Continuing education

The Axis-Horizontal reference plane

for precision diagnosis: part 2
In this second part in the series, Drs. RK Tamburrino, JL Linton, and SH
Shah add a third reference point to the Axis-Horizontal line to create the
Axis-Horizontal plane

Introduction
Educational aims and objectives
In Part 1 of this series1, the Axis-Horizontal reference • How facebow orientation can affect the
line was introduced as the proposed sagittal standard for bite fork positioning.
• How facebow orientation affects mounting of
orienting mounted study casts and radiographs in Adjusted the maxillary model.
Natural Head Position (ANHP). For cases that involve • The importance of a neutral reference plane
and how it relates to head positioning.
occlusal equilibration, positioner fabrication, or maxillary
orthognathic surgery, the Axis-Horizontal reference line Expected outcomes
Correctly answering the questions on page 24,
would provide the most accurate reference for these worth 2 hours of CE, will demonstrate the reader
procedures. This article will expand upon the concept of can:
• Realize the bite fork registers the maxillary
the Axis-Horizontal line to include a third reference point, position in three planes of space independent
thus creating the Axis-Horizontal plane. of the facebow.
• Realize the importance of a neutral reference
plane for facebow orientation to properly orient the
The bite fork and transverse cast orientation bite fork.
• Realize how to mark the Axis-Horizontal reference plane on a patient’s
All articulator systems use a bite fork mechanism (or similar face.
apparatus), as shown in Figure 1, to record the maxillary
position in all three planes of space, independent of any
existing patient condition or anatomy. When the maxillary
model is mounted, the bite fork provides a stable reference
to position the cast with regard to the upper framework and
hinge axis of the articulator (Figure 2).
The bite fork jig assembly on most articulator systems
has a “built in” reference of true vertical and also demarcates
a neutral transverse orientation when used properly (Figure
3). Thus, if the facebow is also oriented in a neutral
transverse and horizontal position all subtleties and
variations of the maxillary dentition and jaw position will
be reflected solely onto the bite fork (Figure 4).
Orientation of the bite fork with relation to the bite fork
jig is variable and is interdependent on both the facebow
representation of the reference plane and head positioning.
Errors in head positioning will be passed through to the
transverse facebow orientation and project onto the bite
fork, which will ultimately produce maxillary mountings
with cant misrepresentations.
If the transverse cant of the facebow frame is not neutral Figure 1: A maxillary cast on the bite fork jig assembly prior to
when the facebow is recorded, there will be an inherent mounting. The maxillary position is registered independent of the
articulator and is only as accurate as the facebow recording
misrepresentation of the transverse spatial relationship of
the maxillary cast as shown in Figure 5. When the facebow/
bite fork are then transferred to the articulator for mounting and many people present with subtle cants of the occlusal
the maxillary cast, the stem of the bite fork will be reoriented plane2,3. For an initial mounting using the modified
to the true vertical. Thus, any transverse canting of the estimated facebow technique described previously in Part
occlusal plane will be magnified in the opposite direction of 11, this imbalance is acceptable. However, when a precision
the facebow disorientation. This is illustrated with Figure 6. mounting is necessary, these variations of ear position will
The fundamental assumption used in Part 1 of this ultimately affect the transverse reference position of the
article was that a patient presents as symmetric and has no facebow and subsequent mounting of the maxillary model3.
transverse canting of the occlusal plane1. However, it is
well accepted that no person is perfectly symmetric. For The Axis-Horizontal reference plane
example, the ear canals are often not at equal vertical and Using the information previously in Part 11 and the
horizontal positions on the right and left side of the face, information described above, an ideal reference position

Volume 3 Number 2 Orthodontic practice 25

Continuing education

Figure 2: Illustrations showing how the maxillary cast relates to the horizontal and vertical references Figure 3: A jig assembly
inherent to the articulator showing horizontal and
vertical orientation of
the components

Figure 4: Illustration of the facebow/jig assembly as true horizontal references with the resultant orientation of the bite fork

Figure 5: The same maxillary cast using the identical bite fork registrations, but different facebow orientations

should be oriented perpendicular to the true vertical lines direction and magnitude when viewed frontally.
when a patient in ANHP is viewed from both the front and As a result, the upper member of the articulator serves
the side, as shown in Figure 7. If the maxillary model as a frame of reference in all three planes of space for the
is mounted according to this reference plane, the occlusal patient3, and also represents the Axis-Horizontal reference
plane will be at the correct inclination when viewed plane (Figure 8).
sagittally, and any cant will be properly represented in
26 Orthodontic practice Volume 3 Number 2

Figure 6: Illustration of how the jig will always represent true vertical and horizontal. Errors in transverse facebow orientation will
alter the representation of the maxillary cast
Figure 7: Representation of an ideal reference plane
Three distinct points are required to construct a plane.
For precision mountings where rotational movements of
the mandible are critical to the case outcome, the goal is
to have the rotational axis of the articulator reference the
same rotational reference axis of the patient’s mandible.
Therefore, depending on the operator’s preference, this first
point may be either the true hinge axis (measured with an
axiographic recording) or a rotational axis that is estimated
through palpation of the lateral pole of the condyle3. For
a truly accurate representation of the patient, using the ear
canals as a transverse reference (and using an earbow-type
facebow) is not advised due to the inherent introduction of
error. The rotational axis is then the first point of the plane
and is shown in Figure 9.
The second point of the plane is placed anywhere on a
line constructed through the rotational axis point that is also
Volume 3 Number 2 Orthodontic practice 27
Continuing education
Figure 8: The articulator
representation of the Axis-
Horizontal reference line
perpendicular to the true vertical line, as shown in Figure
10. The technique for marking this second point, which
now demarcates the Axis-Horizontal line, was described
previously in Part 11.
The third reference point is placed on the opposite
side of the face at the same vertical position as the second
point. There are several methods that can be employed
to accomplish this. However, if one has a laser level3 or
radiographic unit, such as the i-CAT (Imaging Science
International), that has the ability to project a true horizontal
line or “cross-hairs” onto a patient’s head, this is relatively
easy. After placing the patient into the radiographic unit,
select the alignment light. With the patient positioned into
the unit, position the head so that the alignment light passes
through both points on the Axis-Horizontal line (Figure
11). Then, view the patient from the front and position
Continuing education

Figure 11: Proper

Figure 9: Marking the
rotational axis of the
mandible
sagittal orientation
of the patient in the
radiograph unit in
preparation for marking
the third reference
point
Figure 10: Determination of the Axis-Horizontal
reference line on the patient

Figure 12: Marking the third reference point, and thus demarcating the Axis-Horizontal Plane,
using the alignment light on the radiograph unit

the head into what the operator feels is the correct frontal
orientation. This is illustrated with Figure 12. Since the
alignment light will be projected across the entire face, the
operator can easily place a radiopaque marker or barium
paste on the face to denote the third reference point along
this position. The Axis-Horizontal reference plane has now
been determined and will appear on the radiograph and the
face for future reference.
Conclusion
No patient is 100% symmetric, and may have slight
variations in the transverse cant of the occlusal plane. The
Axis-Horizontal plane provides a neutral reference position
in all three planes of space for a treatment planning reference.
The final article of this series will focus on a technique and
device for recording and transferring the Axis-Horizontal
plane to the articulator to have a truly precision mounting
for both evaluation of position and function.
Acknowledgement
The authors would like to extend their gratitude to
Dr. Timothy Tremont for his knowledge, research, and
commitment to excellence. His original work, The Four
Faces of Orthognathic Surgery®3,4, and his teachings are the
basis for many of the geometrical concepts and techniques
described in this paper.
References
1. Tamburrino RK, Linton JK. The Axis-Horizontal Reference Line
for Precision Diagnosis (2012). Ortho Practice US 3: 25-28.
2. Williams RE. Personal Communication. 2012.
3. Tremont TJ. The Four Faces of Orthognathic Surgery®. Course
Manual. 2010.
4. Tremont TJ. The Four Faces of Orthognathic Surgery®. AAO
Annual Meeting. 2004
Ryan K. Tamburrino, DMD, a native of Pittsburgh and
co-founder of the Center for Orthodontic Excellence,
graduated from Duke University with a double major in
biomedical engineering and mechanical engineering/
materials science. He then attended the University of
Pennsylvania for dental school and stayed an additional
2 years for specialty training in orthodontics.
During his orthodontic training, Dr. Tamburrino concurrently
completed additional training in advanced orthodontic diagnosis,
functional occlusion, and TMJ health with the AEO/Roth-Williams
Group and Andrews’ Six Elements courses.
Dr. Tamburrino is on faculty as an attending clinician in the graduate
orthodontic clinic at the University of Pennsylvania. Additionally, he is
on faculty and lectures internationally/nationally with the Roth/Williams
Center for Functional Occlusion and Complete Clinical Orthodontics
(CCO) courses. He also routinely speaks at various local study groups.
With involvement in several ongoing clinical research projects, both
privately and in conjunction with the Department of Orthodontics at
the University of Pennsylvania, Dr. Tamburrino’s main interests lie in the
areas of TMJ imaging and diagnosis, achieving skeletal and esthetic
harmony in three planes of space, the science of functional occlusion,
and early orthodontic intervention.
Jina Lee Linton, received DDS degrees from Yonsei
University College of Dentistry in Seoul, Korea and
Columbia University School of Dental and Oral Surgery
in New York. She also holds an MA and Certificate of
Orthodontics from Columbia University, and a PhD from
Yonsei University. Currently, in Seoul, Korea, she is in
private practice and is an attending professor at the
Department of Plastic Surgery, Medical College, Han Yang University.
Shalin Raj Shah, DMD MS received his Certificate of
Orthodontics and Masters of Science in Oral Biology
from the University of Pennsylvania and is a Diplomate
of the American Board of Orthodontics. He is also
a graduate of the University of Pennsylvania College
of Arts and Sciences and School of Dental Medicine.
Currently, Dr. Shah is Clinical Associate of Orthodontics
at the University of Pennsylvania and is in private practice (Center
for Orthodontic Excellence) in Princeton Junction, New Jersey and
Philadelphia, Pennsylvania.

28 Orthodontic practice Volume 3 Number 2