RESEARCH AND EDUCATION

An in vitro evaluation of the maxillary occlusal plane

orientation obtained with an electronic application:
A preliminary investigation
Thomas C. Maveli, DDS, MS,a Montry Suprono, DDS, MSD,b Mathew T. Kattadiyil, BDS, MDS, MS,c and
Khaled Bahjri, MD, DrPH, MPHd

The Glossary of Prosthodontic ABSTRACT

Terms1 defines a facebow as Statement of problem. In the evaluation and fabrication of dental prostheses, maxillary occlusal
“an instrument used to record plane orientation in the sagittal and coronal planes may affect functional and esthetic outcomes.
the spatial relationship of the The accuracy of a recently developed electronic application in transferring this orientation to a
maxillary arch to some anatomic semiadjustable articulator has not been evaluated.
reference point or points and Purpose. The purpose of this in vitro study was to evaluate the coronal and sagittal orientation of
then transfer this relationship to the occlusal plane on maxillary casts mounted with an electronic application facebow system onto a
an articulator; it orients the corresponding semiadjustable arcon articulator.
dental cast in the same rela-
Material and methods. A maxillary typodont was placed into a phantom head (control) oriented
tionship to the opening axis of with the Frankfort horizontal plane parallel to the horizon. A digital protractor was used to
the articulator.” measure the angle between the occlusal plane of the maxillary arch of the phantom head and the
Dental prostheses’ esthetics Frankfort horizontal plane along the sagittal and coronal planes. The commercial system (test
and function can be affected group) was used to make 15 facebow records of the maxillary typodont within the phantom head.
by the sagittal and coronal The system records were used to mount diagnostic casts of the maxillary typodont onto a
orientation of the maxillary semiadjustable arcon articulator. The same measurements were made on the mounted diagnostic
casts and were compared with the control. Statistical differences between the occlusal plane of
occlusal plane (OP). Kattadiyil
the control and the occlusal plane of the mounted maxillary casts were determined using the
et al2 reported that the esth- 1-sample t test (a=.05).
etic preference for smiles was
Results. The coronal orientation of the occlusal plane was significantly different (P<.001) between
affected by perceived changes
test group and control. No significant differences (P>.05) were found in the sagittal orientation of
in OP orientation. Evaluating the occlusal plane.
the angulation discrepancy bet-
ween the interpupillary and Conclusions. Within the limitations of this study, variations in the coronal plane orientation were
observed with the system. Variations in this plane may lead to adverse evaluation and clinical
intercanine lines, Koidou et al3
outcomes. (J Prosthet Dent 2017;-:---)
reported better smile esthetics
with individuals who had smaller mean angulation it.8,9 The Whip Mix Corp recently introduced an
discrepancies. application for a digital tablet (MaxAlign; Whip Mix
Only a few articles have reported the technique of Corp) that documents patient information in the dental
virtual facebows,4-7 with even fewer studies evaluating office. The information is sent to the dental laboratory

Support provided by Whip Mix Corp.

a
Private practice, Houston, Texas.
b
Assistant Professor, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.
c
Professor and Director, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.
d
Assistant Professor, Epidemiology, Biostatistics, and Population Medicine, Loma Linda University School of Public Health, Loma Linda, Calif.

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Clinical Implications
The commercial system presents an innovative
method for recording occlusal plane orientation.
Clinicians should be aware of the significant
variations in the coronal plane when using this
system and adjust accordingly.

to aid in providing predictable results for mounting

casts.
The MaxAlign system’s reproducibility of the OP
orientation requires a comparison of the coronal and
sagittal orientation of the OP from the records made. The
purpose of this study was to evaluate effects of the cor-
onal and sagittal orientation of the OP on maxillary casts
mounted with the system onto a corresponding semi-
adjustable arcon articulator. The casts from the MaxAlign
system (test group) were evaluated relative to a phantom
head containing a maxillary typodont (control) on which
the records were made. The null hypothesis was that Figure 1. Maxillary typodont in phantom head.
maxillary casts mounted using the system would show no
significant differences in the sagittal and coronal orien-
tablet was placed on its stand and calibrated using the
tation of the maxillary OP compared with those of the
application’s calibration tool to ensure that it was level.
control.
The tablet was placed 23 cm away and positioned parallel
to the phantom head (Fig. 3). Vertical and horizontal red
MATERIAL AND METHODS
lines were used to position the facial midline and incisal
Positioning of the phantom head edges of the maxillary central incisors. After proper
The methodology used has been described in an earlier alignment, a photograph was made using the applica-
study by Maveli et al.10 A maxillary typodont (SM-PVR- tion. The width of the central incisors was measured and
860; Columbia Dentoform Teaching Solutions) was used to adjust the photograph (by means of a ruler
attached to a phantom mannequin head (P-6/3 Standard overlay in the application) so that the width of the in-
Mannequin System; Frasaco USA) containing anterior cisors in the photograph matched the measurements
landmarks (infraorbital rim and infraorbital foramina) (Fig. 4). The application then overlaid the photograph
that were identified and marked using average anatomic with a template to verify the position of the maxillary
values.11,12 The Frankfort horizontal plane (FHP) was central incisors. Fifteen digital records that simulated
demarcated by drawing a line from the infraorbital rim to facebow records were made using the MaxAlign system.
the superior aspect of the external auditory meatus. Us-
ing a digital protractor (Pro 360 Digital Protractor; M-D Fabrication and mounting of typodont casts
Building Products, Inc) that was calibrated and set equal An impression of the maxillary typodont was made using
to the horizon (0.0 degrees), the phantom head was polyvinyl siloxane impression material (Capsil; GC
positioned so that the FHP was parallel to the horizon America). Fifteen maxillary casts were fabricated using
(Fig. 1). A glass slab was held against the teeth of the Type III dental stone (Microstone; Whip Mix Corp).
maxillary typodont, and the digital protractor was used to Mounting of the casts was performed by attaching the
measure the angle between the phantom head’s maxil- tablet to the manufacturer’s stand (MaxAlign LabStand;
lary arch OP and the FHP. The angles were measured Whip Mix Corp) and verifying the alignment by using the
and recorded along the sagittal (AP) and coronal (LAT) tablet calibration tool. The casts were positioned on the
planes (Fig. 2). Repeated measurements were made and stand with the central incisors aligned to a line etched on
recorded 2 more times. the front of the stand (Fig. 5). The “Lab Screen” in the
application overlaid the photograph of the phantom head
MaxAlign system with a live video feed of the casts on the stand. The stand
Figures 3 to 6 demonstrate the procedures used for this was adjusted so that the position of the central incisors
study. According to the manufacturer’s instructions, the and the maxillary occlusal plane matched to those in the

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Figure 2. Angle measurement on phantom head. A, Frontal view. B, Lateral view. FHP, Frankfort horizontal plane; OP, occlusal plane.

photograph (Fig. 6). For final verification, after alignment The 1-sample t test was used to compare and
of the cast was completed, another photograph was evaluate statistically significant differences in the cor-
made and overlaid with the photograph of the phantom onal and sagittal orientations between the OP of the
head. The maxillary cast was then mounted to a semi- control and the OP of the mounted maxillary casts
adjustable arcon articulator (Whip Mix Model 3040 (a=.05).
Articulator; Whip Mix Corp) using Type III dental stone
(Mounting Stone; Whip Mix Corp).
RESULTS
The angle made by the maxillary OP and the FHP was
measured and recorded as previously described (Fig. 7). The ICCR test results revealed a high correlation (0.99)
Differences between the OP orientations of the mounted between both operators for all measurements (AP and
casts were compared with the measurements made of the LAT) and were verified by the CA test. Mean differences
phantom head. Two operators (T.M., M.S.) were cali- between the test groups and the control were compared
brated prior to making measurements and were blinded using the average of measurements by both operators
from each other to reduce operator bias. and then using the 1-sample t test. In the sagittal plane,
Statistical analyses were performed using software no significant differences were observed between the test
(IBM SPSS Statistics, v20; IBM Corp). Operator calibra- group and the control in the measurements made by
tion was verified by intra- and interoperator reliability both operators (P=.106 for TM, P=.666 for MS) (Table 1,
testing. The reliability of measurements made along the Fig. 8).
coronal and sagittal planes by both operators was eval- When the mean differences between the test group
uated using an intraclass correlation coefficient reliability and control were compared in the coronal plane, a sig-
(ICCR) test and was verified using the Cronbach alpha nificant difference from the control was found (P<.001 for
(CA) test. both operators) (Table 2, Fig. 9).

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Figure 4. Ruler tool used to correlate dimensions of maxillary central

incisors to maxillary cast.

Figure 3. Positioning of tablet and alignment procedure.

Figure 6. Verifying position of maxillary cast before mounting.

The tested facebow system did not replicate the

sagittal and coronal OP orientation of the control. The
Figure 5. Tablet and diagnostic cast placed on stand.
mean differences from the control were 0.275 degrees in
the sagittal plane and 1.27 degrees in the coronal plane.
These results are comparable with those from an earlier
DISCUSSION
study that used similar methodology to evaluate differ-
Based on the results obtained in the present study, the ences in occlusal plane orientation by using several
null hypothesis was partially accepted. No significant facebow systems.10 In that study, the mean differences
differences were found in the sagittal plane of the from the control in the tested facebows ranged from
maxillary casts when mounted with the MaxAlign sys- 0.03 to 6 degrees in the sagittal plane and 0.31 to 1.38
tem. However, significant differences were found in the degrees in the coronal plane. The OP orientation along
coronal plane. The ICCR and CA test results revealed a the coronal plane revealed a significantly reduced cant
high correlation of the measurements made by each compared with the control, which could affect the es-
operator for the sagittal and coronal planes, revealing thetics or outcomes of interim or definitive restora-
acceptable calibration. tions.10 This needs to be evaluated in future research. In

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Figure 7. Angle measurement on casts. A, Frontal view. B, Lateral view. FHP, Frankfort horizontal plane; OP, occlusal plane.

Table 1. Comparison of sagittal plane with control (one-sample statistics

test value=7.03) 8.0
95% CI of
Difference

95% Sagittal Mean

Sagittal Mean
Operator Mean SD P Difference Lower Upper 7.5
1 7.15 1.08 .666 0.12 -0.48 0.72
2 7.46 0.96 .106 0.43 -0.10 0.96
Control
7.0

Table 2. Comparison of coronal plane with control (one-sample statistics

test value=2.03) 6.5
95% CI of
Difference
Coronal Mean
Operator Mean SD P Difference Lower Upper 6.0
1 2
1 0.74 0.47 <.001 -1.29 -1.55 -1.04
2 0.78 0.44 <.001 -1.25 -1.49 -1.00
Operator

Significant a=.05
Figure 8. Test group to control comparison in sagittal plane.

comparison, the sagittal OP orientation was more Control

2.0
accurately replicated and did not reveal significant
95% Coronal Mean

differences.
Occlusal plane orientation should be accurately 1.5
transferred because of its significant effect on func-
tion,13,14 esthetics,2,15-17 and orthognathic surgery plan- 1.0
ning and outcome.18 One consequence of inaccurate OP
transfer is unnatural cant of the maxillary cast when
viewed in reference to the horizontal plane.10 In the 0.5
present study, the significant variations observed in the
coronal OP orientation may create unnatural cant of the 0.0
maxillary cast that could affect esthetics. 1 2
The in vitro nature of the study has inherent disad- Operator
vantages.19 The reproducibility of facebow transfers Figure 9. Test group to control comparison in coronal plane.
evaluated in vivo has been documented20; therefore,
further in vivo research using the MaxAlign system is significant differences in the sagittal OP orientation
indicated. transfer were noted. Further research is needed to eval-
The MaxAlign system presents a novel technique for uate the clinical implications of these results.
recording OP orientation. In this preliminary investiga-
CONCLUSIONS
tion of the electronic facebow system, coronal OP
orientation transfer revealed a significant difference, with Within the limitations of this in vitro study, the following
a mean difference of 1.2 degrees from the control. No conclusions were drawn:

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J Prosthet Dent 2015;114:566-73. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.

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