A plane of orientation
point of reference
Gerard E. Krueger, D.D.S., M.S., l and Robert
Lnivcrsiry of Iowa. Colleqr of Ihrisrry. Iowa (liry.
T rue horizontal is that plane which is perpendicular to
the force of gravity. Natural head position (NHP) is the
position of the head most comfortable for a patient
gazing at the horizon.’
Studies investigating NHP have shown that any
intracranial reference plane, including the Frankfort
horizontal plane, reveals a wide variation between
subjects relative to the true horizontal plane.“‘ Downs’
stated that the eyes and cars can bc related in a different
fashion to the faces of individuals without affecting the
denture and profile relationship.
In 1955, Page6 wrote that a reference plane is the
physical requirement in orienting any bcxiy thrcc-
dimensionally. Foster’ stressed that diagnostic casts
should show the relation of teeth IO the supporting
structures and the facial skeleton as a whole.
AMcCollum” first introduced the Frankfort horizontal
plane to prosthodontin in 1939 when he developed the
axis-orbital plane of orientation that he justified as being
“horizontal, or nearly so, when the body is erect.” The
Frankfort horizontal plane was originally an antropo-
logic reference adoptd at an anthropologic congress in
Frankfort, Germany in 1882.I This plane has been cited
as easily acccssiblc, well defined, and, on the average,
coinciding well with the true horizontal plane relative to
NHP.
The purpose of this study was to implement the true
horizontal plane as the plane of orientation through the
use of an extracranial anterior point of reference. It was
bclicvcd that this method would offer a more accurate,
esthetic rcprcscntation of the patient’s dcntition within
the articulator and improve on the original intent of the
Frankfort horizontal plane.
Gonzalez and Kingcry’ gave three criteria in xl&on
of any plane of orientation: (1) cast of location, (2)
convenience, and (3) reproducibility. Thcsc criteria were
examined to determine the clinical uscfulncss of the pro-
posed plane of orientation determined by using NIIP.
MATERIAL AND METHODS
Ten dental students at The University of Iowa were
chosen as subjects. Criteria in sclcction were that they
56
with an extracranial anterior
L. Schneider, D.D.S., M.S.**
Iowa
have a stable, natural dcntition of at least 12 teeth per
dental arch and a history of minimal symptoms of head,
neck, or shoulder pain or trauma.
Each subject was fitted with a Hanau 132-2S.M
face-bow (Teledyne-Hanau Div., Buffalo, N.Y.). Kcd
modeling compound was added to the biteplate and
symmetrically positioned onto the maxillary teeth. The
mandibular dcntition was guided into the compound in
centric relation to provide stability and comfort. The
face-bow was positioned to arbitrary hinge axis locations
according to Bcyron in Bergstrom.‘” This was checked
for symmetry and the “T” locking mechanism was firmly
tightened. The face-bow assembly was not altered for the
duration of the experiment.
Each of three examiners was supplied with two
infraorbital pointers modified by fixing a standard line
level (No. 555; Johnson Level and Tool Mfg. Co., Inc.,
Milwaukee, Wis.) to them. True horizontal plane was
captured by leveling the bubble gauge with the subject in
NHP. The subject stood in the orthoposition as
described by Molhavc,” which is the “intention” posi-
tion from standing IO walking. By raising and lowering
the head with decreasing amplitude, the subject found a
comfortable head position while looking into the mirror
image of their own gaze. The bubble gauge was then
leveled and reverified IO the examiners’ satisfaction.
Each of three examiners recorded NHP on each of the
10 subjects twice daily for 4 consecutive days. ‘I’hc
experiment was repeated a week later.
All face-bow recordings were placed into one cxpcri-
mental articulator (Hanau 130-28) and the anterior
height was adjusted IO level the bubble gauge. The
vertical placement of the maxillary incisiors was cstimat-
cd by measuring the distance between the undersurface
of the upper arm of the articulator and the summit of the
raised dimple marking the midline of the bitcplatc. All
measurements were performed by one person with a
4-inch vernier ralipcr gauge (0.001 inch; Scars Crafrs-
man model No. 40173). The articulator remained sta-
tionary for the duration of the experiment IO ensure a
constant level of the foundation.
RESULTS
All three examiners found the leveling procedure
comparable to the orbital reference with regard to case of
JULY 19M VOI UME M NUYBFR 1
POINT OF REFERENCE FOR PLANE OF ORIENTATION

h
-2
i-7 3
z

3
T -

Fig. 1. Graphic illustration of resulti;.

Table I. Means (inches)

Range of
daily means
Daily means Weekly mean Over-
Over- all
Subject 1 2 3 4 5 6 7 8 Wkl Wk2 all Wkl Wk 2 Change mean

1 2.51 2.45 2.52 2.57 0.12 0.12 2.51 2.51

2 2.09 2.12 2.01 1.99 1.90 1.91 1.79 0.13 0.12 0.33 2.05 1.87 0.18 1.97
3 2.27 2.44 2.38 2.40 2.43 2.42 2.31 2.37 0.17 0.12 0.17 2.37 2.38 0.01 2.38
4 1.88 1.91 1.96 1.93 1.97 2.18 2.06 2.08 0.08 0.21 0.30 1.92 2.07 0 15 2.00
5
6 2.53 2.67 2.58 2.55 2.61 2.47 2.51 2.56 0.14 0.14 0.20 2.58 2.54 0.04 2.56
7 2.17 2.38 2.30 2.30 2.40 2.38 2.41 2.24 0.21 0.17 0.24 2.29 2.36 0 07 2.32
8 2.09 2.18 2.26 2.32 0.23 0.23 2.21 2.21
9 1.98 2.20 2.11 2.17 2.29 2.32 2.17 2.15 0.22 0.17 0.34 2.11 2.23 0.12 2.17
10 2.29 2.31 2.30 2.18 2.21 2.22 2.27 2.27 0.13 0.06 0.13 1.27 2.24 0.03 2.26
Average (inches) 0.16 0.14 0.23 blos
(mm) 04.1 03.6 05.8 0.23

location and convenience. The means (Table I), ranges
(Table II), and standard deviations (Table III) of the
collected data were determined for evaluation of repro-
ducibility (Fig. 1).
Rounding to the nearest 0.01 inch sufficiently elimi-
nated measuring error and met the needed accuracy of
the technique. The accuracy of the measurer was
compared to that of another arbitrary measurer by
matching repeated measurings of one face-bow record.
Results showed no significant difference between mea-
surers (t = 0.832, p 5 .43).
For the sake of definition, a recording was found to be
clinically acceptable if 50% or more of the bubble
remained within the guide marks of the gauge. This
clinical range of acceptability was found to correspond to
+O.lO inch in vertical height change within the articu-
lator.
The difference between each examiner’s first and
second recordings averaged <0.03 inch (<l mm). Anal-
ysis of variance was performed to test for differences
among examiners. Results indicated that there was no
statistical difference (F value of 0.12; p 5 .89). The
analysis of variance and covariance with repeated mea-
sures design was used to determine whether the time
factor of 1 week affected NHP. F values of 1.15 and 0.81
were not statistically significant (F,, =: 3.21). We con-

THE JOURNAL OF PROSTHETIC DENTISTRY s?

 KRUEGER AND SCHNEIDER

Table II. Ranges (inches)

Daily
Subject
No. 1 2 3 4 5 6 7 8

1 0.28 0.30 0.47 0.15

2 0.17 0.30 0.26 0.08 0.15 0.32 0.12
3 0.27 0.18 0.10 0.13 0.16 0.18 0.16 0.23
4 0.20 0.28 0.30 0.09 0.15 0.12 0.25 0.10
5
6 0.25 0.19 0.35 0.18 0.34 0.30 0.22 0.24
7 0.54 0.30 0.31 0.21 0.23 0.16 0.17 0.24
8 0.43 0.29 0.52 0.27
9 0.48 0.25 0.22 0.39 0.14 0.40 0.24 0.20
10 0.18 0.26 0.21 0.25 0.17 0.45 0.32 0.18
Average

Table III. Standard deviations (inches)

Daily

Subject 1 2 3 4 5 6 7 8

1 0.10 0.10 0.17 0.06

2 0.08 0.13 0.09 0.04 0.05 0.11 0.04
3 0.11 0.07 0.04 0.05 0.06 0.07 0.05 0.10
4 0.07 0.10 0.12 0.04 0.06 0.05 0.09 0.05
5
6 0.10 0.11 0.11 0.07 0.13 0.12 0.08 0.09
7 0.21 0.11 0.11 0.09 0.09 0.05 0.07 0.10
8 0.16 0.11 0.20 0.11
9 0.15 0.08 0.10 0.14 0.06 0.14 0.08 0.08
10 0.07 0.11 0.07 0.11 0.07 0.16 0.13 0.06
Average

eluded that the experiment can be replicated whether the
time lapse is short or as long as 1 week.
DISCUSSION
During the 3-week period of data collection there
were four shifts in the T locking mechanism holding the
biteplate to the face-bow. The four shifts occurred with
three subjects. To prevent any chance of erroneous
results, the entire week of data involved in a shift was
eliminated. Therefore, both weeks of data for subject No.
5 and the second week of data for subjects No. 1 and No.
8 were discarded.
Proper interpretation of the standard deviations ((Y;
Table III) necessitated calculating ?2a, which gave a
confidence limit of >95%. The +2cu limits, on the most
part, paralleled the ranges found for the same data. The
overall vertical fluctuation of NHP within each subject
varied from as narrow as kO.18 inch to as wide as
+0.34 inch (+4.6 mm and f 8.6 mm; 95% confi-
dence).
The examiners were found to be able to center the
bubble within the marks on the gauge, when recording
NHP, more accurately than was originally deemed as
clinically acceptable.
All other studies have found NHP to fluctuate within
a narrow range. l-53“-13 Before this study, NHP was
measured in degrees from tracings of cephalograms or
photographs. McWilliam and Rausen” stated that cra-
nial posture must be regarded as a small range of
positions oscillating about a mean.
In regard to reproducibility, NHP could not be
recorded for a second mounting without resetting any
custom condylar or incisal recordings, although this
point could be argued for any plane of orientation. The
average fluctuation of NHP within each subject was
sufficiently smaller than the determined variation of the
Frankfort horizontal plane, in relation to the true
horizontal plane, thus warranting its use.
PRACTICAL SIGNIFICANCE
The technique of capturing NHP relative to the true
horizontal plane in the face-bow transfer offers the

58 JULY 1986 VOLUME 56 NUMBER 1

POINT OF REFERENCE FOR PLANE OF ORIENTATION

Weekly range
_. Overall range
Mean daily range
Dropping dropping
Wkl Wk2 Overall Wkl Wk2 high & low high I& low

0.30 0.30 0.47 0.34 0 47 0.34

0.20 0.20 0.20 0.32 0.38 0.26 0.19 0.54 0.43
0.17 0.18 0.18 0.43 0.26 0.31 0.23 0 43 0.31
0.22 0.16 0.19 0.31 0.34 0.29 0.31 (’ 48 0.46

0.27 0.28 0.27 0.35 0.39 0.34 0.33 (‘ 39 0.38

0.34 0.20 0.27 0.83 0.42 0.32 0.32 (;.33 0.42
0.38 0.38 0.67 0.45 0 67 0.45
0.34 0.25 0.29 0.61 0.57 0.37 0.31 0.90 0.43
0.23 0.28 0.25 0.38 0.45 g.cLc 0.35 !1& 0.38
0.27 0.22 0.24 0.49 0.40 0.33 0.29 0 57 0.40

Mean daily SD Weekly SD

Wkl Wk2 Overall Wk 1 Wk2 Overall SD

0.11 0.11 0.12 0.12

0.09 0.07 0.08 0.10 0.09 0.13
0.08 0.07 0.07 0.09 0.08 0.09
0.08 0.06 0.07 0.09 0.10 0.13

0.10 0.11 0.10 0.11 0.11 0.11

0.13 0.08 0.10 0.15 0.10 0.13
0.15 0.15 0.17 0.17
0.12 0.09 0.10 0.14 0.12 0.14
0.09 0.11 0.10 0.10 0.11 0.11
0.10 0.08 0.10 0.12 0.10 0.13

dentist and laboratory technician a more accurate esthet-
ic representation on the articulator. The procedure is
simple and logical, and it can be applied to any face-bow
apparatus.
The attributes of the technique may be appreciated in
gross occlusal plane discrepancies, maxillofacial and
cranial abnormalities, unusual postural circumstances,
and difficult esthetic situations. Oral surgeons may be
better able to diagnose and document osteotomy patients
for improvements in esthetics and provide a better
understanding of their treatment presentations and pre-
surgical cast alterations.
SUMMARY
An extracranial anterior point of reference, namely, a
standard line level (bubble gauge), was used to capture
the true horizontal plane relative to NHP. NHP relative
to true horizontal plane was found to be convenient and
easy to locate and record. The vertical fluctuation of
NHP varied from as narrow as + 0.18 inch to as wide as
-+0.34 inch.
This esthetically coordinated plane of orientation may
provide the dentist and laboratory technician a mounting
that more closely simulates the clinical situation. The
proposed technique may be beneficial for those patients
requiring difficult prosthodontic and maxillofacial
reconstruction, as well as those requiring combined
orthodontic, oral surgery, and prosthodontic treatment.
REFERENCES
1. Moorrees C, Kean MR: Natural head position, a basic consider-
ation in the interpretation of cephalomctric radiographs. Am J
Anthropol 16:213, 1958.
2. B.jerin R: A comparison between the Franklorr horizontal and
the sella turcica-nasion as reference planes in cephalometric
analysis. Acta Odontol Stand 15:1, 1957.
3. Downs WB: The role of cephaiometrics in orthodontics. Case
analysis and diagnosis. Am J Orthod 38~162, 1952.
4. Foster TD, Howat AP, Naish PJ: Variation in cephalometric
reference lines. Br J Orthod 8~183, 1981.
5. Lundstrom A: Head posture in relation to slpe of the sella-nasion
line. Angle Orthod 5279, 1982.
6. Page HL: The cranial plane. Dent Digest 61:152, 1955.

THE JOURNAL OF PROSTHETIC DENTISTRY

 KRUEGER AND SCHNEIDER

7.
Foster TD: The use of the face-bow in making permanent study registrations of natural head position. Swed Dent J
casts. J PROSTHETDENT 9:717, 1959. 15(Suppl):239, 1982.
8. McCollum, BB: Fundamentals involved in prescribing restor- 12. Frankel R: The applicability of the occipital reference base in
ative dental remedies. Dent Items of Interest 61:724, 1939. cephalometrics. Am J Orthod 77: 379, 1980.
9. Gonzalez JB, Kingery RH: Evaluation of planes of reference for 13. Solow B, Tallgren A: Natural head position in standing subjects.
orienting maxillary casts on articulators. J Am Dent Assoc Acta Odontol Stand 29:591, 1971.
76~329, 1968.
Reprintrequests to:
10. Bergstrom G: On the reproduction of dental articulation by
DR. GERARD E. KRUEGER
means of articulators. Acta Odontol Stand S(Supp1 4):25,
6740 CROSSWINDS DR., N., STE. F
1950.
ST. PETERSBURG,FL 33710
11. McWilliam JS, Rausen R: Analysis of variance in assessing

Bound volumes available to subscribers

Bound volumes of the JOURNALOF PROSTHETICDENTISTRY are available to subscribers (only) for the 1986 issues from the
publisher at a cost of $42.00 ($51.75 international) for Vol. 55 (January-June) and Vol. 56 (July-December). Shipping
charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are
shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal
name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V.
Mosby Co., Circulation Department, 11830 Westline Industrial Drive, St. Louis, MO 63146, USA; phone (800) 325-4177,
ext. 351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular
JOURNAL subscription.

60 JULY 1986 VOLUME 56 NUMBER 1