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05/09/2014

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Deviation from the Broadrick occlusal curve following
posterior tooth loss
H. L. CRADDOCK*, C. C. YOUNGSON\u2020 & M. MANOGUE\u2021*Lecturer in Restorative Dentistry, Leeds
Dental Institute, Leeds, UK,\u2020Professor in Restorative Dentistry, Liverpool Dental School, Liverpool, UK and \u2021Senior Lecturer, Leeds Dental
Institute, Leeds, UK
SUMMARYProduction of an appropriate occlusal

curve for dentitions which have become deranged because of tooth loss, overeruption, tipping and drifting can present challenges for the dental tech- nician. An earlier paper (J Oral Rehabil, 2005 32: 895\u2013900.) demonstrates that the use of the Broadrick \ufb02ag method for producing the occlusal curve is relatively accurate for most intact arches. This study demonstrates that when a posterior tooth has remained unopposed for 5 years or more positional changes, which cause deviation from the Broadrick curve, occur. The extent of the deviation may be

extreme, potentially leading to dif\ufb01culties in restor- ing a harmonious occlusal scheme. This study also demonstrates that the Broadrick curve may provide an accurate reproduction of the occlusal curve, even when the tooth forming the posterior determinant of the curve is tipped. A moderate degree of tipping of this tooth has little effect on the radius of the Broadrick curve.

KEYWORDS: Broadrick occlusal curve, posterior tooth
loss
Accepted for publication 24 September 2005
Introduction

Patterns of dental disease have changed dramatically over the last quarter of a century, with most patients keeping at least a partial dentition for their entire lives. The increasing incidence of tooth wear, together with changes following tooth loss, may mean that the patient\u2019s natural occlusal curve is not evident. Indeed following a deranged occlusal curve, while carrying out occlusal reconstruction, may result in occlusal interfer- ences that could lead to destruction of restorations and tooth tissue. Derangement of the occlusal curve because of tooth positional changes after loss of a posterior tooth have not been quanti\ufb01ed in the litera- ture and this investigation aims to determine the extent of deviation from an \u2018ideal\u2019 curve for a sample of partially dentate patients.

Review of the Literature
Over the last one and a half centuries, authors have
attempted to explain the geometry of the occlusal curve

by reference to various anatomical landmarks. Ferdi- nand Graf Spee (1), originally described the form of the occlusal curve, and postulated its anatomical determi- nants in 1890. He postulated that the occlusal curve forms part of a circle or \u2018cylinder\u2019, the axis of which is formed by the crista lachrymalis posterior and the horizontal midorbital plane (Fig. 1). Since then, the relevance and development of the curve of Spee has been studied by a number of authors. Page (2) presen- ted evidence that the occlusal curve originates from a combination of hinge axes controls and the mandibular angle, and that it is distinct from the curve of Spee with its theoretical distal extension to the head of the condyle. The occlusal curve demonstrated by Page ends at the most posterior cusp of the most posterior tooth, whereas the curve of Spee is postulated to extend to the anterior surface of the condylar head. A further complication in this discussion is the occlusal plane, whose de\ufb01nition is \u2018the plane established by the occluding surfaces of premolars and molars (3)\u2019. This is a trapezoidal surface extending from the distal cusps of the most distal lower teeth to the tips of the canines,

\u00aa2006 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2842.2005.01587.x
Journal of Oral Rehabilitation200633; 423\u2013429

and is obviously curved in many cases. This is in con\ufb02ict with the true de\ufb01nition of a plane, which must be \ufb02at, and brings into question the use of terminology currently in use.

Ferrarioet al. (4) compared what they described as the \u2018curve of Spee\u2019 (which was in fact the occlusal curve) on male and female groups of human subjects. They determined that there was a difference in the curves between the sexes and that there was a differ- ence in the curves on each side of the arch. The male curves were larger than female and the left side was larger than the right in both groups. These researchers used computer graphics plotted onto images of patient study models to determine and measure the curves. Therefore as there was no distal extension of the curve to the head of the condyle, they were in actual fact plotting the occlusal curve.

Orthlieb (5) used cephalometric images to study the relationship of the curve of Spee to the axial angulations of the posterior teeth. He concluded that the mandibular incisors followed the tangent law. He noted, however, that the posterior mandibular teeth exhibited a progressive differential angle with the direction of the tangent. This investigation was able to determine the true curve of Spee, extending to the condylar head, using radiographic tracings. A large sample group of (470) subjects was studied. As well as mathematically de\ufb01ning the differential angulation of the posterior teeth (Fig. 2), the study also found signi\ufb01cant differences in the curve, relative to the degree of overbite, and the skeletal classi\ufb01cation. This study shows that the development of the curve of Spee is likely to be multi-factorial, and that the curve

is likely to vary signi\ufb01cantly between individuals. Closure of proximal contacts and mesial drift was felt by Orthlieb to be attributable to the forces generated by this progressive angulation of the curve of Spee.

Both of the above studies demonstrate that the original \u2018Tangent Law\u2019 for the determination of the angulation of the mandibular posterior teeth to be invalid, and that signi\ufb01cant variation can occur both between individuals, and between each side in any given subject. It follows that if we are to measure deviations of an individual tooth from the occlusal curve, we must be able to accurately determine the curve for that particular dental quadrant in our speci- \ufb01ed subject.

Looking at the occlusal curve and its role in occlusal rehabilitation and reconstruction, Weinberg (6) advo- cated maintaining the patients natural occlusal plane, arguing that optimum transmission of occlusal forces are most likely if this is followed. He argued that if an inappropriate curve were created, the crown root ratio would be altered, together with the torquing forces transmitted.

Following extensive tooth loss, the patients\u2019 occlu- sal plane may become distorted because of tipping, drifting and overeruption and prosthodontic restor- ation may be complicated by these changes. Lynch and McConnell (3) considered this problem, and suggested the use of a \u2018Broadrick \ufb02ag\u2019, in order to reproduce the ideal curve of Spee for an individual, utilising Graf Spee\u2019s original principles. They utilized dental landmarks to create the curve, and introduced modi\ufb01cations for different skeletal patterns. Although this method did not allow for the incremental nature of the occlusal curve described by Orthleib, it may

Fig. 1.Determination of the curve of Spee.
Fig. 2.Progressive differential angle, mean angle between ideal
tangential direction and long axis of different posterior mandib-
ular teeth.
H. L. CRADDOCKet al.
424
\u00aa2006 Blackwell Publishing Ltd,Journal of Oral Rehabilitation33; 423\u2013429
provide useful guidance in clinical restorative proce-
dures.
Aim of the study

To compare the deviation of the clinical occlusal curve with a theoretical ideal, for patients with and without the presence of an unopposed posterior tooth.

Method
Samples tested

Following consultation with a statistician, a sample size calculation showed an adequate sample size for this study would be 90 subjects and 90 controls. This was calculated to detect a difference of 0\u00c65 mm, at 90% power. Two hundred adult patients were examined and had study models made of their upper and lower dentitions. These models were later scanned and recorded as digital images.

Selection criteria

Local Ethical Committee approval was gained. Patients from Leeds Dental Institute, with one to three adjacent unopposed posterior teeth were invited to take part in the study. For the purposes of this study \u2018posterior\u2019 is de\ufb01ned as an upper or lower \ufb01rst or second premolar, or \ufb01rst, second or third molar. The control group had intact dentitions, without unopposed teeth.

Adult patients of 18 years or above were recruited. As documentary evidence of when the missing teeth were lost was unavailable, subjects in the test group had documented evidence that the missing teeth had been absent for 5 years or more. There was no speci\ufb01ed upper age limit. Written informed consent was obtained from all subjects following a written and verbal explanation of the purpose of the study and methods to be used in the investigations.

Exclusion criteria

Unless documentary evidence was available showing that the missing tooth/teeth had been lost for a minimum of 5 years, patients were excluded from the study. Teeth that were prevented from independent movement, by involvement in support or retention for \ufb01xed or movable prostheses were also excluded.

Sources of subjects

One hundred consecutive patients with one or more unopposed posterior teethwere invited to take part in the study. One hundred age and sex matched subjects, with matching interdental bone height at the sites examined were recruited as controls. The age for each subject was matched\u00c62 years with a control of the same sex. Bone height was determined by measuring from the ameloc- emental junction on bitewing or periapical radiographs taken using paralleling techniques. Matching was to within 1 mm of that of the subjects under investigation. The sample consisted of 50 female and 50 male patients.

Measurement of deviation from the Broadrick occlusal curve

Alginate impressions were taken of the upper and lower dentition. After casting in dental stone, the study models were trimmed in a seven-sided con\ufb01guration, so that the buccal plane would lie parallel to the scanner * surface when the models were placed on it. The models were then scanned on a Black Widow 3696 USB scanner at a resolution of 350 DPI. For the subject group only the side with tooth loss was scanned. The same side was scanned for the control.

Using the Broadrick \ufb02ag method described by Lynch and McConnell (3), the ideal occlusal plane was created using the scanned models. The anterior determinant was the mid point on the distal slope of the lower canine tooth, and the posterior determinant was the mid point on the distal slope of the disto-buccal cusp of the lower second molar. These points were used as the centre of circles from which arcs were drawn (Fig. 3). In class 1 incisal relationships, an arc of 4-inch radius was drawn from the centre of the distal slope of the incisal edge of the lower canine. The same size arc was also drawn from the tip of the distal cusp of the lower second molar tooth. The intercept of these arcs was used to determine the centre of a circle, which was drawn to lie against the points on the lower canine and second molar already described. For class 2 incisal relationships the initial arc diameter was 3\u00c675 inches, and class 3 relationships a 5-inch arc was used. The degree of overjet measured on the study models was used to determine the incisal classi\ufb01cation. The distance of the furthest cusp tip from the Broadrick curve was measured along the long axis of the tooth for each individual. Where the deviation was

*Devcom Ltd, Sterling, UK.
T H E B R O A D R I C K C U R V E A F T E R P O S T E R I O R T O O T H L O S S 425
\u00aa2006 Blackwell Publishing Ltd,Journal of Oral Rehabilitation33; 423\u2013429

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