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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 719-725
Determination of the relative parallelism of occlusal plane to three ala-tragal lines in various skeletal malocclusions: A cephalometric study


1 Department of Prosthodontics, NSVK dental college and Hospital, Bangalore, India
2 Department of Prosthodontics, V.S. Dental College and Hospital, Bangalore, India
3 Department of Orthodontics, V.S. Dental College and Hospital, Bangalore, India

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Date of Submission14-May-2010
Date of Decision23-Feb-2011
Date of Acceptance29-Dec-2011
Date of Web Publication3-May-2013
 

   Abstract 

Background: Establishment of a proper occlusal plane is needed for developing an occlusion that is compatible with the biomechanics of a stomatognathic system. There has been a great deal of controversy regarding the anatomic reference point/s taken for identifying the Camper's plane (Ala-Tragus) to which the occlusal plane is oriented parallel in regular complete denture Prosthodontic practice. There has been no study in literature to correlate the occlusal plane to the Camper's plane in various skeletal malocclusions using landmarks on a lateral Cephalogram.
Aim : The aim of the study isto determine the relative parallelism of the occlusal plane to ala- tragal lines in various malocclusions.
Methodology: A total of sixty subjects belonging to Class I, Class II and class III malocclusions were selected for the study. Markings with radiopaque marker of 1 mm diameter were adhered against the superior, middle and inferior border of the tragus and against the lower borer of ala of the nose. Lateral cephalograms were obtained for all of the pateints. Tracing was performed for all of these radiographs.
Statistical Analysis Used: Analysis of Variance (ANOVA) test and Post-Hoc test of Bonferroni were used to compare the angles formed at the superior, middle and inferior borders with the occlusal plane.
Results: The result from the present study showed that in Class I and Class III malocclusion, the line drawn from the lower border of ala of the nose to the inferior position of the tragus (Camper' plane C) was relatively parallel to occlusal plane; and, in Class II malocclusion, the line drawn from the lower border of ala of nose to middle border of tragus (Camper's plane B) was relatively parallel to occlusal plane.

Keywords: Camper′ plane, lateral cephalogram, occlusal plane

How to cite this article:
Venugopalan SK, SatishBabu C L, Rani M S. Determination of the relative parallelism of occlusal plane to three ala-tragal lines in various skeletal malocclusions: A cephalometric study. Indian J Dent Res 2012;23:719-25

How to cite this URL:
Venugopalan SK, SatishBabu C L, Rani M S. Determination of the relative parallelism of occlusal plane to three ala-tragal lines in various skeletal malocclusions: A cephalometric study. Indian J Dent Res [serial online] 2012 [cited 2020 Nov 28];23:719-25. Available from: https://www.ijdr.in/text.asp?2012/23/6/719/111246
Complete denture prosthodontics is challenging because rehabilitation of edentulous patients with complete dentures has to be done by considering various biological and mechanical factors while restoring the functions and health of the stomatognathic system. Developing an occlusion that is compatible with the functional movements of stomatognathic system is one of the key factors in determining the prognosis of the completely edentulous patients. [1] Occlusal plane is defined as the average plane established by the incisal and occlusal surfaces of the teeth (GPT). [2] Although the orientation of occlusal plane is under the control of the clinician, it should be established taking into considerations the esthetics, phonetics and biomechanical factors. [1],[3] Several guidelines have been postulated for determining the occlusal plane,and many people have used a number of intra-oral and extra oral landmarks [4] to determine and orient occlusal plane in the process of fabricating complete dentures. The intra-oral landmarks that we considered were as follows: Occlusal plane should coincide with the lower one-third of the retromolar pad; [5] occlusal plane should coincide with lateral borders of the tongue; [6] maxillary occlusal plane should be at a distance of 2.56 mm below the parotid papilla; [7] occlusal plane should be 1.37 mm above the commisure of lip; [7] occlusal plane can be established 0.94 mm above the buccinator grooves; [7] occlusal plane can be established parallel to Hamular-incisive-papilla plane; [8] and, one of the newer concepts of establishing occlusal plane, which is by placing it parallel to and mid-way between the residual ridges. [9]

Extra-oral landmarks that were considered included: Anteriorly, occlusal plane should be parallel to interpupillary line and 1-3 mm below the resting upper lip; [10] posteriorly, parallel to ala tragal lines - a line running from the inferior border of the ala of the nose to some defined point on the tragus of the ear, usually considered to be the tip of the tragus. Ideally, the ala-tragus plane is considered to be parallel to the occlusal plane. Even though the ala tragal line (called Camper's line when it is a plane from the inferior border of ala of the nose to the superior border of tragus of each ear) is the most commonly used landmark and the only extra-oral landmark used to establish posterior occlusal plane in edentulous subjects, its use still remains controversial. This controversy is primarily due to the disagreement on the exact point of reference on the tragus (superior, middle or inferior) to establish the ala tragal line.

Also, there have been no studies indicating the method of locating the proper position on the tragus while establishing the occlusal plane in case of various malocclusions. Hence, the present study was undertaken to determine the relative parallelism of the different ala-tragal lines to the occlusal plane in various skeletal malocclusions.

Materials

Sixty dentulous subjects were selected for the study, which included under graduate dental students and patients who visited V.S. Dental College and Hospital for treatment. The subjects selected were selected based on the following criteria:

Inclusion criteria

  1. Subjects should have a full complement of permanent dentition (Excluding third molars);
  2. Subjects should be in the age group between 14-24 years;
  3. Subjects should have an occlusion which can be clearly classified into any one of Angle's classes of occlusion, that is, class1, class II or class III molar relation.
Criteria for angle's classification used in the study

  1. Angle's Class 1: The mesiobuccal cusp of the maxillary first permanent molar occludes in the mesiobuccal groove of the mandibular first permanent molar;
  2. Angle's Class 2: The Distobuccal cusp of maxillary first permanent molar occludes in the mesiobuccal groove of the mandibular first molar;
  3. Angle's Class 3: The mesiobuccal cusp of the maxillary first permanent molar occluding in the interdental space between the mandibular first and second molar.
Angle's Criteria was used only to select the samples to be subjected to cephalometric radiographs, and after the cephalometric analysis, the samples were categorized into skeletal class I, II and III malocclusion based on the findings in the analysis.

Exclusion criteria

Subjects with the following conditions were excluded from the study:

  1. Attrition of teeth;
  2. Temporomandibular joint (TMJ) pathologies;
  3. Extensive restorations which included long span bridges (>4 units) in the posterior segment of the maxillary or mandibular arch;
  4. History of Orthodontic treatment;
  5. Periodontal disease which included: periodontal pockets, trauma from occlusion, pathological drifting of teeth;
Materials used [Figure 1] and [Figure 2]
Figure 1: Planemeca lateral cephalogram unit

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Figure 2: Armamenatrium

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  • Lateral cephalograms X-ray unit [Planmeca, 80 kup, 15 mA, 1 sec]
  • Lateral cephalograms X-ray film [Green Sensitive, KODAK -TMAT]
  • Automatic X-ray film processor[Dürr Dental-XR25S]
  • 1 millimeter diameter metallic balls- 4 No's
  • Double sided adhesive tape.
  • Tracing sheet [One side matte, 50 μ thick]
  • Dome's Template.
  • 4 H pencil.
  • Paper clips.
  • X-ray viewer.
  • Indelible pencil.
Methodology

Preparation of the subjects for cephalograms [Figure 3]
Figure 3: Preparation of the subject for the cephalogram

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On each of the subjects, the superior, middle and inferior border of tragus and lower border of the ala of the nose were marked with indelible pencil. Metallic balls were then adhered to these marks using double sided tapes, such that these points were visible on the radiograph.The patient was then positioned in the cephalostat, and lateral cephalogram was taken and developed using an automatic processor.

Cephalometric tracing

Cephalometric X-rays were traced on an acetate tracing paper using a 4 H pencil. The following cephalometric planes and angles were drawn for the purpose of the study: [Care was taken in selecting subjects for the study such that there were twenty subjects in each of the three groups with skeletal class I, class II, and class III type of malocclusion. (Confirmed by cephalometric analysis)]

  1. Cephalometric Planes: [Figure 4]
    Figure 4: Cephalometric tracing

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    1. Occlusal plane: The average plane established by the incisal and occlusal surfaces of the teeth. (OP)
    2. Lower border of Ala of the Nose to superior border of tragus (Campers plane A).
    3. Lower border of Ala of the Nose to middle border of tragus (Campers plane B).
    4. Lower border of Ala of the Nose to inferior border of tragus (Campers plane C)
    5. Sella to Gnathion (S-Gn)
  2. Cephalometric Angles: [Figure 4]
    1. Camper's plane A to Sella-Gnathion (Campers plane angle A)
    2. Camper's plane B to Sella-Gnathion (Campers plane angle B)
    3. Camper's plane C to Sella-Gnathion (Campers plane angle C)
    4. Occlusal Plane to Sella-Gnathion (Angle O)


The study

The data from the sixty cephalometric radiographs, Class I, Class II and Class III, were collected, and was subjected to statistical analysis to see which of the three Ala-tragal lines, i.e. Camper's plane angle A, Camper's plane angle B, Camper's plane angle C, was closer to the occlusal plane angle (Angle O). The Camper's plane angle which is closer to the occlusal plane angle is considered to be relatively parallel to the occlusal plane.


   Results Top


The descriptive statistics obtained from the data is presented in the [Table 1], [Table 2] and [Table 3]. The inference of the descriptive statistics has been presented through [Figure 5], [Figure 6] and [Figure 7] depicted below.
Figure 5: Angular measurement of Sella-Gnathion to Camper's Plane A, B, C and Occlusal Plane in Class-I Malocclusion

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Figure 6: Angular measurement of Sella-Gnathion to Camper's Plane A, B, C and Occlusal Plane in Class-II Malocclusion

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Figure 7: Angular measurement of Sella-Gnathion to Camper's Plane A, B, C and Occlusal Plane in Class-III Malocclusion

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Table 1: Descriptive statistics for Class - I malocclusion cases

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Table 2: Descriptive statistics for Class - II malocclusion cases

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Table 3: Descriptive statistics for Class - III malocclusion cases

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Results and analysis for class I malocclusion

Comparison of camper's plane A, B, C and occlusal plane in class-I malocclusion

From the above ANOVA Table, [Table 4] we noticed that there is a significant difference between the angles (P<0.05). In order to find out which angle is not significantly different from Angle O, multiple comparisons (post-hoc) were carried out test using Bonferroni method.From the multiple comparisons table [Table 5], we noticed that there is a significant difference between Angle O and Angle A (P<0.001). Also, there is a significant difference between Angle O and Angle B (P<0.05). However, we observed that there is no significant difference between Angle O and Angle C (P>0.05).As there is no significant difference between Angle O and Angle C, we conclude that Angle C is the nearest to Angle O.
Table 4: Results of analysis of variance test seen in the study (For Class - I malocclusion)

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Table 5: Results of post - hoc test of Bonferroni (For Class - I Malocclusion)

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Results and analysis for class II malocclusion

From the ANOVA Table, [Table 6] we noticed that there is a significant difference between the angles (P<0.05). In order to find out which angle is not significantly different from Angle O, multiple comparisons (post-hoc) were carried out test using Bonferroni method.From the multiple comparisons table [Table 7], we noticed that there is a significant difference between Angle O and Angle A (P<0.01). Also, there is a significant difference between Angle O and Angle C (P<0.05). However, we observed that there is no significant difference between Angle O and Angle B (P>0.05).As there is no significant difference between Angle O and Angle B, we conclude that Angle B is the nearest to Angle O.
Table 6: Results of analysis of variance test seen in the study (For Class - II malocclusion)

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Table 7: Results of post - hoc test of bonferroni (For Class - II malocclusion)

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Results and analysis for class III malocclusion

From the above ANOVA table [Table 8], we noticed that there is a significant difference between the angles (P<0.05). In order to find out which angle is not significantly different from angle O, we carry out multiple comparisons (post-hoc) test using Bonferroni method.From the above multiple comparisons table [Table 9], we noticed that there is a significant difference between Angle O and Angle A (P<0.01). However, no significant difference is observed between Angle O and Angle B and Angle O and Angle C (P >0.05).We observe that the difference between angle C and angle O is the smallest compared to angle B and angle O. Therefore, we conclude that angle C is nearest to angle O.
Table 8: Results of analysis of variance test seen in the study (For Class - III malocclusion)

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Table 9: Results of post - hoc test of bonferroni (For Class - III malocclusion)

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   Discussion Top


Establishing the plane of occlusion in the process of rehabilitating the completely edentulous patients is one of the important considerations which determine the prognosis of the case. Based on the biomechanical and physiological considerations, musculature of the tongue and cheeks were trained to function normally at this level where natural teeth were present, and will again function correctly when they are called upon to stabilize the bolus of food at the same vertical position of the occlusal table as originally existed [1],[3],[4],[5] Though there are several methods to establish the plane of occlusion, [5] ala-tragal line seems to be the most widely used guideline. Studies have shown [1],[2],[5] that all the three positions of the tragus, i.e. superior, middle and inferior have been considered to determine the ala-tragal lines to establish the plane of occlusion, and the results also support all the three positions. However, not many studies were found to have taken into consideration the skeletal malocclusions, i.e. Class I, Class II and Class III in determining which of the three positions of the tragus will help us in favorably locating an alatragal line which is acceptable from a biomechanical and physiologic point of view. Hence, the present study was undertaken to determine which of the three positions on the tragus, i.e. superior, middle or inferior, while determining the Camper's plane in dentulous subjects will help us in establishing the plane of occlusion in edentulous patients with Class I, class II and class III skeletal relation.

Since the study needed three groups of subjects with skeletal class I, Class II and Class III to be evaluated separately, the size of the sample in each of these groups were kept as twenty subjects, so that, statistically significant conclusions could be drawn from the results of the study.To meet the requirements of the inclusion and exclusion criteria, the dentulous subjects for this study was selected from patients and the students from the V.S.Dental College and Hospital.It was decided that the age group of the study subjects would be between 14-24 years, as a full complement of teeth with little or no wasting diseases can be found in this age group more readily.Angle's classification of malocclusion was used to determine the type of dental malocclusion to divide the subject into different groups, and later on they were subjected to cephalometric analysis to divide them into groups of skeletal class I, class II and class III malocclusion.

Subjects with wasting diseases like attrition, extensive restorations (long span bridges- greater than 4 units), history of orthodontic treatment and TMJ pathologies were excluded, as these conditions influence the jaw position and ridge relation.Subjects younger than 14 years would not have the full complement of teeth, hence the occlusion cannot be easily determined, and subjects older than 24 years can have wasting diseases, TMJ pathologies, extensive restorations and periodontal problems, making them unsuitable candidates for the study.Though photographs and lateral cephalograms have been used in earlier studies to determine the suitable plane of occlusion, in the present study right lateral cephalograms were used to study the relationship between the three different Camper's plane and the occlusal plane, as lateral cephalograms can be standardized for all subjects. And also, it was a better method of locating the occlusal plane as compared to photographs. [1],[9]

Planmeca lateral cephalograms unit, which was available in the college, was used for the study. Kodak-TMAT films, which provided acceptable lateral cephalograms were used for the study. Automatic processor (DüRR Dental) was used for developing all the lateral cephalograms, and for standardizing the procedure of developing and fixing, and for elimination of inter-operator variations in processing of X-ray films. 1 mm metallic balls were used to make the landmarks visible on radiographs and for uniformity, as against the use of lead foil or radiopaque dyes, and also for convenience double sided adhesive tape was used to attach the metallic balls at the superior, middle and inferior positions. This is because it was easier to visualize the positions and it did not cause any inconvenience to the subjects while attaching and removing.To determine the parallelism of different Camper's plane to the occlusal plane, a plane connecting two anatomical landmarks, such that, it intersects all the four planes was essential [i.e. Camper's plane A, Camper's plane B, Camper's plane C and Occlusal plane]. and for this, the Sella and Gnathion were considered (as they are located one above (Sn) and one below (Gn) the occlusal plane, and when these two are joined it would intersect all the four lines).


   Conclusion Top


The results from the present Cephalometric analysis to determine the relative parallelism of the occlusal plane to the ala-tragal lines of the dentulous subjects in various malocclusions showed that:

  • In Class I malocclusion, there was no significant difference between the occlusal plane angle and Camper's plane angle C, and thus we can infer that the Campers' plane C (i.e. the plane drawn from the lower border of ala of the nose to the inferior border of tragus) was parallel to the Occlusal plane.
  • In Class II malocclusion, there was no significant difference between the occlusal plane angle and Camper's plane angle B, and thus we can infer that the Campers' plane B (i.e. the plane drawn from the lower border of ala of the nose to the middle border of tragus) was parallel to Occlusal plane.
  • In Class III malocclusion, there was no significant difference between the occlusal plane angle and Camper's plane angle C and thus we can infer that the Campers' plane C (i.e. the plane drawn from the lower border of ala of the nose to the inferior border of tragus) was parallel to Occlusal plane.


 
   References Top

1.Hartono R. The Occlusal plane in relation to facial types. J Prosthet Dent 1967;17:249-558.  Back to cited text no. 1
    
2.The Glossary of Prosthodontic terms. J Prosthet Dent 2005;94:48.  Back to cited text no. 2
    
3.Bassi F, Rizzatti A, Schierano G, Preti G. Evaluation of the utility of the cephalometric parameters in construction complete denture. Part II: Placement of anterior teeth. J Oral Rehabil 2001;28:349-53.  Back to cited text no. 3
    
4.Monteith BS. A cephalometric method to determine the angulation of the occlusal plane in edentulous patients. J Prosthet Dent 1985;54:81-7.  Back to cited text no. 4
    
5.Fu PS, Hung CC, Hong JM, Wang JC. Three-dimensional analysis of the occlusal plane related to the hamular-incisive-papilla occlusal plane in young adults. J Oral Rehabil 2007;34:136-40.  Back to cited text no. 5
    
6.Yasaki M. The Height of the occlusal rim and the interocclusal distance. J Prosthet Dent 1961;11:26-3.  Back to cited text no. 6
    
7.Lundquist DO, Luther WW. Occlusal plane determination. J Prosthet Dent 1970;23:489-98.  Back to cited text no. 7
    
8.Sinobad D. The Position of the occlusal plane in dentulous subjects with various skeletal jaw relationships. J Oral Rehabil 1988;15:489-98.  Back to cited text no. 8
    
9.Zarb GA, Bolender CL, Carlsson GE. Boucher's Prosthodontic Treatment for Edentulous Patients, 10 th ed. St. Louis: C.V. Mosby Co.; 1990.   Back to cited text no. 9
    
10.Ismain YH, Bowman JF. Position of the occlusal plane in natural and artificial teeth. J Prosthet Dent 1968;20:407-11.  Back to cited text no. 10
    

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Correspondence Address:
Shashinandan K Venugopalan
Department of Prosthodontics, NSVK dental college and Hospital, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111246

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]

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