Comparison of Occlusal Plane in Dentate and Partial dentate

individuals by using custom-made Broadrick Flag

A RESEARCH PROJECT

Submitted to the Board of Advanced Studies and Research Dow University of

Health Sciences In partial fulfillment of the Requirement for the degree of

MASTER OF SCIENCE

(PROSTHODONTICS)

By

DR. MUHAMMAD KAZIM

DEPARTMENT OF PROSTHODONTICS
Dr. Ishrat ul Ebad Khan Institute of Oral Health Sciences
Dow University of Health Sciences
Karachi, Pakistan
JULY, 2023
 DEDICATION

I dedicate my work to my family

 ACKNOWLEDGEMENTS

“If I have seen further than others, it is by standing upon the shoulder of giants.”

- Sir Isaac Newton

In completion of this work, the author would like to convey his sincerest gratitude and
appreciation to the various individuals that have assisted and guided him towards his goal.
Firstly, to The Almighty, The All-Knowing, without whom, none of this would have been
possible.
I would begin by sincerely thanking my supervisors for the unyielding support they gave to me
in order to successfully completes the research project. I appreciate their efforts because they
offered me all the necessary guidelines; i needed in order to achieve this academic task.
I deeply thank my family and friends for all the encouragements they gave to me during study.
 DECLARATION

I, Dr. Muhammad Kazim hereby state that my Master’s project titled Comparison of

Occlusal Plane in Dentate and Partial dentate individuals by using custom-made

Broadrick Flag is my own work and has not been submitted previously by me for taking any
degree from Dow University of Health Sciences or anywhere else in the country/world.
At any time if my statement is found to be incorrect even after my Graduate the university has
the right to withdraw MSc degree.

Dr. Muhammad Kazim

Subject: Prosthodontics
Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences,
Dow University of Health Sciences

Signature_________________________________
Date:
 CERTIFICATE

This is to certify that the thesis entitled Comparison of Occlusal Plane in Dentate and

Partial dentate individuals by using custom-made Broadrick Flag submitted by Dr.

Muhammad Kazim to the Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow
University of Health Sciences, Karachi for the award of the degree of Master of Science
(Prosthodontics), is a bonafide record of the research work carried out by him under my
supervision and guidance. The content of the project, in full or parts have not been submitted to
any other Institute or University for the award of any other degree or diploma.

Supervisor:

Dr. Bushra Jabeen

Qualification:BDS, MCPS
Designation: Associate Professor
Department name: Prosthodontics
Dow International Dental College,
DUHS, Karachi

Date:
 CERTIFICATE

This is to certify that the thesis entitled Comparison of Occlusal Plane in Dentate and

Partial dentate individuals by using custom-made Broadrick Flag submitted by Dr.

Muhammad Kazim to the Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow
University of Health Sciences, Karachi for the award of the degree of Master of Science
(Prosthodontics), is a bonafide record of the research work carried out by him under my
supervision and guidance. The content of the project, in full or parts have not been submitted to
any other Institute or University for the award of any other degree or diploma.

Co-supervisor:

Dr. Bharat Kumar

Qualification: BDS, FCPS
Designation: Assistant Professor
Department name: Prosthodontics
Dow International Medical College
DUHS, Karachi

Date:
 Table of Contents
ABSTRACT...................................................................................................................................................................ii
Background:...............................................................................................................................................................iii
Objective:...................................................................................................................................................................iii
Methodology:.............................................................................................................................................................iii
Results:.......................................................................................................................................................................iv
Conclusion:................................................................................................................................................................iv
Keywords:..................................................................................................................................................................iv
CHAPTER 1...................................................................................................................................................................1
1 INTRODUCTION.......................................................................................................................................................2
1.1 Background:..........................................................................................................................................................2
1.1.1: Curve of Spee:..............................................................................................................................................2
1.1.2: Curve of Wilson:...........................................................................................................................................3
1.2 Aim and Objective:...............................................................................................................................................4
1.3 Hypothesis:...........................................................................................................................................................4
1.4 Operational Definitions:......................................................................................................................................4
CHAPTER 2...................................................................................................................................................................6
2 REVIEW OF LITERATURE......................................................................................................................................7
2.1 Loss of Teeth (Prevalence & Incidence):..............................................................................................................7
2.2 Risk Factors for Tooth Loss:.................................................................................................................................7
2.3 Significance of Occlusal Plane:............................................................................................................................8
2.4 Assessment of the plane of occlusion:..................................................................................................................9
2.5: Methods for determining the Occlusal Plane:....................................................................................................10
2.6: Broadrick Occlusal Plane Analyzer:..................................................................................................................12
2.6.1 Components of BOPA:................................................................................................................................12
2.6.2 Method to use BOPA:..................................................................................................................................13
2.6.3 Indications for the use of BOPA:.................................................................................................................15
2.7: Custom-made Broadrick Occlusal Plane Analyzer (BOPA):............................................................................16
2.7.1 Fabrication of a custom-made BOPA:.........................................................................................................16
2.7.2 Indications for a Custom-made BOPA:.......................................................................................................17
2.7.3 Adaptation of BOPA:...................................................................................................................................18
2.8 Literature regarding the determination of OP by using BOPA:.............................................................................18
CHAPTER 3.................................................................................................................................................................20
3 MATERIALS AND METHODOLOGY...................................................................................................................21
3.1 Research Project Design:............................................................................................................................21
3.2 Research Project Population and Settings:..................................................................................................21
3.3 Research Project Sampling Technique:.......................................................................................................21
 3.4 Research Project Sample Size:....................................................................................................................21
3.5 Research Project Duration:..........................................................................................................................21
3.6 Research Project Inclusion Criteria:............................................................................................................22
3.7 Research Project Exclusion Criteria:...........................................................................................................22
3.8 Ethical Considerations:...............................................................................................................................22
3.9 Research Data Collection Procedure:..........................................................................................................22
3.10 Research Data Analysis:..............................................................................................................................39
CHAPTER 4.................................................................................................................................................................40
4 RESULTS..................................................................................................................................................................41
CHAPTER 5.................................................................................................................................................................51
5 DISCUSSION............................................................................................................................................................52
Limitations:...............................................................................................................................................................55
Conclusion:...............................................................................................................................................................55
BIBILOGRAPHY.........................................................................................................................................................56
Annexure I: Scientific Approval Letter........................................................................................................................61
Annexure II: Digital Receipt .......................................................................................................................................62
Annexure III: Similarity Index Receipt........................................................................................................................63
 List of Tables
Table4.1: Measurements obtained from Dentate Patients.......................................................44
Table4.2: Measurements obtained from Kennedy Class I Patients........................................45
Table4.3: Mean and Standard deviation values for each tooth...............................................46
Table 4.4: Tests of Normality..........................................................Error! Bookmark not defined.
Table4.5: Homogeneity of Variances test (ANOVA)................................................................48
Table4.6: Mean ranks and sum of ranks for each tooth type and group...............................49
Table4.7: Mann-Whitney U Test Analysis................................................................................50
 List of Figures

Figure3.1: Customized Broadrick Flag.....................................................................................23

Figure3.2: Whipmix Articulator................................................................................................24
Figure3.3: Facebow Record........................................................................................................25
Figure3.4: Lateral view of Facebow record..............................................................................25
Figure3.5 : Facebow Transfer Articulator with jig..................................................................26
Figure3.6: Facebow Transfer Articulator.................................................................................26
Figure3.7: Occlusion recording with bite registration paste...................................................28
Figure3.8: Occlusion recording with bite registration paste...................................................28
Figure3.9 Occlusion recording with bite registration paste.....................................................29
Figure3.10: Upper and Lower arch articulated with bite registration paste.........................29
Figure3.11: 4 inch measurement................................................................................................30
Figure3.12 Marking of Anterior Survey Point..........................................................................31
Figure3.13: Marking of Posterior Survey Point.......................................................................32
Figure3.14: 4inch marking on teeth...........................................................................................32
Figure3.15: Measurement of Anterior Survey Point................................................................33
Figure3.16: Measurement of Posterior Survey Point...............................................................33
Figure3.17: Customize Broadrick flag Armamentarium.........................................................34
Figure3.18: Customized Broadrick flag....................................................................................35
Figure3.19 : Kennedy class I (anterior view)............................................................................36
Figure3.20: Kennedy Class I (posterior view)...........................................................................36
Figure3.22: Kennedy Class I with Broadrick Flag...................................................................37
Figure3.23: Marking of Anterior Survey Point........................................................................38
Figure3.24: Marking of Posterior Survey Point.......................................................................38
Figure4.1: Gender of Dentate and Kennedy Class I Patients..................................................41
Figure4. 2: Educational Status of Dentate and Kennedy Class I Patients.............................42
Figure4.3: Oral Hygiene Status of Dentate and Kennedy Class I Patients............................43
Figure4. 4: Outlier analysis of Teeth..........................................................................................47
 LIST OF ABBREVIATIONS

OS: Occlusal Scheme

CR: Centric Relation

OP: Occlusal Plane

TMJ: Temporomandibular Joint

BOPA: Broadrick Occlusal Plane Analyzer

PMS: Pankey- Mann-Schuyler

GBD: Global Burden of Disease

ASP: Anterior Survey Point

PSP: Posterior Survey Point

OPSC: Occlusal Plane Survey Center

TMD: Temporomandibular Joint Disorder

IRB: Institutional Review Board

i
ABSTRACT

ii
Background:

In the field of restoration occlusion and an occlusal plane is an important concern when there is

an absence of multiple posterior teeth. Achieving the correct occlusal plane can have a strong

impact on the functional and esthetic rehabilitation of occlusion.

Objective:

The objective of the research is to evaluate the existing occlusal plane of dentate patients and to

compare the occlusal plane in subjects having missing posterior teeth with the dentate

individuals by using custom-made Broadrick flag.

Methodology:

A total of 62 subjects will be examined, out of which 31 will be completely dentate (Group 1)

and other 31 will be partially dentate (Group 2) and study models were taken of their both the

dentition. Interocclusal records were made, and the casts were articulated in a semi-adjustable

articulator. A custom-made Broadrick Flag was fabricated and used to measure the deviation of

the occlusal plane from an ideal one. The distance of the farthest cusp tip from the Broadrick

curve was measured along the long axis of the tooth of the patient. Mann-Whitney U test was

applied to compare the findings between Dentate Patients and Kennedy Class I Patients.

iii
Results:

No statistically significant differences were observed between the distributions of 1 st premolar,

2nd premolar and 1st molar teeth between Dentate Patients and Kennedy Class 1 Patients, as the p-

values were greater than the significance level of 0.05. However, a significant difference was

observed for 2nd molar teeth (p=0.014) between Dentate Patients and Kennedy class 1 patients, as

the p-value was less than 0.05.

Conclusion:

BOPA device with a semi adjustable articulator can be used for achieving both the functional

(correct occlusal plane) as well as the aesthetic needs of the patient.

Keywords:

BOPA, Occlusal plane, Curve of Spee, Curve of Monsoon, Semi Adjustable Articulator

iv
CHAPTER 1

1
 1 INTRODUCTION
1.1 Background:

The occlusal scheme (OS) refers to the arrangement and interaction of the occlusal contacts of

the teeth in the upper and lower jaws during the functional movement of jaws (biting and

chewing) as well as during the centric relation (CR) (1). In Prosthodontics, the occlusal scheme

is considered to be one of the most complicated aspects in the prosthodontics rehabilitation of the

patients, particularly in the posterior region of the oral cavity where the occlusal load and biting

and chewing forces are greater. The occlusal plane (OC) is an important component in the

fabrication of the occlusal scheme for posterior restorations (2). The OC is an imaginary line that

extends from the incisal edges of the anterior teeth to the occlusal surfaces of the posterior teeth

(3). It serves as a reference point for the positioning of dental prostheses and restorations in the

posterior region, ensuring that the occlusion is balanced and functional (3, 4). For the proper

functioning of the teeth and reduction of the TMJ disorders and tooth wear establishment of an

occlusal plane is necessary (5-7). The published literature recommended that the complex 3-D

OC can be determined by two main curves (the Curve of Wilson and the Curve of Spee) (6-9).

1.1.1: Curve of Spee:

It is an anteroposterior curve defined as the curvature of the mandibular occlusal plane from the

tip of the mandibular canine to the distal surface of the last mandibular molar, when viewed from

the side. The curvature of the Curve of Spee is generally concave upward when viewed from the

front, and it varies in depth and length among individuals (10-12).

2
1.1.2: Curve of Wilson:

The Curve of Wilson (mediolateral curve) is defined as the curvature of the occlusal plane from

the distal surface of the last mandibular molar to the distal surface of the last maxillary molar,

when viewed from above. The curvature of the Curve of Wilson is generally concave upward

when viewed from the front, and it varies in depth and length among individuals (11, 12).

These curves depend upon the position and alignment of each tooth present in the arch. When

teeth are rotated, tilted, or extruded, the Curve of Spee can be pathologically disturbed. Restoring

the dentition to an OC that has been altered in this way can introduce interferences during

posterior protrusive movements (13). Studies have shown that such interferences can cause

abnormal muscular activity of mandible, particularly the masseter and temporalis muscles. The

core objective of establishing these appropriate curves is to create a functional occlusal plane that

is aligned with the fibers of the most powerful muscle of the masticatory apparatus (the masseter

muscle) (7, 13).

In partially edentulous arches, regarding the reconstruction of distal free end saddles, the design

of the occlusal plane is playing a very important role to achieve better occlusion and esthetic

(14). There are numerous methods to record the plane of occlusion but among these 3 are the

most common method is used for the fabrication of occlusal plane through the direct method by

selective grinding and indirect method by facebow mounted cast, and the third one is also an

indirect method by using Pankey- Mann-Schuyler (PMS) method with the Broadrick occlusal

plane analyzer (BOPA) (15, 16).

The Broadrick flag is a tool used to reconstruct the Curve of Spee in harmony with the anterior

and condylar guidance. This tool, also known as the Broadrick Occlusal Plane Analyzer, is

3
manufactured by Teledyne Water Pik in Fort Collins, Colorado. It allows for the reconstruction

of the curve of Spee in a way that achieves total disclusion of posterior teeth on mandibular

protrusion movement. By ensuring that the curve of Spee follows the angle of condylar guidance,

the Broadrick flag can help prevent interferences during posterior protrusive movements,

resulting in a more harmonious occlusal plane (13, 17, 18).

1.2 Aim and Objective:

To compare the curve of occlusal plane in patients with Kennedy’s class 1 with dentate

individual by using the custom-made BOPA

1.3 Hypothesis:

Null hypothesis (HO):

There is no difference in the occlusal plane among the dentate and partial dentate individuals.

Alternate hypotheses (Ha):

There is a difference in the occlusal plane among the dentate and partial dentate individuals.

1.4 Operational Definitions:

 Occlusal plane:

The plane achieved by the occluding surfaces of the incisor and posterior teeth. It

represents the curve of occlusions.

4
 Broadrick Occlusal Plane:

It consists of 2 survey points that were marked on the Broadrick flag which was

connected to the upper member of the articulator. The first survey point marked on the

articulator called as anterior with help of a divider, was marked from the lower canine to

the Broadrick flag and intersect with the second survey point that was posterior was

marked from the most distal cusp of lower posterior teeth and the center of the

intersecting point represents the occlusal plane.

 Dentate Individual:

An individual with teeth from the right side of the 2 nd molar to the left side of the 2 nd

molar in both the arches

 Partially Dentate (Kennedy’s Class 1):

Bilateral free end saddles with no posterior teeth on both sides of the jaw.

5
CHAPTER 2

6
2 REVIEW OF LITERATURE

2.1 Loss of Teeth (Prevalence & Incidence):

Loss of tooth is a worldwide problem with growing incidence driven by various factors such as

lower socioeconomic status, age, gender, geographical region, culture and environment (19-21).

The Global Burden of Disease (GBD) study conducted in 2015 revealed that total tooth loss is a

significant health problem that affects a significant no. of people all over the world. The study

reported that around 276 million people worldwide suffer from complete tooth loss, which

corresponds to an age-standardized prevalence of 4.1%. Moreover, the study also found that

edentulism (complete tooth loss) and severe tooth loss were the 28th most prevalent condition

among 310 diseases and injuries (22). The likelihood of experiencing tooth loss tends to rise with

age. However, the highest incidence of tooth loss typically occurs around the age of 65. (22, 23).

2.2 Risk Factors for Tooth Loss:

Several risk factors and predictors have been published in the literature that has an association

with loss of tooth/teeth. These factors can be categorized as proximal, intermediate, or distal

(22).

 Proximal risk factors:

These are those that are directly related to oral health status and include factors such as

poor oral hygiene habits (24, 25), infrequent dental visits, tooth wear (26, 27), periodontal

diseases (9, 28, 29), dental caries and decay (30, 31). Modifying these factors through

7
 regular dental visits, good oral hygiene (such as flossing and regular brushing), and

appropriate management of dental issues can help to reduce the risk of tooth loss.

 Intermediate risk factors:

It includes individual characteristics such as older age (22), gender (females have higher

risk of tooth loss) (22, 32) and underlying health conditions and metabolic and systemic

diseases such as diabetes, osteoporosis, Alzheimer disease, rheumatoid arthritis and

several other diseases (18-23) that can increase the risk of dental diseases and tooth loss.

While these factors may not be directly modifiable, appropriate management of

underlying health conditions and a focus on healthy routine with regular exercise and

healthy diet can support to reduce their impact.

 Distal risk factors:

These are broader social and environmental factors such as smoking (33, 34), nutrition

(24, 25), low socioeconomic status and other related factors(22) have an impact on oral

health and it also include factors such as focus and access to dental care. Addressing

these factors may require systemic changes, such as increasing access to affordable dental

care or improving overall public health, but can ultimately help to reduce the risk of tooth

loss.

2.3 Significance of Occlusal Plane:

The natural dentition features an anteroposterior curve that runs through the cuspid’s tip and the

buccal cusp tips of premolars and molars of the mandible. This curve runs posteriorly, passing

through the anterior point of the condyle of the mandible. This curve was 1 st described by

Ferdinand Graf Spee and called as Curve of Spee (35, 36).

8
Correct management of the occlusal plane is a crucial factor to consider when designing long-

span posterior restorations. The placement of dental restorations on teeth that are not properly

aligned (already rotated, tilted, or extruded), the normal Curve of Spee can be disrupted which

can cause problems with the occlusal plane and result in the incorporation of interferences during

functional movement of the jaw (especially during posterior protrusive movements) (36, 37).

Literature has demonstrated that these interferences can cause abnormal muscle activity in the

mandibular elevator muscles, particularly the masseter and temporalis muscles. This abnormal

activity can result in various deleterious effects on the patient's dental health (7). However,

identifying the correct occlusal plane by restructuring the Curve of Spee to pass through the

mandibular condyle can avoid this problem (17, 37).

2.4 Assessment of the plane of occlusion:

The occlusal plane is determined by a combination of clinical evaluation and diagnostic tools.

The following are the steps involved in the determination of the OC:

 Evaluation of the Candidate's facial profile: Evaluation of the facial profile of the

patient will be helpful in determining the OC relative to the facial features of the

individual (38, 39).

 Assessment of dental midline: For the correct positioning of the teeth relative to the

center of the face, assessment of midline is necessary. If the teeth are deviated from the

midline then the correct OC cannot be established (39, 40).

9
  Evaluation of the Curve of Spee: The curve of Spee is a curve that exists in the occlusal

plane. The dental professional will evaluate the curvature of the curve of Spee and make

any necessary adjustments (37, 41).

 Use of diagnostic tools: Diagnostic tools such as radiographs, models, and photographs

may be used to aid in the determination of the OP. For example, lateral cephalometric

radiograph can be used to identify the inclination of the OP relative to the cranial base

(42, 43).

 Evaluation of occlusal contacts: The dental professional will evaluate the points of

contact between the upper and lower teeth and make any necessary adjustments to ensure

proper alignment and function (44).

2.5: Methods for determining the Occlusal Plane:

Restoration of occlusion in case of multiple missing teeth is very complicated. To establish the

occlusal plane in these cases there are many studies suggesting different techniques to record the

occlusal plane in which the arrangement of teeth was based on structural guidance, radiographic,

and theory of occlusion curves (4, 15, 37, 41, 44).

There are several methods to record and establish the occlusal plane in dentistry, and among

them, the most common methods are:

 Direct method:

10
 This involves the selective grinding of the teeth to achieve a balanced occlusal plane. The

patient is asked to bite on an occlusal registration material, and the clinician then marks

the high points on the teeth and removes them by grinding until the occlusion is balanced

(41, 45).

 Indirect method:

This involves the use of a facebow, which is a tool that measures the spatial relationship

between the upper arch and TMJ. A facebow transfer is made from the patient to an

articulator, which is then used to mount the maxillary and mandibular casts. The occlusal

plane is then established on the articulator (41, 46).

 Digital methods:

With the advent of digital dentistry, various software programs and intraoral scanners can

be used to create a virtual occlusal plane. This involves scanning the patient's teeth and

creating a 3D digital model, which can then be used to fabricate restorations or aligners

(47, 48).

 Pankey-Mann-Schuyler (PMS) method:

This is also an indirect method that involves using a series of records to determine the

position of the occlusal plane. The records include the vertical dimension of occlusion,

centric relation, and facebow transfer with the use of a diagnostic tool, such as the

Broadrick occlusal plane analyzer (13, 49, 50).

11
2.6: Broadrick Occlusal Plane Analyzer:

The Broadrick Occlusal Plane Analyzer (BOPA) is a diagnostic tool utilized in dentistry to

determine the proper position of the occlusal plane or arrangement of posterior teeth (especially

in cases where the curve of Spee has been altered) by measuring the patient's cranial base and

then transferring this information to the maxillary cast establish the positioning of the occlusal

plane relative to the cranial base of the individual (13, 37).

The device was developed by Dr. Richard Broadrick in the year 1963 and has become a widely

used tool in restorative dentistry. The BOPA consists of a U-shaped frame that fits over the

patient's head and a series of adjustable arms that can be positioned to measure the orientation of

the occlusal plane. The arms of the device are positioned according to the curvature of the cranial

base, and can be adjusted to record the precise measurements (13).

2.6.1 Components of BOPA:

This BOPA instrument consists of the following (13):

1. Card index

2. Bow compass with extra center point and needle point

3. Scribing knife

4. Graphite leads

5. Graphite holder

6. Stylus

7. Plastic record cards

8. Aluminum case for storage

12
2.6.2 Method to use BOPA:

First, a cephalometric radiograph should be taken to record the cranial base angle of the patient,

then and the impression of the maxillary arch for cast production. Then the maxillary cast will be

mounted using facebow. Then the BOPA will be placed on the cast according to the curve of

Spee and the device will be adjusted till getting the OP corresponding to the cranial base angle.

The use of the BOPA involves the several steps (3, 13):

1. The card index should be placed on the upper part of the articulator. In case a customized

BOPA is being used, it is possible to use a 2mm thick clear acrylic sheet with dimensions

of 4 inches by 4 inches instead.

2. Place a plastic record card on the dowels located on the right side of the card index and

press it down. These cards have a matte finish on both sides, which allows for easy

recording of markings using ink or pencil. Alternatively, a blank sheet of paper may be

used to record the markings.

3. The recommended radius of the sphere in the Curve of Spee is 3.75 inches for patients

with a skeletal Class II relationship, while a 5 inch radius is more suitable for those with a

skeletal Class III relationship. However, a radius of 4 inches is considered normal and is

often used in the majority of cases, especially in Class I relationships.

4. To set the radius, a lead piece like a regular pencil is placed on the compass and adjusted

to the desired length (for instance, 4 inches).

5. The compass's center point is set to the anterior survey point (A.S.P), which is typically

the disto-incisal of the canines, by adjusting it. However, if the cusp of the canine is flat

13
 or worn, the anterior survey point may be set to the incisal edge. After choosing the point,

it is marked on the cuspid and remains unchanged.

6. By placing the center of the compass on the A.S.P, a plastic record card is marked with a

long arc measuring 3 inches. Eventually, the O.P.S.C will be found at a point along this

arc.

7. To determine the posterior survey point (P.S.P), identify the distobuccal cusp of the lower

last molar. If the lower molar is missing, then the upper cast should be used instead. Soft

modeling compound is applied over the ridge and the articulator is closed until the incisal

pin contacts the incisal guide in a centric relation. The compound is chilled and the

excess is removed, leaving only the compound that simulates the lower buccal cusp. The

upper cast is then removed and a P.S.P can be selected on the modeling compound.

Another option for the P.S.P is the anterior border of the condyle, which is represented by

the most anterior point on the condylar element on the articulator.

8. The P.S.P is used as the center point of the compass, and an arc is drawn to intersect the

arc previously drawn from the A.S.P.

9. Place the center of the Bow Compass, which is still set to the 4-inch radius, at the point

where the arcs intersect on the Plastic Record Card, which is the initial OP survey center.

10. The compass needle is then moved across the occlusal surfaces of the mandibular

posterior teeth to assess how well the arc conforms to the existing OP. The O.P.S.C is

adjusted along the long arc on the plastic record card, which intersects with the A.S.P

line, until the most suitable occlusal plane and line are achieved.

14
 11. Moving the center point of the compass anterior to the arc intersection will result in

raising the line and plane of occlusion at the distal end, while moving it posterior to the

intersection will lower the line and plane of occlusion.

12. Once multiple attempts have been made to find the best occlusal plane survey center, the

ideal location that forms the most satisfactory line and plane of occlusion must be marked

for future reference.

13. The scribing knife is a tool that is inserted into the compass, and it is used for marking

and cutting materials such as plaster, compound, or wax during the correction of the OP.

2.6.3 Indications for the use of BOPA:

BOPA is a diagnostic tool that is indicated for use in the following situations:

 Establishing the orientation of the OP:

It can be utilized to accurately measure the orientation of the OP relative to the cranial

base of the patient. This information is used to mount the maxillary cast on an articulator,

which is a device that simulates the movement of the jaws. By the proper orientation of

the maxillary cast, proper alignment and function of the restorations achieved (13, 18).

 Occlusal instability and occlusal interferences:

By using the BOPA, the occlusal instability can be detected and it can also be used to

correct the primary reason (tooth mobility and tooth wear etc) which is responsible for

causing the occlusal instability and occlusal interferences (13, 41, 50) .

15
  Temporomandibular joint disorders (TMD):

TMJ disorders can also be diagnosed by using the BOPA device as it can correct the

position and alignment of the teeth and occlusal interferences (51).

 Aesthetic concerns:

The proper alignment and positioned of the teeth helps to obtain aesthetic of the

prosthesis. By getting the appropriate alignment of the teeth, the clinician can also get a

beautiful smile (45, 52).

2.7: Custom-made Broadrick Occlusal Plane Analyzer (BOPA):

A custom-made BOPA is a substitute to a pre-fabricated BOPA. The custom made would be

required in in complex cases where adaptations and adjustments are required or when there is

unavailability of a pre-made BOPA. The position and orientation of teeth in concordance to the

patient’s OP will be attained by altering or adjusting the angle or length of the arm or adding

pointers or markings relative to the patient’s plane (13, 41, 50, 53).

2.7.1 Fabrication of a custom-made BOPA:

To fabricate a custom-made BOPA, a clinician or dental technician would typically start by

taking an impression of the patient's maxillary arch and mounting it on an articulator. The

clinician would then use wax or other material to create a temporary occlusal plane on the

mounted cast, and would use this as a reference to design and fabricate a custom BOPA that

matches the patient's occlusal scheme (41).

16
2.7.2 Indications for a Custom-made BOPA:

The usage of custom-made BOPA is recommended in cases where adjustments are required for

the precise details and requirements of the patients as well as the clinician and laboratory

personnel or when there is unavailability of a pre-made BOPA. There are few conditions where a

custom-made BOPA could be helpful, it include:

 Unique occlusal schemes: For those patients who have a complex occlusal scheme, a

custom-made BOPA can accurately determine the arrangement of the teeth (4).

 Full-mouth rehabilitation: A custom-made BOPA could be helpful in patients of full

mouth rehabilitation to precisely execute the restoration process (50).

 Prosthodontics: For the fabrication of dentures, a custom-made BOPA can be useful for

the accurate positioning of teeth according to the functioning and comfort of the patient

(4).

 Orthodontics: For the repositioning of the teeth (premolars and molars) in an

orthodontic patient, it could be beneficial (51).

2.7.3 Adaptation of BOPA:

The adaptation process typically involves modifying the BOPA so that it can be mounted onto

the articulator in a stable and accurate manner. This may involve the use of custom-made

17
adapters, brackets, or screws to attach the BOPA to the articulator. This BOPA device has

already been modified to various articulator systems and some examples are given in the

literature include following articulators: (18, 54)

 Hanau (all models)

 Kavo (Protar)

 Denar

 Jensen (Artex--under development)

Adaptation of BOPA with these articulators help to obtain the appropriate and correct

arrangement and position of teeth with good stability and optimal functioning of premolars and

molars for prosthesis and full mouth rehabilitation cases. Overall, the functioning and aesthetic

of the prosthesis will be improved (18, 40, 54).

2.8 Literature regarding the determination of OP by using BOPA:

A case control study conducted by S Manvi et al. revealed a statistically significant difference (p

< 0.05) in the deviation between the patients with missing posterior teeth and individuals with a

full dentition. The conclusion of the research suggests that the proper utilization of the BOPA

helps to determine the correct OP (53).

Jagadeesh et al. conducted a study on the patients with skeletal class 1, class 2 and class 3 jaw

relations to confirm the accuracy of Broad rick flag. They BOPA as a reliable tool for the

determination of OP (55)

A clinical report published by SV Bedia et al. demonstrated that BOPA helps in the initial

mandibular OP development in diagnostic casts as well as definitive restorations (41).

18
Craddock et al. conducted a study on patients with missing posterior teeth, revealed that when

the posterior teeth remains missing for long duration, the teeth changes its position with time and

this caused deviation from the Broadrick curve. They concluded that BOPA could be helpful for

precise reproduction of OC (56).

Jaydip et al. also conducted a study on dentate and edentulous patients and didn’t find any

statistically significant differences in both the groups of the patients clinically as well as

statistically. They found the close resemblance between anatomically established OP and the

occlusion established by BOPA (15).

19
CHAPTER 3

20
3 MATERIALS AND METHODOLOGY

3.1 Research Project Design:

Cross-sectional study

3.2 Research Project Population and Settings:

This research was executed at Department. of Prosthodontics of DIDC, DUHS.

3.3 Research Project Sampling Technique:

Purposive sampling technique was used to drive the study samples

3.4 Research Project Sample Size:

The sample size of this research was calculated via the OpenEpi.com (online software for sample

calculation) by using mean and S.D of Broadrick occlusal curve reported by Supriya Manvi et al.

in cases (1.15±0.53) and control group (0.88±0.04) (53). The sample size was calculated to be

62 (31 in each group) with 80% power and a significance level (α) of 0.05.

3.5 Research Project Duration:

This project was undertaken over a time period of 5 months after the approval of the project from

the scientific committee and the institutional review board of DUHS

21
3.6 Research Project Inclusion Criteria:

• Individuals of 20 to 60 years of age irrespective of their gender

• Dentate individuals having teeth from the right 2nd molar to the left 2nd molar in both the

upper and lower jaw and Bilateral Class 1 molar and canine relationship

• Partially dentate individuals having Kennedy’s class 1 canine relationship

3.7 Research Project Exclusion Criteria:

• Individuals having tipped or rotated teeth and having previous and ongoing orthodontic

treatment

• Individuals having worn dentition, supra eruption, multiple extensively restored teeth and

having any periodontal pathology or TMJ disorder or any parafunctional habits

• Individuals having other than Kennedy’s class 1

3.8 Ethical Considerations:

The ethical approval of the study was taken from Institutional Review Board (IRB) of Dow

University of Health Sciences (DUHS).

3.9 Research Data Collection Procedure:

After the approval taken from the IRB, DUHS, the subjects of our research were contacted for

the consent taking and given the time for decision taking. After taking the consent from the

patient the impression of both the maxillary and mandibular arch were taken with Irreversible

22
Hydrocolloid impressions (Hygdent, USA) with a stock tray. The Earpiece face bow (whipmix

model no. 8645) was used to transfer the upper cast to a semi-adjustable articulator (whipmix

2000 series) as shown in Figure 3.2 and Figure 3.4. Later, interocclusal records (I Sil Bite, Bite

registration paste, Medisilk) were made to record centric relation and mount the mandibular cast

on the same articulator. The OP analyzer was adapted to compare the ideal OP to the upper

member of the semi-adjustable articulator as described by Lynch and McConnell by using the

Broadrick flag method (37).

Figure3.1: Customized Broadrick Flag

23
Figure3.2: Whipmix Facebow

24
Figure3.2: Whipmix Articulator

Figure3.3: Facebow Record

25
 Figure3.4: Lateral view of Facebow record

Figure3.5 : Facebow Transfer Articulator with jig

26
Figure3.6: Facebow Transfer Articulator

Figure3.8: Facebow Transfer Articulator

27
 Figure3.9: Facebow Transfer Articulator

Figure3.7: Occlusion recording with bite registration paste

28
Figure3.8: Occlusion recording with bite registration paste

Figure3.9 Occlusion recording with bite registration paste

29
 Figure3.10: Upper and Lower arch articulated with bite registration paste

Lynch and McConnell’s custom BOPA:

It consists of 2 survey points that were marked on the Broadrick flag which was fixed to the

upper member of the articulator. The first survey point he marked on the articulator was called

anterior in this with help of a divider 4 inch was marked from the lower canine to the Broadrick

flag and intersect with the second survey point that was posterior was marked from the most

distal cusp of lower posterior teeth. The center of the intersecting point represents the occlusal

plane (37).

30
 Figure3.11: 4 inch measurement

Measurement of the dentate individual:

The A.S.P was marked from the distal slope of mandibular canine and the P.S.P was marked

from the distobuccal cusp of mandibular last molar, from those two-points arcs of the 4 inches

were made towards the upper member of the articulator as shown in Figure 3.15 and Figure 3.16.

31
Figure3.12 Marking of Anterior Survey Point

Figure3.13: Marking of Posterior Survey Point

32
 Figure3.14: 4inch marking on teeth

Figure3.15: Measurement of Anterior Survey Point

33
 Figure3.16: Measurement of Posterior Survey Point

Fabrication of Custom-made Broadrick Flag:

Custom-made Broadrick Flag was fabricated by using two rods of stainless steel (which was

10cm in height) and a piece of 2 mm thick acrylic sheet (which was 11 cm in width) and acrylic

sheet was attached to the stainless steel rods with screws, which was fixed to the upper member

of the whip mix articulator and the graph paper was attached to both sides of the acrylic sheet.

Armamentarium and customized Broadrick flag shown in Fig 3.17 and Fig 3.18 respectively

34
Figure3.17: Customize Broadrick flag Armamentarium

Figure3.18: Customized Broadrick flag

35
Measurement for partial dentate individual:

The A.S.P that was marked from distal slope of mandibular cuspid and P.S.P when the

mandibular molar was missing, the upper (maxillary) cast of the patient was replaced with a soft

modeling compound by placing it over the ridge.

The articulator was closed till the incisal pin of the articulator contacts the incisal guide in a CR.

The excess of the compound was carved and removed and leaved it only contacting into the

upper fossae and simulated the lower buccal cusp that was from those 2-point arcs of the 4

inches were made towards the upper member of the articulator. A positive code was annotated,

when it was deviated outside the existing occlusal curve and a negative code was annotated when

it was deviated inside the occlusal curve. However a zero was given, when there was no

deviation observed. (The complete procedure shown in Fig 3.19 to Fig 3.24)

36
Figure3.19 : Kennedy class I (anterior view)

Figure3.20: Kennedy Class I (posterior view)

37
 Figure 3.21: Customizing Broadrick flag

Figure3.21: Kennedy Class I with Broadrick Flag

38
 Figure3.22: Marking of Anterior Survey Point

Figure3.23: Marking of Posterior Survey Point

3.10 Research Data Analysis:

IBM SPSS version 26.0 was used for the descriptive and analytical statistics in form of

frequencies, and percentages. Tests of normality were applied to check the normal distribution of

the data. One way ANOVA test was executed to check the homogeneity of variances between

teeth groups. The Mann-Whitney U test was performed to compare the distributions of premolars

and molars between "Dentate patients" and "Kennedy Class 1 patients" groups.

39
40
CHAPTER 4

41
4 RESULTS

This research was carried out to compare the curve of OP in patients with Kennedy’s class 1 with

dentate individual by using the custom-made Broadrick plane analyzer.

The study subjects were categorized into two groups based on their oral status: Dentate patients

(those with all the natural teeth, from 2nd molar to 2nd molar have bilateral class I molar and

canine relationship) and partially dentate patient (Kennedy class I having class I canine

relationship). Each group consisted of 32 samples, resulting in a total of 62 individuals included

in the study. The gender distribution, educational status and oral hygiene status of the patients

are presented in Fig 4.1, Fig 4.2, and Fig 4.3 respectively.

Figure4.24: Gender of Dentate and Kennedy Class I Patients

Gender
30

25

20

15

10

0
Dentate Patients Kennedy class 1

42
 Figure4. 25: Educational Status of Dentate and Kennedy Class I Patients

Educational Status
12

10

0
Dentate Patients Kennedy class 1

43
 Figure4.26: Oral Hygiene Status of Dentate and Kennedy Class I Patients

Oral Hygine Status

16

14

12

10

0
Dentate Patients Kennedy class 1

Measurements were taken to determine the differences between the existing OP and the ideal

Broadrick OP at four specific points on the left side of the jaw. These points included the buccal

cusp tip of the mandibular left 1st premolar (Point 1), buccal cusp tip of mandibular left 2 nd

premolar (Point 2), mesiobuccal cusp tip of mandibular left 1 st molar (Point 3), and mesiobuccal

cusp tip of mandibular left 2nd molar (Point 4). The measurements of Dentate and Kennedy Class

1 patients are represented in Table 4.1 and Table 4.2 and the mean and SD for each group of the

teeth is represented in Table 4.3.

44
 Table4.1: Measurements obtained from Dentate Patients

Measurements of Dentate Patients in mm

Teeth Group
Patient’s S. No 1 Premolar
st
2 Premolar
nd
1st Molar 2nd Molar
1. 0.53 1 1.54 0.52
2. -0.52 1.21 1.55 0.55
3. -1.01 -0.52 -1.01 -1.01
4. 0.52 0.54 1.49 0.52
5. -1.54 -1.5 -1.52 -2
6. -1.24 -1.87 -1.01 -1.35
7. 1.23 1.01 0.52 0.55
8. 2.12 2.5 1.52 0.45
9. 1.91 2.4 0.54 0.53
10. 2.54 2.2 0.65 0.44
11. 1 0.43 1.5 0.52
12. 1 1.12 1.4 1.21
13. 0.54 1.01 1.22 0.54
14. 1.54 1.44 1.21 0.54
15. 0.42 0.5 0.5 0.54
16. 1.01 1.5 0.5 1.24
17. 0.65 0.73 1.5 1.5
18. 0.21 1.54 0.54 0.52
19. 0.24 0.5 0.64 0.44
20. 1.22 1.53 1.84 1.91
21. 0.21 0.53 0.76 1.1
22. 0.38 0.81 1.12 1.29
23. 1.35 0.8 1.68 1.2
24. 0.3 0.5 0.8 1.14
25. 0.51 0.22 0.61 0.78
26. 1 0.43 1.5 0.5
27. 1.32 1.5 1.41 0.5
28. 1.3 1.5 1.53 1.4
29. 1.05 1 1 1.5
30. 0.5 0.3 1.5 1.6
31. 0.6 1.21 1.67 0.55

45
 Table4.2: Measurements obtained from Kennedy Class I Patients

Measurements of Kennedy Class I Patients in mm

Teeth Groups
Patient’s S. No 1st Premolar 2nd Premolar 1st Molar 2nd Molar
1. 0.4 0.65 1.24 1.38
2. -0.52 -0.75 -1.04 -1.43
3. 0.6 0.8 1.3 1.42
4. 0.41 1.14 1.64 1.25
5. 0.58 1.24 1.72 1.35
6. 0.56 1.32 1.83 1.42
7. 1.1 1.35 1.65 1.56
8. 1.16 1.55 1.76 1.85
9. 1.21 1.54 1.73 1.93
10. 0.25 0.45 0.62 0.42
11. 1.15 1.4 1.72 2.12
12. 0.16 0.67 0.5 1.62
13. 0.29 0.65 1.15 1.17
14. 1.23 1.63 1.56 1.29
15. 0.24 0.42 0.82 1.1
16. 0.35 0.2 0.32 0.74
17. 0.29 0.55 0.68 0.46
18. 1.25 1.57 1.82 2.12
19. 0.27 0.69 0.85 1.16
20. 0.35 0.76 0.16 1.27
21. 1.32 1.75 1.66 1.27
22. 0.26 0.45 0.83 1.15
23. -0.45 0 -0.5 -0.76
24. -0.54 -1 -1.43 -1.22
25. 1.32 1.5 1 0.5
26. 1.05 1.01 1.3 1.32
27. -1.52 -2.5 -1.01 -1.5
28. 1.12 1.2 1.7 1.5
29. 1.14 1.25 1.54 1.32
30. 1.43 1.5 1.54 1.51
31. 1.5 1.21 1.32 1.53

Table4.3: Mean and Standard deviation values for each tooth

46
 Descriptive Statistics
N Mean Std. Minimum Maximum
Deviation
1st Premolar 62 .6266 .79814 -1.54 2.54
2nd Premolar 62 .8108 .91039 -2.50 2.50
1st Molar 62 .9465 .85867 -1.52 1.84
2nd Molar 62 .8152 .90831 -2.00 2.12

Normality Tests:

Normality tests were executed using the Kolmogorov-Smirnov and Shapiro-Wilk tests for the

variables represented in Table 4.4. The results indicated that all variables were not normally

distributed, as the significance values for each test were less than 0.05 (1st premolar: p = 0.001,

2nd premolar: p = 0.000, 1st molar: p = 0.001 and 2nd molar: p = 0.000). Therefore, non-parametric

tests may be more appropriate for data analysis.

Table 4.4: Tests of Normality

Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
1st Premolar .156 62 .001 .941 62 .005
2nd Premolar .173 62 .000 .882 62 .000
1st Molar .156 62 .001 .822 62 .000
2nd Molar .219 62 .000 .846 62 .000
a. Lilliefors Significance Correction

Outlier analysis:

There are no outliers for the teeth as shown in Figure 4.4. This is because there are no values that
fall outside of the "whiskers" in the box plots, which represent the range of values that are within

47
1.5 times the interquartile range (IQR) from the first and third quartiles. However, there are
extreme values for some cases. For example, for "1 st premolar", case 1 has a value of 10, which
is the highest extreme value. For "2nd premolar", case 1 has a value of 8, which is the highest
extreme value, and case 27 has a value of -2.5, which is the lowest extreme value. These extreme
values may or may not be considered outliers depending on the context and the analysis being
performed.
Figure4. 27: Outlier analysis of Teeth

Homogeneity of variances test

48
Based on the results of the one-way ANOVA with homogeneity of variances test, there was no
significant difference in the means of 1st premolar (F(1, 60) = 0.215, p = 0.645), 2 nd premolar
(F(1, 60) = 0.067, p = 0.797), and 1 st molar (F(1, 60) = 0.035, p = 0.852) between the Dentate
Patients and Kennedy class 1 groups. However, there was a marginally significant difference in
the means of 2nd molar between the two groups (F(1, 60) = 2.467, p = 0.122). The homogeneity
of variances test showed that the assumption of homogeneity of variances was met for all
variables (premolar_1: Levene's F(1, 60) = 0.681, p = 0.412; premolar_2: Levene's F(1, 60) =
0.043, p = 0.837; molar_1: Levene's F(1, 60) = 0.354, p = 0.554; molar_2: Levene's F(1, 60) =
0.985, p = 0.325). Therefore, the assumption of homogeneity of variances was met, and the
results of the one-way ANOVA can be interpreted in Table 4.5.

Table4.5: Homogeneity of Variances test (ANOVA)

Sum of Squares df Mean Square F Sig.

1st Premolar Between Groups .138 1 .138 .215 .645
Within Groups 38.720 60 .645
Total 38.859 61
2nd Premolar Between Groups .056 1 .056 .067 .797
Within Groups 50.501 60 .842
Total 50.558 61
1st Molar Between Groups .026 1 .026 .035 .852
Within Groups 44.950 60 .749
Total 44.976 61
2nd Molar Between Groups 1.987 1 1.987 2.467 .122
Within Groups 48.339 60 .806
Total 50.326 61

Mann-Whitney U test

49
This test was used to compare the distributions of premolars and molars between two
independent groups, "Dentate patients" and "Kennedy class 1" patients. The mean ranks and sum
of ranks for each tooth type and group were calculated and presented in the Table 4.6 along with
the Mann-Whitney U test statistics in Table 4.7.
The results of the Mann-Whitney U test indicated that there was no significant difference
between the distributions of 1st premolar (p=0.593), 2nd premolar (p=0.860), and 1st molar
(p=0.345) teeth between Dentate patients and Kennedy class 1 patients, as the p-values were
greater than the significance level of 0.05. However, there was a significant difference between
the two groups for 2nd molar teeth (p=0.014), as the p-value was less than 0.05. The negative Z-
scores for both the premolars and 1st molar teeth indicated that dentate patients had higher mean
ranks than Kennedy class 1 patients, while the negative Z-score for 2 nd molar teeth indicated that
Kennedy class 1 patients had a higher mean rank than dentate patients.

Table4.6: Mean ranks and sum of ranks for each tooth type and group

Tooth Type Group Mean Rank Sum of Ranks

Dentate Patients 32.73 617.5
1st Premolar
Kennedy Class 1 Patients 30.27 570.5
Dentate Patients 31.10 586.5
2nd Premolar
Kennedy Class 1 Patients 31.90 601.5
Dentate Patients 33.60 634.0
1st Molar
Kennedy Class 1 Patients 27.50 517.0
Dentate Patients 28.47 536.5
2nd Molar
Kennedy Class 1 Patients 33.63 633.5

Table4.7: Mann-Whitney U Test Analysis

Test Statisticsa

50
 1st Premolar 2nd Premolar 1st Molar 2nd Molar
Mann-Whitney U 442.500 468.000 413.500 306.000
Wilcoxon W 938.500 964.000 909.500 802.000
Z -.535 -.176 -.944 -2.458
Asymp. Sig. (2-tailed) .593 .860 .345 .014
a. Grouping Variable: dentate/kennedy

51
CHAPTER 5

52
5 DISCUSSION

Any prosthodontics rehabilitation procedure's main objective is to recreate the missing structures

in a manner consistent with the way they were before the procedure. To attain this purpose, the

majority of prosthodontics principles have been derived from assessments and evaluations made

in normal healthy individual. The approaches and techniques that were developed in this manner

will make it possible to successfully complete the rehabilitation of the majority of patients.

An example of a notion of this sort is the concept of orientation of occlusal plane. Several

authors have put forth their technique in the literature for establishing the occlusal plane for

individuals who are either completely or partially edentulous. The three techniques that are most

frequently employed in cases of partially dentate patients are:

1. Direct examination of natural teeth by purposeful grinding.

2. Indirect examination of casts mounted on a facebow with correctly aligned condylar

pathways.

3. Indirect examination with BOPA by employing the PMS technique

The BOPA is a device which is used for the orientation of occlusal plane in partially dentate

patients to recognize the Curve of Spee (which can be seen in the sagittal plane) which is an

important curvature for the precise determination of the posterior OP of the patient in cases of

rehabilitation and restorations by helping in achieving the better stability of the dentures.

Determination of the OP has a great impact on the success rate of the prosthesis and restorations

as the correct identification of occlusal plane helps in gaining the optimal functioning as well as

aesthetic concerns, teeth wear and TMJ disorders. The adaptation of an OP analyzer serves as a

tool for detection of the Curve of Spee in concordance with cranial base of patients.

53
The objective of our study was to compare the curve of occlusal plane in patients with

Kennedy’s class 1 with Dentate individual by using the custom-made Broadrick plane analyzer.

The adaptation of the OP analyzer to the upper member of the semi-adjustable articulator using

the Broadrick flag method as described by Lynch and McConnell was followed in our study.

A total of 62 individuals took part in the study with a breakdown of 31 completely dentate

patients and 31 partially edentulous patients visited Department of Prosthodontics of DIDC,

DUHS for their dental needs. On standardized digital photographs of dental casts or scanned

photos of dental models, several researchers have studied the curve of Spee. These research have

provided two-dimensional geometry of the occlusal plane. The geometry of the occlusal plane

was examined in the current research by utilizing actual three-dimensional castings. Data

was collected with a digital Vernier Calliper. The method (digital Vernier Calliper) has the

advantage of providing the precise and accurate readings on actual objects, which can be more

considerable and reliable for use in clinical settings as compared to readings taken from

conventional photographs, computer generated scanned images of the articulated casts, or

cephalometric films.

The results presented in this study showed that no statistically significant differences were

observed between the distributions of 1st premolar, 2nd premolar and 1st molar teeth between

Dentate Patients and Kennedy Class 1 Patients, as the p-values were greater than the significance

level of 0.05. However, a significant difference was observed for 2 nd molar teeth (p=0.014)

between Dentate Patients and Kennedy class 1 patients, as the p-value was less than 0.05.

Supriya Manvi et al, compared the patients who were partially dentate (missing posterior teeth)

and completely dentate. They authors concluded in their study that in partially dentate patients

showed marked deviation (53).

54
Jagadeesh et al. (55) executed a study on the patients with skeletal class 1, class 2 and class 3 jaw

relations and SV Bedia et al. (41) also found the BOPA a reliable device for the determination

of Curve of Spee and Occlusal Plane.

Craddock et al. (56) and Jaydip et al. (15) did not found any statistically significant differences in

their studies and concluded that BOPA is a helpful device for achieving the precise and accurate

reproduction of the occlusal plane.

In summary, the results of our research and previously published studies demonstrate the

significance as well as the productivity and efficiency of the BOPA in establishing the occlusal

plane. The BOPA serves as a useful appliance which assists the dental professionals to perform

the restorative and prosthetic procedures with the best possible occlusal results. These findings

have major implications for the clinical practice. Clinicians need to be cautious about the

possibility of variance in the distribution of individual teeth in dentate as well as Kennedy class 1

patients. The differences that were discovered found may have an impact on treatment planning

options, particularly when missing tooth restoration or dental prosthetic fabrication are the part

of the dental procedure. Further studies and evaluations must be conducted to determine the

underlying mechanisms that contribute to the observed variations in tooth distribution and their

possible impact on oral health and treatment outcomes.

55
Limitations:

This research project has only compared the geometric configuration of the occlusal planes.

Other parameters such as aesthetics and phonetics were not evaluated in this study. Only the

patients of Kennedy Class I and dentate groups were compared. However, the other groups like

complete edentulous patients were not included in the study.

Conclusion:

Occlusal plane can be precisely and accurately achieved by using the BOPA device with a semi

adjustable articulator by getting both the functional as well as the aesthetic needs of the patient.

The clinician can use this tool in their daily routine practice for getting good results in prosthesis

and restorations.

56
BIBILOGRAPHY

57
1. Tarazi E, Ticotsky-Zadok N. Occlusal schemes of complete dentures--a review of the literature. Refu'at Ha-
peh Veha-shinayim (1993). 2007;24(1):56-64, 85.
2. Goodacre CJ, Goodacre BJ. What occlusal scheme should Be used with removable partial dentures?
Journal of Prosthodontics. 2021;30(S1):78-83.
3. Mazurkiewicz P, Oblizajek M, Rzeszowska J, Sobolewska E, Ey-Chmielewska H, Szymańska-Kozula R.
Determining the occlusal plane: a literature review. CRANIO®. 2022;40(4):341-7.
4. Chandrakala S, Ramesh G, Nayar S. An Review on Occlusal Plane Analysis in Dentulous Patients. Indian
Journal of Forensic Medicine & Toxicology. 2020;14(4):1347-51.
5. Arora S. Effect of change in occlusal vertical dimension on the masticatory muscles and TMDS: A review
of literature. Journal of Advanced Medical and Dental Sciences Research. 2021;9(5):39-42.
6. Alkhalaf ZA, Sghaireen MG, Issrani R, Ganji KK, Alruwaili NN, Alsaleh RM, et al. The Effect of
Accentuation of Curve of Spee on Masticatory Efficiency—A Systematic Review and Meta-Analysis. Children.
2023;10(3):511.
7. Mirmortazavi A, Madani AS, Ghazi A, Poornazari N. Evaluation of relationship between curve of spee and
temporomandibular joint symptoms in patients referred to Occlusion section of Prosthodontics department of
Mashhad Dental School. Res Dent Sci. 2021;18(2):119-27.
8. Natanzi MC, Zavaree MA, Torabi M, Damghani FT, Hakimaneh SMR, Shayegh SS, et al. Evaluation of
the curve of spee, curve of wilson and monson’s sphere in Iranian adults. Journal of Craniomaxillofacial Research.
2019:122-8.
9. Irani S, Barati I, Badiei M. Periodontitis and oral cancer-current concepts of the etiopathogenesis.
Oncology Reviews. 2020;14(1).
10. Marshall SD, Caspersen M, Hardinger RR, Franciscus RG, Aquilino SA, Southard TE. Development of the
curve of Spee. American Journal of Orthodontics and Dentofacial Orthopedics. 2008;134(3):344-52.
11. Raghavan R, Shajahan P, Purushothaman P. Occlusal concepts in complete denture prosthodontics: a
literature review. International Journal of Science and Healthcare Research. 2020;5(1):96-100.
12. Lakshmi S. Preclinical Manual of Prosthodontics-E-Book: Elsevier Health Sciences; 2022.
13. Gupta R, Luthra R, Sheth HH. Broadrick’s occlusal plane analyzer: A review. International Journal of
Applied Dental Sciences. 2019;5(1):95-8.
14. Field J, Storey C. Removable prosthodontics at a glance: John Wiley & Sons; 2020.
15. Shah DJ. Use of Occlusal Plane Analyzer in Dentate and Edentate Individuals to Measure Deviation from
Ideal Occlusal Plane: Tamilnadu Government Dental College, Chennai; 2013.
16. Dawson P. Evaluation, Diagnosis, and Treatment of Occlusal Problems. St Louis, Mo: Mosby. Year Book.
1989:7-13.
17. Ré J-P, Perez C, Giraudeau A, Ager P, El Zoghby A, Orthlieb J-D. Reconstruction of the curve of Spee.
Stomatologie. 2008;105:29-32.
18. Small BW. Occlusal plane analysis using the Broadrick flag. General Dentistry. 2005;53(4):250-2.
19. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st
century–the approach of the WHO Global Oral Health Programme. Community Dentistry and oral epidemiology.
2003;31:3-24.
20. Russell SL, Gordon S, Lukacs JR, Kaste LM. Sex/Gender differences in tooth loss and edentulism:
historical perspectives, biological factors, and sociologic reasons. Dental Clinics. 2013;57(2):317-37.
21. Silva Junior MF, Batista MJ, de Sousa MdLR. Risk factors for tooth loss in adults: A population-based
prospective cohort study. Plos One. 2019;14(7):e0219240.
22. Aida J. Tooth loss. Oral Epidemiology: A Textbook on Oral Health Conditions, Research Topics and
Methods. 2021:223-33.
23. Borg-Bartolo R, Roccuzzo A, Mourelle PM, Schimmel M, Gambetta-Tessini K, Chaurasia A, et al. Global
prevalence of edentulism and dental caries in middle-aged and elderly persons. A systematic review and meta-
analysis. Journal of dentistry. 2022:104335.
24. Coll PP, Lindsay A, Meng J, Gopalakrishna A, Raghavendra S, Bysani P, et al. The prevention of
infections in older adults: oral health. Journal of the American Geriatrics Society. 2020;68(2):411-6.
25. Gondivkar SM, Gadbail AR, Gondivkar RS, Sarode SC, Sarode GS, Patil S, et al. Nutrition and oral health.
Disease-a-month. 2019;65(6):147-54.

58
26. Badavannavar AN, Ajari S, Nayak KUS, Khijmatgar S. Abfraction: Etiopathogenesis, clinical aspect, and
diagnostic-treatment modalities: A review. Indian journal of dental research. 2020;31(2):305.
27. Warreth A, Abuhijleh E, Almaghribi MA, Mahwal G, Ashawish A. Tooth surface loss: A review of
literature. The Saudi dental journal. 2020;32(2):53-60.
28. KARTHIKEYAN MURTHYKUMAR D, KAARTHIKEYAN DG. Prevalence of tooth loss among chronic
periodontitis patients-A retrospective study. International Journal of Pharmaceutical Research. 2020;12(2).
29. Helal O, Goestemeyer G, Krois J, Fawzy El Sayed K, Graetz C, Schwendicke F. Predictors for tooth loss in
periodontitis patients: Systematic review and meta‐analysis. Journal of Clinical Periodontology. 2019;46(7):699-
712.
30. Lucas-Rincón SE, Robles-Bermeo NL, Lara-Carrillo E, Scougall-Vilchis RJ, Pontigo-Loyola AP, Rueda-
Ibarra V, et al. Interproximal caries and premature tooth loss in primary dentition as risk factors for loss of space in
the posterior sector: A cross-sectional study. Medicine. 2019;98(11).
31. Kawahara H, Inoue M, Okura K, Oshima M, Matsuka Y. Risk factors for tooth loss in patients undergoing
mid-long-term maintenance: a retrospective study. International Journal of Environmental Research and Public
Health. 2020;17(17):6258.
32. Furuya T, Inoue E, Tanaka E, Maeda S, Ikari K, Taniguchi A, et al. Age and female gender associated with
periodontal disease in Japanese patients with rheumatoid arthritis: Results from self-reported questionnaires from the
IORRA cohort study. Modern Rheumatology. 2020;30(3):465-70.
33. Saito M, Shimazaki Y, Fukai K, Furuta M, Aida J, Ando Y, et al. Risk factors for tooth loss in adult
Japanese dental patients: 8020 Promotion Foundation Study. Journal of investigative and clinical dentistry.
2019;10(2):e12392.
34. Schwendicke F, Nitschke I, Stark H, Micheelis W, Jordan RA. Epidemiological trends, predictive factors,
and projection of tooth loss in Germany 1997–2030: Part II. Edentulism in seniors. Clinical oral investigations.
2020;24:3997-4003.
35. Kuo P-H. The effects of curve of spee in skeletal class II patients treated with combined orthodontics and
surgery. 2022.
36. Marshall SD, Kruger K, Franciscus RG, Southard TE. Development of the mandibular curve of spee and
maxillary compensating curve: A finite element model. PloS one. 2019;14(12):e0221137.
37. Lynch CD, McConnell RJ. Prosthodontic management of the curve of Spee: use of the Broadrick flag. The
Journal of prosthetic dentistry. 2002;87(6):593-7.
38. Shkarin V, Kochkonyan T, Ghamdan A-H, Dmitrienko S. Occlusal plane orientation in patients with
dentofacial anomalies based on morphometric cranio-facial measurements. Archiv EuroMedica. 2021;11(1):116.
39. Batwa W, Hunt NP, Petrie A, Gill D. Effect of occlusal plane on smile attractiveness. The Angle
Orthodontist. 2012;82(2):218-23.
40. Farret MM. Occlusal plane canting: a treatment alternative using skeletal anchorage. Dental press journal
of orthodontics. 2019;24:88-105.
41. Bedia SV, Dange SP, Khalikar AN. Determination of the occlusal plane using a custom-made occlusal
plane analyzer: a clinical report. The Journal of Prosthetic Dentistry. 2007;98(5):348-52.
42. Jayachandran S, Ramachandran C, Varghese R. Occlusal plane orientation: a statistical and clinical
analysis in different clinical situations. Journal of Prosthodontics: Implant, Esthetic and Reconstructive Dentistry.
2008;17(7):572-5.
43. Čelar A, Tafaj E, Graf A, Lettner S. Association of anterior and posterior occlusal planes with different
Angle and skeletal classes in permanent dentitions: A lateral cephalometric radiograph study. Journal of Orofacial
Orthopedics. 2018;79(4):267.
44. Jeong M-Y, Lim Y-J, Kim M-J, Kwon H-B. Comparison of two computerized occlusal analysis systems for
indicating occlusal contacts. The journal of advanced prosthodontics. 2020;12(2):49.
45. Foong KW, Patil PG. Fabrication of maxillary single complete denture in a patient with deranged
mandibular occlusal plane: A case report. The Saudi dental journal. 2019;31(1):148-54.
46. Maveli TC, Suprono MS, Kattadiyil MT, Goodacre CJ, Bahjri K. In vitro comparison of the maxillary
occlusal plane orientation obtained with five facebow systems. The Journal of Prosthetic Dentistry.
2015;114(4):566-73.
47. Petričević N, Guberina M, Ćelić R, Mehulić K, Krajnović M, Antonić R, et al. Use of digital photography
in the reconstruction of the occlusal plane orientation. Official Publication of the Medical Association of Zenica-
Doboj Canton Bosnia and Herzegovina. 2009;6(2):243-8.

59
48. Huang C-H, Hsu C-Y. Computer-assisted orientation of dental periapical radiographs to the occlusal plane.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2008;105(5):649-53.
49. Avinash KV, Sampathkumar R, Swathi AL, Raghu V, Reddy C, Shetty J, et al. PANKEY-MANN-
SCHUYLER PHILOSOPHY-CRITICAL ANALYSIS. 2019.
50. Darraj A, Mattoo KA. Full mouth rehabilitation involving occlusal plane correction-case report. Journal of
Medical Science and Clinical Research. 2017;5(9):28204-208.
51. Suganthapriya S. Evaluation of occlusal and craniofacial planes in temporomandibular disorder patients
using broadrick’s occlusal plane analyzer and cephalometric methods: Tamilnadu Government Dental College and
Hospital, Chennai; 2018.
52. Mohapatra A, Das SS, Srivastava G, Sahoo PK, Dhar U. Full Mouth Rehabilitation of a Patient with
Uneven Occlusal Plane and Severe Attrition: A Clinical Report. Indian Journal of Forensic Medicine & Toxicology.
2020;14(4):8150-4.
53. Manvi S, Miglani S, Rajeswari C, Srivatsa G, Arora S. Occlusal plane determination using custom made
broadrick occlusal plane analyser: A case control study. International Scholarly Research Notices. 2012;2012.
54. Das S, Saha S, Das S, Das SL, Maji AK, Pahari S. RESTORING CURVE OF SPEE BY BROADRICK
OCCLUSAL PLANE ANALYSER FOR A SUCCESSFUL REHABILITATION-A STUDY.
55. Jagadeesh K, Kashinatha H, Bembalgi MS, Kumar PR, Yarlagadda KB, Ateeq PM. Reliability of broadrick
flag in determination of curve of spee in Indian population. The journal of contemporary dental practice.
2012;13(5):627-31.
56. Craddock H, Youngson C, Manogue M. Deviation from the Broadrick occlusal curve following posterior
tooth loss. Journal of Oral Rehabilitation. 2006;33(6):423-9.

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