Prosthodontic management of the curve of Spee: Use of the Broadrick flag

Christopher D. Lynch, BDS,a and Robert J. McConnell, BDS, PhDb National University of Ireland, Cork, Ireland
Proper management of the occlusal plane is an essential consideration when multiple long-span posterior restorations are designed. When restorations are added to an existing tooth arrangement characterized by rotated, tipped, or extruded teeth, excursive interferences may be incorporated, resulting in detrimental sequelae. The curve of Spee, which exists in the ideal natural dentition, allows harmony to exist between the anterior tooth and condylar guidance. An instrument called the Broadrick flag has been used to assist in the reproduction of tooth morphology that is commensurate with the curve of Spee when posterior restorations are designed; its use prevents the introduction of protrusive interferences. Consideration also must be given to lateral excursive movements when the occlusal plane is designed. In this article, the importance of the curve of Spee in prosthdontic and restorative dentistry is discussed, and a patient treatment demonstrating use of the Broadrick flag is described. (J Prosthet Dent 2002;87:593-7.)

n the normal natural dentition, there exists an anteroposterior curve that passes through the cusp tip of the mandibular canine and the buccal cusp tips of the mandibular premolars and molars, and that extends in a posterior direction to pass through the most anterior point of the mandibular condyle.1 Originally described by Ferdinand Graf Spee1 in 1890, this curve exists in the sagittal plane and is best viewed from a lateral aspect (Fig. 1); it permits total posterior disclusion on mandibular protrusion, given proper anterior tooth guidance. Spee located the center of the curve along “a horizontal line through the middle of the orbits behind the crista lachryma posterior,”2 a structure identified in the textbooks of the era3 as a vertical ridge on the lacrimal bone giving partial origin to the orbicularis oculi muscle. Spee’s idea was advanced in 1920 by George Monson.4 Based on anthropological observations, Monson described a 3-dimensional sphere that passed through the incisal edges and occlusal surfaces of the mandibular teeth. It is not usually noted that while Spee described a curve of approximately 2.5-inch radius (6.5-7.0 centimeters),1 Monson2 proposed the now widely accepted curve of 4-inch radius. Spee noted that it would be possible to locate the center of the curvature “by reconstruction and measurement with the compass.” The curve of Spee may be pathologically altered in situations resulting from rotation, tipping, and extrusion of teeth. Restoration of the dentition to such an altered occlusal plane can introduce posterior protrusive interferences.5 Such interferences have been shown to cause abnormal activity in mandibular elevator muscles, especially the masseter and temporalis muscles.6 This can be avoided by reconstructing the

I

Fig. 1. Curve of Spee. (Reproduced by Dr Mary McConnell from Spee FG. Die Verschiebungsbahn des Unterkiefers am Schädel. Arch Anat Physiol 1890;16:285-94)

aRegistrar, bProfessor,

Department of Restorative Dentistry. Department of Restorative Dentistry.

curve of Spee to pass through the mandibular condyle, which has been demonstrated to allow posterior disclusion on mandibular protrusion.7 As the angle of condylar guidance is greater than the curve of Spee, posterior disclusion is achieved.8 The Broadrick flag9 (Broadrick Occlusal Plane Analyser; Teledyne Water Pik, Fort Collins, Colo.) permits reconstruction of the curve of Spee in harmony with the anterior and condylar guidance, allowing total posterior tooth disclusion on mandibular protrusion. Its use assumes proper functional and esthetic positioning of the mandibular incisors. Should the anterior guidance be inappropriate, it must be redesigned prior to use of the Broadrick flag. The position of the designed restorations should not interfere with lateral excursive mandibular movements. The tooth arrangement in the bucco-lingual
THE JOURNAL OF PROSTHETIC DENTISTRY 593

JUNE 2002

and mandibular right first molar were absent. B.10 The curve of Monson4. a decision was made to restore this space with a combination fixed partial denture. 2. anterior border of condylar element on articulator could be selected as PSP. Cork. a marked discrepanVOLUME 87 NUMBER 6 . from which long arc of 4-inch radius was drawn on flag with use of compass. a combination of the curves of Spee and Wilson in a 3-dimensional plane. Mounted diagnostic casts of patient’s left side. B. A plane is referred to as the curve of Wilson. it was found that the maxillary left second premolar. After trial preparations and a diagnostic wax-up.THE JOURNAL OF PROSTHETIC DENTISTRY LYNCH AND McCONNELL A B Fig.12 However. Posterior survey point (PSP) was located on disto-buccal cusp of distal left mandibular molar. resulting in narrow occluso-gingival space for potential pontic to replace maxillary left first molar. A. Mandibular right first molar was absent. maxillary left first molar.11 is. 2. Diagnostic casts were mounted in a semi-adjustable articulator (Denar Anamark Fossae. Marked discrepancy was evident in level of occlusal plane: mandibular left first molar was extruded. A). Anterior survey point (ASP) was selected on midpoint of disto-incisal edge of mandibular left canine. 3. in effect. This clinical report describes the effective application of the Broadrick flag in prosthodontic and restorative dentistry and reviews the principles of its use from anatomical science. Teledyne Water 594 Pik). A. Mounted diagnostic casts of patient’s right side. CLINICAL REPORT A 26-year-old man seeking restoration of missing teeth in the maxillary left and mandibular right posterior quadrants was referred to the Restorative Department of the Cork University Dental School and Hospital (Wilton. On clinical examination. Occlusal plane on this side was considered normal. If position of this tooth were deemed unacceptable. The endodontically treated maxillary left first premolar was fractured close to the gingival margin. Ireland). B Fig. Visual examination confirmed that the occlusal plane on the right side was normal (Fig.

Short arc of 4-inch radius was drawn from PSP on flag to intersect long arc at center of curve of Spee. Note extrusion of mandibular left first molar. 595 . A). 4. The point of JUNE 2002 the compass was placed at the center of the flag. 4. the occlusal surface of the mandibular first molar was reduced to the level of the redefined occlusal plane (Fig. The occlusion was restored to a canineprotected occlusion. Because the position of the distal mandibular molar was judged to be acceptable. This tooth was planned for restoration with a gold onlay. Care was taken to ensure even occlusal contacts in maximum intercuspation and avoid posterior interferences in protrusive or lateral excursions.LYNCH AND McCONNELL THE JOURNAL OF PROSTHETIC DENTISTRY A B Fig. B). 5. and 4-inch radius was drawn through buccal surfaces of mandibular teeth. cy was noted in the level of the occlusal plane on the patient’s left side. On the stone cast. A. resulting in a narrow occluso-gingival space for a pontic that would replace the maxillary left first molar (Fig. 3. The Broadrick flag was chosen to assess and. The mandibular left first molar was extruded. and a short arc was drawn on the flag to intersect the long arc at the center of the curve of Spee (Fig. B). 2. and the diagnostic wax-up was fabricated (Fig. while the heavily restored mesial cusps of the mandibular left second molar were below the level of the curve (Fig. with the maxillary left first premolar and second molar as abutments. and the flag was attached to the upper member of the articulator. the posterior survey point (PSP) was located on the distobuccal cusp of this tooth (Fig. mesial cusps of mandibular left second molar were below level of curve. if necessary. 4. B. the mandibular left second premolar with a metal-ceramic crown. and the maxillary left edentulous area with a 3-unit fixed partial denture. redesign the level and orientation of the occlusal plane on the patient’s left side. from which a long arc of 4-inch radius was drawn on the flag with a compass (Fig. A). Trial preparations were performed on articulated duplicate casts. The mandibular left first molar was markedly extruded. The maxillary cast was removed from the articulator. the mandibular left second molar with a complete-coverage gold crown. A). 5. The anterior survey point (ASP) was chosen on the midpoint of the disto-incisal edge of the mandibular left canine. B). Point of compass was placed at center of flag. and a 4-inch radius was drawn through the buccal surfaces of the mandibular teeth. B). The anterior guidance and esthetic appearance of the mandibular anterior teeth were assessed clinically and found to be satisfactory. 3.

and vacuum-formed acrylic templates were fabricated. but it may be moved in an anterior or posterior direction from the intersection of this arc with that drawn from the posterior survey point. Such “low” mandibular posteriors would also lead to extrusion of the opposing maxillary teeth. Conversely. Final restorations were fabricated in the traditional manner (Fig. 6). No abnormal wear facets were evident. Further occlusal reduction for a cast gold restoration then was performed and the onlay preparation completed. Diagnostic wax-up of restorations on patient’s left side. Occlusal surface of mandibular first molar reduced to level of redefined occlusal plane on stone cast. 5. 6. as it identifies the most likely position of the center of the curve of Spee. controlled conservative reduction was performed on the mandibular and maxillary left second molars. the crown-to-root ratio would be less than ideal. At subsequent recall appointments. occlusal contacts were present in MIP. Provisional restorations were fabricated. The center of the curve also may be varied to achieve the same effect. After a 4-week trial period. a 4-inch curve would create a steep posterior curve in patients with a class III skeletal relationship. B Fig. The center should always lie along the long arc drawn from the anterior survey point. With the respective template as a guide. VOLUME 87 NUMBER 6 The diagnostic wax-up was duplicated. A. This alteration will not affect the position of the anterior survey point. If the maxillary posterior teeth were to be restored to this low occlusal plane. Hence. and the gingival health remained optimal. leading to further posterior interferences. With use of the mandibular acrylic template. DISCUSSION The Broadrick flag is a useful tool in prosthodontic and restorative dentistry.THE JOURNAL OF PROSTHETIC DENTISTRY LYNCH AND McCONNELL A Fig. B. Cast dowel-and-core restorations were fabricated for the maxillary first premolar and mandibular second premolar and cemented in the normal manner. no interferences in protrusive and lateral excursions were detected. A 5-inch radius would be more suitable in this situation. causing posterior protrusive interferences. 596 . The patient reported total comfort and satisfaction with the masticatory performance and esthetics of the definitive restorations. Compromise can be achieved by altering the length of the radius of the curve. an important fact when the position of the mandibular anterior teeth is esthetically and clinically suitable. the patient reported that the provisional restorations were comfortable. this position should not be regarded as fixed or immutable. the occlusion remained unchanged. the mandibular left first molar was reduced intraorally to the occluso-gingival height predetermined on the diagnostic cast. Esthetics and function place a considerable demand on the design of the occlusal plane. In patients with a retrognathic mandible. However. a 33⁄4-inch curve is more appropriate when a class II skeletal relationship exists. Definitive restorations cemented on left side. a standard 4-inch curve would result in a flat posterior curve.

8 It should be further considered that the arrangement of the maxillary and mandibular teeth influences lateral excursive movements. Williamson EH.4 Hyperactivity in the temporalis and masseter muscles has been demonstrated during mandibular protrusive movements when inappropriate posterior tooth contacts are present. J Am Dent Assoc 1923. 2. Bryce TH. Stockstill JW. Arch Anat Physiol 1890. Chaffee NR. and Dr Mary McConnell. Practical uses of the Curve of Spee. Monson GS. Part I. care must be taken not to create new interferences. the mandibular molars have a slight lingual inclination and the buccal cusps of these teeth are higher than the lingual. p. J Prosthet Dent 2000. Green & Co. Acrylic templates also were used for conservative preparation of the other teeth.74:1039-53.2002.10:927-35.83:272-5. it follows that the PSP may be taken as the anterior border of the condyle. thus permitting protrusive and lateral excursions free from posterior interferences. Vol. 85-6. Spee FG. 5. Bowley JF. in that it locates the center JUNE 2002 doi:10. the prosthodontist can predictably produce high-quality restorations in harmony with the anterior and condylar guidance and avoid the introduction of possibly harmful sequelae to the patient. J Am Dent Assoc 1980. Monson4. Reprint requests to: DR CHRISTOPHER D. The template allowed accurate reduction of the extruded mandibular first molar to the level of the redesigned occlusal plane.399-413. In the clinical report presented. This arrangement is referred to as the curve of Wilson. Spee FG. Should this be the scenario. as this would introduce posterior protrusive interferences. Wilson GH.00 + 0. the template was a vital tool for transferring the designed blueprint from the diagnostic wax-up on the articulator to the mouth. J Am Dent Assoc 1923. Excursive interferences may result in wear. The gliding path of the mandible along the skull. represented by the most anterior point on the condylar element on the articulator. 9. 10. Symington J.16:285-94. 1911. It bears repeating that the now widely accepted 4-inch radius was proposed by Monson rather than Spee. Die Verschiebungsbahn des Unterkiefers am Schädel. 4. Philadelphia: Lea & Febiger. MA. Cooper LF. and temporomandibular joint dysfunction.36:551-68. and the duplication of provisional restorations from the waxup. followed by appropriate reduction for the cast restoration. BDS. HDE.10 and it facilitates lateral excursions free from posterior interferences.LYNCH AND McCONNELL THE JOURNAL OF PROSTHETIC DENTISTRY When the center of the curve or its radius is altered for esthetic reasons. Needles7 noted that to ensure posterior disclusion on mandibular protrusion. Attanasio R. 1915. fracture of restorations. Hotz M. Biedenbach MA. J Nat Dent Assoc 1920:7. Chicago: Quintessence. Fixed partial dentures combining both resinbonded and conventional retainers: a clinical report. 3rd ed. Applied mechanics to the theory of mandibular movements. 1997. Proper planning is required. Occlusion as applied to crown and bridgework. the transfer of information with an acrylic template. Dent Cosmos 1932.11 proposed that the mandibular teeth should be arranged to close around a sphere of 4-inch radius. of the curve of Spee. the curve should extend through the condyle. Quain’s elements of anatomy. the level and orientation of the distal molar tooth may not always be suitable. 6. 8. 22-37. Needles JW. LYNCH DEPARTMENT OF RESTORATIVE DENTISTRY UNIVERSITY DENTAL SCHOOL AND HOSPITAL WILTON. 89. We acknowledge the assistance of Dr Michael Shanahan. for her translation of Ferdinand Graf Spee’s article from German to English.1067/mpr. Hitchcock HP. Hobo S. Shillinburg HT.10:918-27. CORK IRELAND FAX: (353)21-434-5737 E-MAIL: clynch85@hotmail. 0022-3913/2002/$35. 11. in the preparation of the clinical treatment described. Mandibular movements and articulator design.49:816-23. for her reproduction of the curve of Spee in Figure 1. A manual of dental prosthetics. with the mandibular incisal edges and cusp tips touching the sphere. Care should be taken to ensure that the angle of the condylar guidance is not less than the curve of Spee. p.com Copyright © 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. London: Longmans. The use of an acrylic template can facilitate controlled conservative reduction.6 Careful restoration design to ensure proper anterior guidance will prevent the introduction of such interferences and the establishment of such abnormal activity. This ensured that the fabricated onlay was in harmony with the occlusal plane and that minimal tooth structure was removed. B Dent Sc. BA. When the PSP is located. J Prosthet Dent 1983. With use of the Broadrick flag. We thank Ms Catherine MacGillycuddy. Dent Clin North Am 1992. When viewed from a frontal aspect. IV.100:670-5. Schäfer EA. p. Fundamentals of fixed prosthodontics.125178 597 . Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles. 7. Needles JW. but the predictability of a successful result can be enhanced by the use of a diagnostic wax-up. A preliminary diagnostic and treatment protocol. Extensive restorations designed with this tool permit mandibular excursions free from posterior interferences. Lundquist DO. 12. REFERENCES 1. Whitsett LD. Monson GS. Attention should be paid to this principle when the diagnostic wax-up is designed. 10/1/125178 SUMMARY The Broadrick flag is a valuable tool in prosthodontic and restorative dentistry. 3.

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