
ry trauma to the patient.
The maxillary cast in the articulator is the base-
line from which all occlusal relationships start, and it
should be positioned in space by identifying three
points which cannot be on the same line. The plane
is formed by two points located posterior to the
maxillae and one point located anterior to them
(Fig. 1).
POSTERIOR POINTS OF REFERENCE
Often the two posterior points are located by
measuring prescribed distances from skin surface
landmarks. Some of the commonly used posterior
points were shown by Beck to be clinically near
the hinge axis. He concluded that the Bergstrom
point* (Fig. 2, a) most frequently is closest to the
hinge axis. He identified the Beyron point? (Fig. 2, h)
as the next most accurate posterior point of refer-
ence. Studies by Weinberg state that a deviation
from the hinge axis of 5 mm will result in an
anteroposterior displacement error of 0.2 mm at the
second molar. An error of this size is usually of no
consequence in removable prostheses with nonrigid
attachments. With these prostheses: intended toler-
ances in the occlusion and the mobility of the
supporting tissues may make a precise location of the
hinge axis an exercise with no advantage.
On the other hand, fixed and removable partial
dentures with rigid attachments demand close toler-
ances in cusp pathways. These restorations may
require the use of a kinematic technique that will
locate the hingeaxis exactly.
If the maxillary cast is positioned without the
correct maxillae-hinge axis relationship, arcs of
movement in the articulator will occur which differ
from those of the patient. Verification of the man-
dibular cast position by using interocclusal records
made at increased vertical dimensions of occlusion
The opinions or assertions contained herein are those of the writer
and are not to be construed as official or as reflecting the views
of the Department of the Navy.
Presented before the Academy of Denture Prosthetics, San Anto-
nio, Texas.
*Captain, DC, USS; Commanding Officer.
*Bergstrom point: A point 10 mm anterior to the center of a
spherical insert for the auditory meatus and 7 mm below the
Frankfort horizontal plane. (Adapted from Beck.)
fBeyron point: A point 13 mm anterior to the posterior margin of
the tragus of the ear on a line from the center of the tragus to
the corner of the eye. (Adapted from Beck.)
MAY 1979 VOLUME 41 NUMBER 5
ANTERIOR POINT OF REFERENCF.
Fig. 1. A spatial plane is formed by two posterior points
and one anterior point.
will be difficult or impossible unless subsequent
records are the same thickness. Also, an occlusion
that is restored to an incorrect arc of closure may
have interceptive and deflective tooth contacts in the
hinge-closing movement if there are subsequent
changes in the vertical dimension of occlusion.
Deflective contacts also may be present in functional
and parafunctional lateral movements from the time
the restoration is initially inserted. Such contacts are
undesirable in either natural or artificial occlusions
and can contribute to periodontal trauma, muscle
spasm, TMJ pain, and loss of supporting edentulous
tissues.
THE ANTERIOR POINT OF REFERENCE
The selection of the anterior point of the triangu-
lar spatial plane determines which plane in the head
will become the plane of reference when the prosthe-
sis is being fabricated. The dentist can ignore but
cannot avoid the selection of an anterior point. The
act of affixing a maxillary cast to an articulator
relates the cast to the articulators hinge axis, to the
vertical axes, to the condylar determinants, to the
anterior guidance, and to the mean plane of the
articulator. The act achieves greater importance by
the use of a constant third point of reference and
repeatable posterior points of reference. When three
points are used the position can be repeated, so that
different maxillary casts of the same patient can be
positioned in the articulator in the same relative
position to the end-controlling guidances. With
complicated and time-consuming recording tech-
Fig. 2. Posterior points of reference. a, Bergstrom point.
b, Beyron point.
Fig. 3. Orbitale (o), axis-orbital plane (a-o), and Frankfort
horizontal plane (f-o).
niques such as a pantographic tracing, the dentist
does not have the time, nor the patient the means, to
repeat records each time the technique calls for a
new maxillary cast. For this reason it is important to
identify the mark permanently or be ahle to repeti-
tively measure an anterior point of reference as well
as the posterior points of reference.
THE JOURNAL OF PROSTHETIC DENTISTRY
489
WILKIE
Fig. 4. Face-bow supported at the level of the axis-orbital
plane.
Fig. 5. Maxillary record base and vertical support arm
are fixed by plaster in the transfer cup.
SELECTION OF AN ANTERIOR REFERENCE
POINT
In selecting the reference plane, the dentist should
have knowledge of the following anterior points and
the rationale for the selection of each.
1. Orbitale (FZg. 3). In the skull, orbitale is the
lowest point of the infraorbital rim. On a patient it
can be palpated through the overlying tissue and the
skin. One orbitale and the two posterior points that
determine the horizontal axis of rotation will define
the axis-orbital plane. Relating the maxillae to this
plane will slightly lower the maxillary cast anteriorly
from the position that would be established if the
Frankfort horizontal plane were used. Practically,
Fig. 6. The transfer cup is attached to the articulator.
the axis-orbital plane is used because of the ease of
locating the marking orbitale and because the
concept is easy to teach and understand.
Orbitale and the two posterior landmarks defining
the plane are transferred from the patient to the
articulator with the face-bow. The articulator must
have an orbital indicator guide that is in the same
plane as the hinge of the articulator. Orbitale is
transferred from the patient to this guide by means
of the orbital pointer on the anterior crossarm of the
face-bow.
The axis-orbital plane can be transferred to the
articulator in another manner. The face-bow itself is
raised to the axis-orbital plane on the patient (Fig.
4). A metal arm attached to the maxillary record
base is rigidly fixed by plaster in a cup that also
attaches to a vertical support arm on the face-bow
(Fig. 5)* and subsequently to a vertical support arm
on the articulator (Fig. 6).t The relationship of these
two vertical support arms to the hinge line is
identical. Therefore the record base which is rigidly
fixed to the vertical arm attachment can be trans-
ferred from the patient to the articulator. This will
relate the maxillary cast to the axis-orbital plane or
to any other plane with which the face-bow is
paralleled on the patient.
2. Orbitale minus 7 mm (Fig. 7)~ The Frankfort
horizontal plane passes through both poria and one
orbital point. Because porion is a skull landmark,
Sicher recommends using the midpoint of the upper
border of the external auditory meatus as the poste-
rior cranial landmark on a patient. Most articulators
do not have a reference point for this landmark.
Gonzalez pointed out that this posterior tissue
*Hanau Earpiece Face-bows, Models 140-l and 140-2. Hanau
Engineering Co., Inc., Buffalo, N. Y.
fHanau Transfer Index, lModels 140-10.5 and 140-106, Hanau
E:ngineering Co., Inc., Buffalo, N. Y.
490 MAY 1979 VOLUME 41 NUMBER 5
ANTERIOR POINT OF REFERENCE
Fig. 7. 11-0, Axis-orbital plane. f-0, Frankfort horizontal
plane. Facial landmark (o minus 7 mm) used to relate
maxillary cast to Frankfort horizontal plane.
landmark on the average lies 7 mm superior to the
horizontal axis. The recommended compensation for
this discrepancy is to mark the anterior point of
reference 7 mm below orbitale on the patient or to
position the orbital pointer 7 mm above the orbital
indicator of the articulator. Bergstroms arcon artic-
ulator automatically compensates for this error by
placing the orbital index 7 mm higher than the
condylar horizontal axis. In either technique, the
Frankfort horizontal plane of the patient becomes the
horizontal plane of reference in the articulator.
3. Nasion minus 23 mm. According to Sicher,
another skull landmark, the nasion (Fig. 8), can be
approximately located in the head as the deepest
part of the midline depression just below the level of
the eyebrows. The nasion guide, or positioner, of the
Quick Mount face-bow* (Fig. 9), which is designed
to be used with the Whip-Mix Articulator,* fits into
this depression. This guide can be moved in and out,
but not up and down, from its attachment to the
face-bow crossbar. The crossbar is located 23 mm
below the midpoint of the nasion positioner. When
the face-bow is positioned anteriorly by the nasion
guide, the crossbar will be in the approximate region
of orbitale. The face-bow crossbar and not the nasion
guide is the actual anterior reference point locator.
During the face-bow transfer, the crossbar of the
*The Whip-Mix Corp., Louisville, Ky.
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 8. The nasion.
Fig. 9. Nasion guide (ng) and face-bow crossbar (cb).
face-bow supports the upper frame of the Whip-Mix
articulator. The inferior surface of the frame is in the
same plane as the articulators hinge points. From
this it can be concluded that the Quick Mount
face-bow used with the Whip-Mix articulator
employs an approximate axis-orbital plane.
Locating the orbital point with this technique is
dependent upon the large nasion guide, the morpho-
logic characteristics of the nasion notch, and the
variance of the nasion-orbitale measurement from 23
mm in the patient.
4. Incisal edge plus articulator midpoint to articulator
axis-horizontalplane distance. Guichet has emphasized
that a logical position for the casts in the articulator
would be one which would position the plane of
occlusion near the mid-horizontal plane of the artic-
ulator. A deviation from this ob.jective may position
casts high or low relative to the instruments upper
and lower arms. The effect of these high or low
positions may be inaccurate occlusal relationships
491
\tlLKIE
Fig. 10. Campers line (cl) and occlusal plane (op).
due to dimensional changes in the artificial stone or
plaster used for cast-mounting purposes.
In accordance with this concept, the distance from
the articulators mid-horizontal plane to the articu-
lators axis-horizontal plane is measured. This same
distance is measured above the existing or planned
incisal edges on the patient, and its uppermost point
is marked as the anterior point of reference on the
face. This point can be recorded for future use by
measuring vertically downward to it from the inner
canthus of the eye and recording this measurement.
The inner canthus is used because it is an accessible,
unchanging landmark on the head.
With this technique the face-bow transfer will
carry the two predetermined posterior points of
reference and this anterior point of reference to the
anticulators axis-horizontal plane. The dentist can
then proceed, knowing that the incisal edges will fall
on the articulators mid-horizontal plane unless a
subsequent decision raises or lowers them.
It must be recognized that this technique does not
relate the Frankfort plane or the axis-orbital plane
parallel to the horizontal plane. Additionally, only
the incisal edges or the most anterior portion of the
occlusal plane will be midway between the upper
and lower articulator arms. A tentative or an actual
occlusal plane will not be parallel to the horizontal
plane unless by coincidence.
5. Alae of the nose. A part of many complete
denture techniques is to make the tentative or the
actual occlusal plane parallel with the horizontal
plane. lhis can be achieved in two ways: i 1: a lint
from the ala* of the nose to the center of the auditor)
meatus describes Campers line (Fig. IO). Au,gsbtuger
concluded, in a review of the literature, that the
occlusal plane parallels this line with miuor maria-
tions in different facial types. Knowing this, the
dentist can transfer C.Iampers lint from the patient
to the articulator by marking the right or left ala on
the patient, setting the anterior reference pointer of
the face-bow to it, and with the face-bow, transfer-
ring the ala anteriorly. and the hinge points poster-
iorly, from the patient to the articulators hinge-of,-
bital indicator plane. 4 second method of estab-
lishing this relationship is to make a wax occlusion
rim parallel to C:ampers line on the face (Fig-. 1 I j.
The desired location for the maxillary incisal edges
should be marked on the wax occlusion rim as an
initial step in determination of the occlusal plane.
This ensures that the tentative occlusal plane will
not be too high or low. The wax occlusion rim made
parallel with Campers line is transferred to the
articulator with a face-bow (Fig. 12). Its occlusal
plane is rnade parallel with the upper and 1owe1
articulator arms (Fig. 13). In this way, the ala-cl~lc
plane (a plane that coincides with Campers line) anti
the tentative occlusal plane arc horizontal and
become the planes of reference in this technique.
Other intraoral landmarks, esthetics. considera-
tion for the residual ridges, and tongue and cheek
guidance factors may alter the ,/inal o~clu.sni plnnr.
Laboratory auxiliaries do not have the benefit or
knowledge of these patient-related factors. lhere-
fore, if the laboratorysjudgment alone is relied upon
to establish the final occlusal level, an unsightly
plane or one which transmits the wrong forces to the
weaker ridge may result.
Practically, the dentist may omit the construction
of an occlusion rim or elect not to identify a tentative
occlusal plane. However, when performing the try-in
and record verification procedures with the patient.
the occlusal plane should be adjusted to the opti-
mum position that will favor esthetics, transmit the
desired forces to the ridges, and permit comfortable
control of food morsels by the tongue and the
cheeks.
*The a/a nm is defined as the rounded eminence of the inferior
lateral surface of the nose. (Adapted from Henry Gray: Anato-
my of the Human Body, W. H. Lewis ied). Philadelphia, 1942,
Lea & Febiger. p 1010.)
492
MAY 1979 VOLUME 41 NJMBER 5
ANTERIOR POINT OF REFERENCE
Fig. 11. Making the occlusion rim parallel to Campers line
Fig. 12. Transfer of the occlusion rim to the articulator with a face-bow
DISCUSSION
Other reasons for selecting an anterior point of
reference must be considered.
1. A planned choice of an anterior reference point
will allow the dentist and the auxiliaries to visualize
the anterior teeth and the occlusion in the articulator
in the same frame of reference that would be used
when looking at the patient. The objective is usually
to achieve a natural appearance in the form and the
position of the anterior teeth. Mounting the maxil-
lary cast relative to the Frankfort horizontal plane
will accomplish this objective. When this reference
plane is used, the teeth will be viewed as though the
patient were standing in a normal postural position
with the eyes looking straight ahead.
2. An occlusal piane not paraliel to rhe horizontal
in the beginning steps of denture fabrication may be
unknowingly located incorrectly because of a
tendency for the eye to subconsciously make planes
and lines parallel. Therefore the dentist may wish to
initially establish the restored occlusal plane parallel
to the horizontal in order IO better control the
occlusal plane in its final position. The objective is to
achieve a natural appearance in the occlusal plane.
Mounting the cast relative to LumpPrs ~.VZB best meets
this objective.
3. The dentist may wish to establish a baseline for
comparison between patients, ar for thch same patient
at different periods of time. Only through the use of
a three-point mounting that is const,ml: from one
THE JOURNAL OF PROSTHETIC DENTISTRY 493
WILKIE
Fig. 13. A maxillary cast in the articulator is related to Campers line.
Fig. 14. A maxillary cast in the articulator related to
Campers line as horizontal. Making the dotted line
parallel with the horizontal relates the maxillary cast to
the Frankfort horizontal plane.
patient to another or for the same patient can valid
comparisons be made. Orthodontists, investigators
using cephalometrics, anthropologists, and other
dental specialists have used the Frankfort horizontal
plane more frequently than any other plane of
reference to accomplish this objective. Although
other planes can be used, the dentist should make
sure that all auxiliary personnel know Z&C/I plane is
being used and understand the rationale for its
use.
Confusion occurs in practical application of the
objectives when the dentist and the laboratory tech-
nicians apply different objectives to the same
patient. The dentist may very well have positioned
the maxilllary cast in relation to the Frankfort
horizontal plane or used one of the other more
superior anterior points of reference. Laboratory
personnel may then proceed to establish the occlusal
plane parallel to the horizontal; or, said another
way. parallel to the upper and lower articulator
arms. The result will be an occlusal plane that drops
from anterior to posterior when placed in the
patients mouth and lines of force that will not be at
right angles to the mean plane of the ridge. This
fault is commonly observed; it results when the
dentist ignores the selection of an anterior point of
reference and the laboratory arbitrarily establishes
every occlusal plane parallel to the articulator arms.
The consequences of the reverse situation will also
be detrimental to the patient. The dentist may use
Campers line as the reference for the maxillary cast
mounting. The laboratory may then position the
anterior teeth and the occlusal plane as though the
Frankfort horizontal plane were being used. The
result will be an occlusal plane that rises severely
from anterior to posterior in the patients mouth and
maxillary anterior teeth that may be excessively
linguoverted. Again, force transmission to the resid-
ual ridges may not bc as desired.
The advantages and disadvantages of using either
494 MAY 1979 VOLUME 41 NUMBER 5
ANTERIOR POINT OF REFERENCE
Fig. 15. A maxillary cast related to Campers line (dotted
line) as the horizontal plane of reference. The occlusal
plane (solid line) is parallel to Campers line and the
horizontal. RULE: to achieve the effect of the Frankfort
plane (double line) as the horizontal reference plane, raise
the back of the articulator.
the Frankfort horizontal plane or Campers line as
the plane of reference have been pointed out. Both
philosophies can be applied advantageously when
the dentist uses the following technique.
First, decide on the principal plane of reference to
be used. Next, position the face-bow on the marked
posterior points of reference and align the anterior
reference pointer to the alternate anterior reference
point on the face. Then carry the face-bow to the
articulator. Relate it posteriorly to the hinge and
anteriorly to the articulators anterior point of refer-
ence guide. With the maxillary cast in place, mark a
line on the cast parallel to the horizontal. Return the
face-bow to the patient and repeat the steps; but this
time use the principal anterior point of reference and
affix the maxillary cast to the articulator once the
face-bow transfer is made. In this manner the cast
will be mounted parallel to one plane of reference,
and a line parallel to the other will be visible on the
maxillary cast (Fig. 14).
As a more practical and less time-consuming
alternative, the following technique can be used: (1)
If the Campers line-horizontal reference plane is used,
raise the back of the articulator to achieve the effect
of the Frankfort horizontal plane mounting (Fig.
1.5); (2) if the Frankfort horizontal plane reference is
used, raise the anterior of the articulator to achieve
the effect of paralleling the occlusal plane and
Campers line (Fig. 16) with the horizontal.
There is one last precaution to observe when
relating the maxillary case in space to a horizontal
Fig. 16. A maxillary cast is related to the Frankfort plane
(double line) as the horizontal plane of reference. RULE: to
achieve the effect of Campers line (dotted iine) and the
occlusal plane (solid line) as the horizontal refcrrnce plane,
raise the front of the articulator.
Fig. 17. Frontal view reference line. IP. Interpupillary
line. hi, Hinge line. op, Transverse line across occlusal
surfaces.
reference plane. The relating planes are usually
thought of as being viewed from the lateral aspect.
When viewed from the frontal aspecr, there are
reference lines as well. The hinge line, rhe interpupil-
lary line, and a transverse line across the occlusal
surfaces are three common frontal-view reference
lines (Fig. 17). The latter two are observed in the
patient, with the hinge line being better seen in the
articulator. Generally these three lines art not paral-
THE JOURNAL OF PROSTHETIC DENTISTRY
495
WILKIL
lel. This is caused by posterior hinge reference points
that are not equidistant from the eye pupils. An
occlusal plane that is parallel to the interpupillary
line will be pleasing to the eye of the viewer. It
cannot be guaranteed that an occlusal plane parallel
to the hinge will have the same pleasing appearance.
This further justifies the dentist making these deter-
minations in the patient and further contraindicates
giving auxiliary personnel the opportunity to decide
on occlusal plane location relative to articulator
landmarks.
SUMMARY
Three points in space determine the position of the
maxillary cast in an articulator. The dentist is most
frequently concerned with selecting the posterior two
of the three reference points. In addition, the dentist
will, either consciously or unknowingly, select the
anterior of these points of reference. This decision
will affect the development of occlusion and esthet-
ics. The dentist and the auxiliaries must share a
common objective in using an anterior point of
reference. Five commonly used anterior points of
reference and the reasons for the use of each har,c,
been discussed.
REFERENCES
I.
2.
3.
4.
5.
6.
7.
Beck, II. 0.: A clinical evaluation of the Arcon concept ,>I
articulation .J PKOSTHET DENT 9:409, 1959.
Weinberg. 1,. A.: An evajuation of the face-bow mountiny. ,J
PRosTHEtT I-hmT 11:X?, 1961.
&her, H.: Oral Anatomy, ed 2. St. Louis, 195. Ihc C 1.
.Mosby Cu.. p 91.
Gonzakx. J H., and Ii mgery, K. II.: Evaluation oi plants ~)t
rrfwcnw for orienting maxillary casts on articulaturc. .J :1m
I)rnt Assoc 76:329, 1968.
Beck. Ii. 0.: and Morrison, W. E.: Investigation of an .4rcorl
articulator. J PROSTFIEI. DENT 6:359, 1956.
Guichct, N. F.: Occlusion, A Teaching Manual. Anaheim.
1970, The LIenar Corp., p 56.
f\ugsburger. K. Ii.: Occlusal plane relation to facial type. .j
P~cxrm~. Ihvr 3:75.5. 1953.
Reprint requests to.
CAPTAIN NOEL D. WILKIE, IX, CJSN
COMMANDING OPFICER
NAVAL REGIONAI. I)EvrAL &vr~~
Box 111
PEARL HARBOR, I~AWAII 96860
ARTICLES TO APPEAR IN FUTURE ISSUES
Fabrication of a maxillary occlusal treatment splint
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Posterior maxillary osteotomies: An aid for a difficult prosthodontic problem
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Technique for making a customized shade guide
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The effect of relining on the accuracy and stability of maxillary complete
dentures-An in vitro and in vivo study
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D.D.S.. M.S.D., R. W. Dykema, D.D.S., M.S.D.. and R. W. Phillips, M.S., D.Sc.
Temperature change caused by reducing pins in dentin
Wayne W. Barkmeier, D.D.S., M.S., and Robert I,. Cooley, D.M.D., M.S
Simplified Class V matrix or resin restorations
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Current concepts in cranioplasty
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MAY 1979 VOLUME 41 NUMBER 5