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 points which cannot be on the same line. The plane
an essential part of many techniques in dentistry. is formed by two points located posterior to the
Two major objectives are restoration of the occlusion maxillae and one point located anterior to them
and control of the form and the position of the teeth. (Fig. 1).
The degree of knowledge that the dentist and the
auxiliaries have, coupled with their ability to apply
POSTERIOR POINTS OF REFERENCE
this knowledge, will determine how well these objec- Often the two posterior points are located by
tives are satisfied. measuring prescribed distances from skin surface
The dentist should thoroughly understand the landmarks. Some of the commonly used posterior
concept of the anterior point of reference and how it points were shown by Beck’ to be “clinically” near
should be chosen to accomplish the treatment objec- the hinge axis. He concluded that the Bergstrom
tives. The student of prosthodontics should give point* (Fig. 2, a) most frequently is closest to the
concentrated thought to the anterior point of refer- hinge axis. He identified the Beyron point? (Fig. 2, h)
ence and be acquainted with several concepts as as the next most accurate posterior point of refer-
alternatives to be used in treating the difficult ence. Studies by Weinberg’ state that a deviation
patient. Both dentist and student should be thor- from the hinge axis of 5 mm will result in an
oughly familiar with the difficulties that arise if the anteroposterior displacement error of 0.2 mm at the
choice and the use of the anterior reference point are second molar. An error of this size is usually of no
not well coordinated with all individuals taking part consequence in removable prostheses with nonrigid
in fabricating the prosthesis. attachments. With these prostheses: intended toler-
To do less means that the maxillary cast will be ances in the occlusion and the mobility of the
positioned in the articulator arbitrarily. Such uncon- supporting tissues may make a precise location of the
scious or purposeful neglect by the dentist may result hinge axis an exercise with no advantage.
in additional and unnecessary record making, an On the other hand, fixed and removable partial
unnatural appearance in the final prosthesis, and dentures with rigid attachments demand close toler-
even damage to the supporting tissues. To delegate ances in cusp pathways. These restorations may
the positioning of the maxillary cast in the articula- require the use of a kinematic technique that will
tor to someone who is not fully knowledgeable and locate the hinge’axis exactly.
who is unaware of the consequences of an arbitrary If the maxillary cast is positioned without the
mounting can result in extra expense and unnecessa- correct maxillae-hinge axis relationship, arcs of
ry trauma to the patient. movement in the articulator will occur which differ
The maxillary cast in the articulator is the base- from those of the patient. Verification of the man-
line from which all occlusal relationships start, and it dibular cast position by using interocclusal records
should be positioned in space by identifying three 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 Fig. 2. Posterior points of reference. a, Bergstrom point.
records are the same thickness. Also, an occlusion b, Beyron point.
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 articulator’s hinge axis, to the
vertical axes, to the condylar determinants, to the Fig. 3. Orbitale (o), axis-orbital plane (a-o), and Frankfort
horizontal plane (f-o).
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 niques such as a pantographic tracing, the dentist
repeatable posterior points of reference. When three does not have the time, nor the patient the means, to
points are used the position can be repeated, so that repeat records each time the technique calls for a
different maxillary casts of the same patient can be new maxillary cast. For this reason it is important to
positioned in the articulator in the same relative identify the mark permanently or be ahle to repeti-
position to the end-controlling guidances. With tively measure an anterior point of reference as well
complicated and time-consuming recording tech- as the posterior points of reference.

THE JOURNAL OF PROSTHETIC DENTISTRY 489

 WILKIE

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
Fig. 4. Face-bow supported at the level of the axis-orbital concept is easy to teach and understand.
plane. 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
Fig. 5. Maxillary record base and vertical support arm fixed to the vertical arm attachment can be trans-
are fixed by plaster in the transfer cup. 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
SELECTION OF AN ANTERIOR REFERENCE paralleled on the patient.
POINT 2. Orbitale minus 7 mm (Fig. 7)~ The Frankfort
In selecting the reference plane, the dentist should horizontal plane passes through both poria and one
have knowledge of the following anterior points and orbital point. Because porion is a skull landmark,
the rationale for the selection of each. Sicher’ recommends using the midpoint of the upper
1. Orbitale (FZg. 3). In the skull, orbitale is the border of the external auditory meatus as the poste-
lowest point of the infraorbital rim. On a patient it rior cranial landmark on a patient. Most articulators
can be palpated through the overlying tissue and the do not have a reference point for this landmark.
skin. One orbitale and the two posterior points that Gonzalez’ pointed out that this posterior tissue
determine the horizontal axis of rotation will define
the axis-orbital plane. Relating the maxillae to this
*Hanau Earpiece Face-bows, Models 140-l and 140-2. Hanau
plane will slightly lower the maxillary cast anteriorly Engineering Co., Inc., Buffalo, N. Y.
from the position that would be established if the f’Hanau Transfer Index, lModels 140-10.5 and 140-106, Hanau
Frankfort horizontal plane were used. Practically, E:ngineering Co., Inc., Buffalo, N. Y.

490 MAY 1979 VOLUME 41 NUMBER 5

ANTERIOR POINT OF REFERENCE

Fig. 8. The nasion.

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. Bergstrom’s’ arcon artic-
ulator automatically compensates for this error by
placing the orbital index 7 mm higher than the Fig. 9. Nasion guide (ng) and face-bow crossbar (cb).
condylar horizontal axis. In either technique, the
Frankfort horizontal plane of the patient becomes the face-bow supports the upper frame of the Whip-Mix
horizontal plane of reference in the articulator. articulator. The inferior surface of the frame is in the
3. Nasion minus 23 mm. According to Sicher,” same plane as the articulator’s hinge points. From
another skull landmark, the nasion (Fig. 8), can be this it can be concluded that the Quick Mount
approximately located in the head as the deepest face-bow used with the Whip-Mix articulator
part of the midline depression just below the level of employs an approximate axis-orbital plane.
the eyebrows. The nasion guide, or positioner, of the Locating the orbital point with this technique is
Quick Mount face-bow* (Fig. 9), which is designed dependent upon the large nasion guide, the morpho-
to be used with the Whip-Mix Articulator,* fits into logic characteristics of the nasion notch, and the
this depression. This guide can be moved in and out, variance of the nasion-orbitale measurement from 23
but not up and down, from its attachment to the mm in the patient.
face-bow crossbar. The crossbar is located 23 mm 4. Incisal edge plus articulator midpoint to articulator
below the midpoint of the nasion positioner. When axis-horizontalplane distance. Guichet” has emphasized
the face-bow is positioned anteriorly by the nasion that a logical position for the casts in the articulator
guide, the crossbar will be in the approximate region would be one which would position the plane of
of orbitale. The face-bow crossbar and not the nasion occlusion near the mid-horizontal plane of the artic-
guide is the actual anterior reference point locator. ulator. A deviation from this ob.jective may position
During the face-bow transfer, the crossbar of the casts high or low relative to the instrument’s upper
and lower arms. The effect of these high or low
*The Whip-Mix Corp., Louisville, Ky. positions may be inaccurate occlusal relationships

THE JOURNAL OF PROSTHETIC DENTISTRY 491

 \tlLKIE

actual occlusal plane parallel with the horizontal

plane. ‘l’his can be achieved in two ways: i 1: a lint
from the ala* of the nose to the center of the auditor)
meatus describes Camper’s 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.Iamper’s 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 articulator’s hinge-of,-
bital indicator plane. ‘4 second method of estab-
lishing this relationship is to make a wax occlusion
rim parallel to C:amper’s 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.
Fig. 10. Camper’s line (cl) and occlusal plane (op). This ensures that the tentative occlusal plane will
not be too high or low. The wax occlusion rim made
due to dimensional changes in the artificial stone or parallel with Camper’s line is transferred to the
plaster used for cast-mounting purposes. articulator with a face-bow (Fig. 12’). Its occlusal
In accordance with this concept, the distance from plane is rnade parallel with the upper and 1owe1
the articulator’s mid-horizontal plane to the articu- articulator arms (Fig. 13). In this way, the ala-cl~lc
lator’s axis-horizontal plane is measured. This same plane (a plane that coincides with Camper’s line) anti
distance is measured above the existing or planned the tentative occlusal plane arc horizontal and
incisal edges on the patient, and its uppermost point become the planes of reference in this technique.
is marked as the anterior point of reference on the Other intraoral landmarks, esthetics. considera-
face. This point can be recorded for future use by tion for the residual ridges, and tongue and cheek
measuring vertically downward to it from the inner guidance factors may alter the ,/inal o~clu.sni plnnr.
canthus of the eye and recording this measurement. Laboratory auxiliaries do not have the benefit or
The inner canthus is used because it is an accessible, knowledge of these patient-related factors. ‘l‘here-
unchanging landmark on the head. fore, if the laboratory’sjudgment alone is relied upon
With this technique the face-bow transfer will to establish the final occlusal level, an unsightly
carry the two predetermined posterior points of plane or one which transmits the wrong forces to the
reference and this anterior point of reference to the weaker ridge may result.
anticulator’s axis-horizontal plane. The dentist can Practically, the dentist may omit the construction
then proceed, knowing that the incisal edges will fall of an occlusion rim or elect not to identify a tentative
on the articulator’s mid-horizontal plane unless a occlusal plane. However, when performing the try-in
subsequent decision raises or lowers them. and record verification procedures with the patient.
It must be recognized that this technique does not the occlusal plane should be adjusted to the opti-
relate the Frankfort plane or the axis-orbital plane mum position that will favor esthetics, transmit the
parallel to the horizontal plane. Additionally, only desired forces to the ridges, and permit comfortable
the incisal edges or the most anterior portion of the control of food morsels by the tongue and the
occlusal plane will be midway between the upper cheeks.
and lower articulator arms. A tentative or an actual
occlusal plane will not be parallel to the horizontal
*The a/a nm is defined as the rounded eminence of the inferior
plane unless by coincidence. lateral surface of the nose. (Adapted from Henry Gray: Anato-
5. Alae of the nose. A ‘part of many complete my of the Human Body, W. H. Lewis ied). Philadelphia, 1942,
denture techniques is to make the tentative or the Lea & Febiger. p 1010.)

492 MAY 1979 VOLUME 41 NJMBER 5

ANTERIOR POINT OF REFERENCE

Fig. 11. Making the occlusion rim parallel to Camper’s line

Fig. 12. Transfer of the occlusion rim to the articulator with a face-bow

DISCUSSION 2. An occlusal piane not paraliel to rhe horizontal

Other reasons for selecting an anterior point of in the beginning steps of denture fabrication may be
reference must be considered. unknowingly located incorrectly because of a
1. A planned choice of an anterior reference point tendency for the eye to subconsciously make planes
will allow the dentist and the auxiliaries to visualize and lines parallel. Therefore the dentist may wish to
the anterior teeth and the occlusion in the articulator initially establish the restored occlusal plane parallel
in the same frame of reference that would be used to the horizontal in order IO better control the
when looking at the patient. The objective is usually occlusal plane in its final position. The objective is to
to achieve a natural appearance in the form and the achieve a natural appearance in the occlusal plane.
position of the anterior teeth. Mounting the maxil- Mounting the cast relative to L’umpPr’s ~.VZB best meets
lary cast relative to the Frankfort horizontal plane this objective.
will accomplish this objective. When this reference 3. The dentist may wish to establish a baseline for
plane is used, the teeth will be viewed as though the comparison between patients, ar for thch same patient
patient were standing in a normal postural position at different periods of time. Only through the use of
with the eyes looking straight ahead. 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 Camper’s line.

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
patient’s 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
Fig. 14. A maxillary cast in the articulator related to
Camper’s line as horizontal. Making the dotted line every occlusal plane parallel to the articulator arms.
parallel with the horizontal relates the maxillary cast to The consequences of the reverse situation will also
the Frankfort horizontal plane. be detrimental to the patient. The dentist may use
Camper’s line as the reference for the maxillary cast
mounting. The laboratory may then position the
patient to another or for the same patient can valid anterior teeth and the occlusal plane as though the
comparisons be made. Orthodontists, investigators Frankfort horizontal plane were being used. The
using cephalometrics, anthropologists, and other result will be an occlusal plane that rises severely
dental specialists have used the Frankfort horizontal from anterior to posterior in the patient’s mouth and
plane more frequently than any other plane of maxillary anterior teeth that may be excessively
reference to accomplish this objective. Although linguoverted. Again, force transmission to the resid-
other planes can be used, the dentist should make ual ridges may not bc as desired.
sure that all auxiliary personnel know Z&C/I plane is 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 Camper’s line (dotted

line) as the horizontal plane of reference. The occlusal
plane (solid line) is parallel to Camper’s line and the Fig. 16. A maxillary cast is related to the Frankfort plane
horizontal. RULE: to achieve the “effect” of the Frankfort (double line) as the horizontal plane of reference. RULE: to
plane (double line) as the horizontal reference plane, raise achieve the “effect” of Camper’s line (dotted iine) and the
the back of the articulator. occlusal plane (solid line) as the horizontal refcrrnce plane,
raise the front of the articulator.
the Frankfort horizontal plane or Camper’s 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 articulator’s 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’). Fig. 17. Frontal view reference line. IP. Interpupillary
As a more practical and less time-consuming line. hi, Hinge line. op, Transverse line across occlusal
alternative, the following technique can be used: (1) surfaces.
If the Camper’s line-horizontal reference plane is used, reference plane. The relating planes are usually
raise the back of the articulator to achieve the effect thought of as being viewed from the lateral aspect.
of the Frankfort horizontal plane mounting (Fig. When viewed from the frontal aspecr, there are
1.5); (2) if the Frankfort horizontal plane reference is reference lines as well. The hinge line, rhe interpupil-
used, raise the anterior of the articulator to achieve lary line, and a transverse line across the occlusal
the effect of paralleling the occlusal plane and surfaces are three common frontal-view reference
Camper’s line (Fig. 16) with the horizontal. lines (Fig. 17). The latter two are observed in the
There is one last precaution to observe when patient, with the hinge line being better seen in the
relating the maxillary case in space to a horizontal articulator. Generally these three lines art‘ not paral-

THE JOURNAL OF PROSTHETIC DENTISTRY 495

 WILKIL

lel. This is caused by posterior hinge reference points reference and the reasons for the use of each har,c,
that are not equidistant from the eye pupils. An been discussed.
occlusal plane that is parallel to the interpupillary
line will be pleasing to the eye of the viewer. It REFERENCES
cannot be guaranteed that an occlusal plane parallel I. Beck, II. 0.: A clinical evaluation of the Arcon concept ,>I’
to the hinge will have the same pleasing appearance. articulation .J PKOSTHET DENT 9:409, 1959.
2. Weinberg. 1,. A.: An evajuation of the face-bow mountiny. ,J
This further justifies the dentist making these deter-
PRosTHEtTI-hmT 11:X?, 1961.
minations in the patient and further contraindicates 3. &her, H.: Oral Anatomy, ed 2. St. Louis, 195’. I‘hc C 1.
giving auxiliary personnel the opportunity to decide .Mosby Cu.. p 91.
on occlusal plane location relative to articulator 4. Gonzakx. J H., and Ii’ mgery, K. II.: Evaluation oi plants ~)t
landmarks. rrfwcnw for orienting maxillary casts on articulaturc. .J :1m
I)rnt Assoc 76:329, 1968.
SUMMARY 5. Beck. Ii. 0.: and Morrison, W. E.: Investigation of an .4rcorl
articulator. J PROSTFIEI. DENT 6:359, 1956.
Three points in space determine the position of the 6. Guichct, N. F.: Occlusion, A Teaching Manual. Anaheim.
maxillary cast in an articulator. The dentist is most 1970, The LIenar Corp., p 56.
frequently concerned with selecting the posterior two 7. f\ugsburger. K. Ii.: Occlusal plane relation to facial type. .j
P~cxrm~. Ihvr 3:75.5. 1953.
of the three reference points. In addition, the dentist
will, either consciously or unknowingly, select the
anterior of these points of reference. This decision Reprint requeststo.
CAPTAIN NOEL D. WILKIE, IX, CJSN
will affect the development of occlusion and esthet-
COMMANDING OPFICER
ics. The dentist and the auxiliaries must share a NAVAL REGIONAI. I)EvrAL &v’r~~
common objective in using an anterior point of Box 111
reference. Five commonly used anterior points of PEARL HARBOR, I~AWAII 96860

ARTICLES TO APPEAR IN FUTURE ISSUES

Fabrication of a maxillary occlusal treatment splint

Harmon F. Adams, D.D.S.

Posterior maxillary osteotomies: An aid for a difficult prosthodontic problem

John M. Alexander, D.D.S., and ,Joseph E. Van Sickels, D.D.S.

Technique for making a customized shade guide

Samuel W. Askinas, D.D.S.. and Daniel A. Kaiser. D.D.S., M.S.D.

The effect of relining on the accuracy and stability of maxillary complete

dentures-An in vitro and in vivo study
M. T. Bar-co, Jr., D.D.S., M.S.D., B. K. Moore, Ph.D., M. L. Swartz, M.S., M. E. Boone,
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

.Janet G. Bauer, D.D.S.

Current concepts in cranioplasty

John Beumer, III, D.D.S., M.S., Dave N. Firtell, D.D.S., and Thomas A. Curtis, D.D.S.

MAY 1979 VOLUME 41 NUMBER 5