The International Journal of Periodontics & Restorative Dentistry

Clinical Considerations and Rationale for

the Use of Simplified Instrumentation in
Occlusal Rehabilitation. Part 1: Mounting
of the Models on the Articulator

Stefano Gracis, DMD, MSD* The temporomandibular joint (TMJ)

is a complicated mechanism; not
only does it allow pivoting, rotating,
opening, and closing movements,
The development of an occlusal scheme with an appropriate number and loca-
tion of occlusal contacts is of utmost importance for the long-term success of any but also movements of translation
prosthetic rehabilitation. This, however, can be a time-consuming procedure. To and laterotrusion. Furthermore, the
avoid undue mistakes, a high degree of competence must be demonstrated by structures that make it up are not
both the clinician and the technician. Especially when performing extensive reha- rigid, precise, and unchangeable;
bilitations, many operators believe that to have optimum control of the occlusal rather, the muscles, ligaments, and
variables, it is necessary to employ rather sophisticated instruments and compli- bone have a certain degree of elas-
cated procedures. This article presents a rationale for an approach that uses a ticity. Into this milieu, the clinician is
simplified but sound instrumentation in the clinical and laboratory steps neces- asked to introduce a prosthesis that
sary to produce a successful prosthesis. In part 1, the registration of the spatial is within the adaptive capacity of the
position of a patient’s maxillary and mandibular arches will be described. (Int J
neuromuscular system.
Periodontics Restorative Dent 2003;23:xxx–xxx.)
In a rehabilitation, the develop-
ment of the occlusion—that is, the
development of an occlusal scheme
incorporating an appropriate num-
ber and location of occlusal contacts
with the condyle/disc assembly in
an optimum position—is paramount
for the transmission of the functional
and parafunctional forces gener-
ated. This should be done regardless
of the extent of the restoration. The
primary reasons for this are: (1) to
avoid damaging the TMJ, teeth and
muscles, since what is done at the
*Private Practice, Milan, Italy.
tooth level can have consequences
*Reprint requests: Dr Stefano Gracis, Via Brera 28/A, 20121 Milan, Italy. at the level of all these structures1;
e-mail: sgracis@dentalbrera.com and (2) to design and manufacture

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The equipment for an

Table 1 Types of instruments
occlusal rehabilitation
Parameters that
Articulator type Facebow can be modified When developing an occlusal
Hinge No None scheme and trying to define the
Fixed condylar path No None proper number and location of
Semiadjustable Earbow or Condylar inclination,
occlusal contacts, in most cases it is
kinematic immediate side shift,
progressive side shift certainly useful and necessary to use
Fully adjustable Kinematic Condylar inclination, an instrument that, to a certain
immediate side shift, extent, reproduces the static and
progressive side shift,
dynamic relationships of the mas-
upper and rear wall inclination,
morphology of fossae, ticatory system. 4 Certainly, it is
intercondylar distance necessary when: (1) performing a
functional occlusal analysis; (2) de-
termining the changes to be made
to the maxillary anterior teeth or
occlusal plane; or (3) fabricating a
provisional or definitive restoration
long-lasting rehabilitations. In gen- • The lateral excursive guidance that incorporates these changes or
eral, the clinician is always looking for should be sufficiently steep to includes a large enough number of
ways to simplify the procedures for allow for disclusion of all teeth on teeth that it would be impractical
the fabrication of a prosthesis and the nonworking side during lat- not to work with mounted casts.
decrease the time necessary to inte- eral excursions (no posterior However, the question of how
grate it into the mouth of the patient. interferences). sophisticated or complicated this
This article will provide some sug- • In maximum intercuspation (MI), equipment needs to be remains.
gestions on how to achieve these posterior teeth should make Articulators are mechanical
goals. bilateral simultaneous contact instruments that represent the max-
The assumption for this discus- with occlusal forces applied axi- illa, mandible, and TMJs. Their main
sion is that the occlusal scheme to be ally. task is to provide a frame where it is
created is one that is currently possible to relate, in the three planes
viewed as the “ideal” occlusal Both schemes can be acceptable. of space, the maxillary cast with the
scheme—that of “mutual protec- The decision of which scheme is mandibular cast relative to the hinge
tion” with either “canine guidance” appropriate can be made, case by axis of the patient and of the instru-
or “group function.”2 (For definitions case, depending on preexisting skel- ment. There are four types of articu-
of these and any other subsequent etal/dental relationships. lators available5 (Table 1).
terms used, the reader is referred to The purpose of this article is to The simple hinge and fixed
The Glossary of Prosthodontic provide guidelines in occlusal reha- condylar path articulators should be
Terms.3) The two schemes have the bilitation for the selection of an artic- used only in those situations where
following requirements in common: ulator, and to discuss the equipment it may be possible to avoid using
and the clinical procedures neces- any instrument, such as in the fabri-
• The incisal guidance should be sary for the proper mounting of cation of individual inlays, onlays, or
sufficiently steep to allow for dis- casts. single crowns. The primary detri-
clusion of all posterior teeth dur- ment to the use of these simple
ing protrusion. instruments for the fabrication of

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more extensive restorations is that rehabilitation: (1) the main objective Procedures for mounting
their size, shape, and options for at the occlusal level during excur- models on the articulator
movement do not have any ana- sive movements is the disclusion of
tomic resemblance. Many authors all posterior teeth by the anterior Recording the position of the
have therefore recommended artic- guidance, and not a bilaterally bal- maxillary arch
ulator systems that incorporate the anced occlusion; and (2) the condy-
use of a facebow,6–8 ie, semiad- lar guidance (principally, but not Positioning the maxillary cast on an
justable and fully adjustable articu- entirely, the inclination of the articu- articulator is the preliminary essential
lators. In making the choice between lar eminence) does not determine step to develop and control tooth
these two, it may be useful to under- the anterior tooth guidance, but morphology and position, and thus
stand the indications for a panto- does influence its effectiveness. As a develop a physiologic occlusion for
graphic tracing, and thus for the lat- consequence, it is possible to use the patient. The objective of record-
ter device: (1) when the anterior more simplified instruments than ing the maxillary arch position is to
guidance is absent and will not be fully adjustable articulators. Semi- transfer that position, in all three
restored/created (Class III skeletal adjustable articulators allow the planes of space, to the articulator.
relationship, anterior open bite, operator to modify the determinants This means the following: (1) the rela-
extensive wear of the anterior teeth); of occlusion that play the largest role tionships between the upper model
or (2) when group function is desired in determining occlusal morphology and articulator’s hinge axis and that
on the working side. (immediate side shift and, in some between the maxillary arch and the
When any of the muscles of cases, progressive side shift). They patient’s true axis should be the
mastication exhibit spasms, it is not are constructed with average values same as much as is practical; and (2)
worthwhile to record a tracing since as far as the other determinants of the maxillary model should have a
it is not possible to record the full occlusion are concerned. However, precise orientation in space with
range of mandibular movements, to avoid mistakes, undue complica- respect to the reference plane
unless the tracing is intended as a tions, or wasted time, it is important selected. To do this, it is indispensi-
diagnostic aid.9 Pantographic trac- to follow certain rules and under- ble to use a facebow. The facebow
ing requires the pantograph to be stand the limitations of the equip- identifies a plane by using three
assembled on the patient and re- ment used. points—two posterior and one ante-
lated to the hinge axis determined rior (Table 2 and Fig 1).
by a kinematic facebow. Even in
“normal” or “asymptomatic” pa- Posterior references. For the poste-
tients, recording the position of the rior reference points, the possible
hinge axis is a technique-sensitive choices are:
procedure. Positioning of the face-
bow and its transfer to the articula- 1. The position of the hinge axis
tor are procedures where mistakes extensions recorded with a kine-
are easily incorporated.10–13 When matic facebow, often tattooed
the benefits of using a kinematic on the skin
facebow and pantographic tracings 2. An arbitrary point 12 to 13 mm
are clear, their use is justified. anterior to the posterior border of
It is not true that the more com- the tragus on tragus-canthus line
plex the articulator is, the more pre- 3. The axis determined by an ear-
cise the clinical result will be.14 This bow placed in the patient’s audi-
is due, in part, to the fact that in a tory meati

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Table 2 Anterior and posterior points of reference for the determination of a reference plane
Posterior point Anterior point Resulting plane
Porion (midpoint of upper border of external Infraorbital point (orbitale) Frankfort’s
auditory meatus)
Hinge axis (or arbitrary axis) Infraorbital point (orbitale) Axis-orbital
Hinge axis (or arbitrary axis) Nasion minus 23 mm Axis-orbital (approximate)

Arbitrary axis (given by an earbow or Arbitrary point measured from Arbitrary

average landmarks) incisal margin
Superior portion of tragus (center of external Ala of the nose Camper’s
auditory meatus)

Fig 1 (left) Facebow identifies a plane by using three points—two

posterior and one anterior.

Fig 2a (below left) Superimposition of the articulator on the side

view of the patient (1:1 ratio) using the earbow as the common ref-
erence shows the position of the axis that an earbow determines.

Fig 2b (below) By keeping the earbow attached to the bite fork

assembly mounted on the articulator, the position of the arbitrary
axis (which is coincident with the articulator axis) is evident.

[AU: Can you provide a written model release for

the figures used in these images? (If not, we will
have to place black boxes over the eyes.)]

The hinge axis can be certainly the articulator’s vertical dimension requires opening the VDO on the
the most precise, since it is found of occlusion (VDO) after the models patient).
with a kinematic facebow. This land- have been mounted (if, eg, the cen- The second landmark is not con-
mark is certainly indicated when- tric relation [CR] position is sidered very reliable. Studies done
ever the operator plans to change recorded with a gothic arch that to determine the variation between

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Fig 3 Anterior and posterior references and resulting planes.

a located hinge axis and various arbi- plays little role at the occlusal level these planes is parallel to the hori-
trary axes show wide disparities. In if the intermaxillary registration is zon, since both posterior landmarks
one study15 95% of the points lo- made without an alteration in oc- are below the orbitale point.
cated 13 mm anterior to the poste- clusal vertical dimension. According to one study, 21 the
rior border of the tragus on the tra- orbitale is located on the average 18
gus-canthus line were within a 5-mm Anterior references. The third point mm above a true horizontal plane
radius from the true hinge axis. In of reference employed when using a passing through the axis. As a con-
two other studies,16,17, the percent- facebow can be one of the follow- sequence, the Frankfort plane forms
ages recorded were 33% and 20%, ing20,21 (Fig 3): an angle of about 8 degrees with
respectively. this arbitrary plane (also called the
Determining the axis by an ear- 1. Orbitale “esthetic plane”), while the axis-
bow provides a quicker and simpler 2. A point at a fixed distance from orbital plane forms an angle of 13
manner in which to record the posi- nasion (eg, nasion minus 23 mm, degrees with the same plane.
tion of the maxillary arch. The ear- which corresponds approxi- Guichet 23 recommends a
bow takes advantage of the rela- mately to orbitale) method that places the incisal edges
tionship that the auditory meati have 3. An arbitrary point measured up (and possibly the entire occlusal
with the glenoid fossae (Fig 2). from the incisal edge of the max- plane) roughly in the middle of the
Teteruck and Lundeen18 demon- illary lateral incisor. articulator (Fig 4). This prevents any
strated in a sample of 47 patients space problems when mounting the
that 75.5% of the arbitrary axes When using either of the first stone casts. For this reason, he sug-
determined by the earbow fell within two reference points in combination gests using a ruler that identifies a
a 6-mm radius from the true hinge with porion [AU: Please verify point at a fixed distance from the
axis. A study of 18 patients found spelling “porion.” (Also in Table 2, incisal edge of the maxillary right lat-
that 89% of the axes determined Fig 3.)] or axis, the resulting planes eral incisor (for the Denar articulator,
were within the same radius magni- (the Frankfort plane and the axis- it is 43 mm). At the same time, this
tude of discrepancy.19 Although it is orbital plane, respectively) tend to anterior landmark, being at least 7 to
true that the axis determined by the produce an excessively steep 10 mm below the orbitale, defines a
earbow rarely coincides with the true anteroposterior angulation of the plane that, when the patient is stand-
hinge axis, the potential error in any occlusal plane on the articulator.22 ing erect with their eyes directed
patient caused by the deviation This is due to the fact that neither of straight forward in a horizontal plane,

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Fig 4a Mounting of the upper model using an arbitrary anterior Fig 4b Relationship of the maxillary cast to the reference plane
reference at a fixed distance from the occlusal plane. Measurement (top dotted line) and to the upper part of the articulator.
on the face 43 mm from the incisal edge of the maxillary right later-
al incisor.

tends to be more parallel to the hori- technician the true spatial position of endpoints of the arbitrary axis to be
zon than the traditional planes of ref- the dental arch, he or she needs to within a few millimeters of the true
erence. This gives the occlusal plane draw directly on the model the pro- axis’s end points. However, to many
an anteroposterior inclination similar jection of the midline, the true verti- this still sounds “heretical.”
to what the clinician observes when cal line, and the corrections to be Those who adhere to this
looking at the patient standing in incorporated in the provisional approach value it for the possibility
front of him or her. restorations (eg, lengthening or that it gives them to communicate in
shortening certain teeth). For a defin- an effective and error-free manner
On the frontal plane. By observing itive restoration, the same should be with the laboratory technician. As a
the two posterior reference points done on the model of the provi- matter of fact, when the technician
on the frontal plane, regardless of sionals in the mouth of the patient. observes the models mounted from
whether they are the superficial pro- With this method, the technician such a “corrected” facebow, he or
jections of the rotation centers of cannot base judgment on what is she can evaluate the features of that
the hinge axis or those given by the seen when analyzing the orientation dentition (length of the different
auditory meati, it should be realized of the occlusal plane of the mounted teeth, cant of the occlusal plane, in-
that in many patients their level is not cast with respect to the top of the clination of the midline, etc), being
symmetric—one tends to be higher working bench, unless he or she certain of the relationship that they
than the other. As a consequence, raises the right or left back supports have with the horizon. The techni-
the line that connects them is not of the articulator by an amount cian will be able to look at the mod-
horizontal (Fig 5). clearly indicated by the dentist.24 els on the articulator in the same
If the operator is using a kine- With the earbow, it is possible to way the clinician observes the pa-
matic facebow, because he or she correct its inclination by manually tient. But this would not be enough
wants to locate and record the true leveling it in the frontal plane before to justify this approach if the method
hinge axis, the eventual slant of the tightening the screws. 14,25 Most were to produce occlusal repercus-
facebow has to be accepted. Then, often, the correction to be made is sions that would be difficult to cor-
to communicate to the laboratory minimal. Thus, it is possible for the rect or compensate for.

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Fig 5a Implications of the facebow position on the mounting of Fig 5b As a consequence, the inclination of the maxillary model
the upper model (in the frontal plane). If the ears are level, the ear- will be consistent with that observed on the patient.
bow will be parallel to the interpupillary line or to the horizon and
perpendicular to the midline (
= 90 degrees).

Fig 5c If one ear’s position is higher than the other (in this exam- Fig 5d Thus, when placing on the articulator the bite fork assem-
ple, the left ear), the earbow will NOT be parallel any longer to the bly that is perpendicular to its base, the model will be involuntarily
interpupillary line or to the horizon, nor to the midline ( < 90 mounted with a cant toward the opposite side.
degrees), but the bite fork assembly will still be perpendicular to it.

Intermaxillary registration for the arbitrariness of what will be will be far greater than those that
done subsequently, ie, the setting could result from the setting of
Registering the mandibular position of the instrument with values that condylar inclination and Bennett
is the second step of the procedures are not individual. As Pameijer7 said, angle with arbitrary values rather
for mounting the models on the “An incorrect registration (either of than with the patient’s individual val-
articulator. This is the key step26 that centric relation or maximum inter- ues.” Before any intermaxillary reg-
compensates for the “inaccuracies” cuspation) will have repercussions istration is made, two important
of what has just been described, and on the occlusal relationships which decisions should be considered.

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Fig 6 When the arbitrary axis is not coincident with the patient’s
true hinge axis, by closing the articulator, an error is introduced at
the occlusal level. The magnitude of the error is larger when the
axis recorded is inferior (I) or superior (S) with respect to the true
hinge axis, rather than when it is posterior (P) or anterior (A) (adapt-
ed from Zuckerman29). [AU: What does “O” indicate?]

First, the clinician has to decide with the antagonists. If a restoration mouth. The magnitude of this
whether to use as the mandibular is fabricated in the patient’s MI posi- occlusal error is directly proportional
position CR (ie, a “reorganized” tion, however, at the time of insertion to the angular, vertical, or horizontal
approach) or MI (ie, a “conforming” it will be necessary to check that discrepancy between the two axes
approach). This decision depends there are no interferences in CR on and the vertical dimension where
on the extent of the rehabilitation— the prosthesis. the intermaxillary registration is
the more extensive it is, the more Regardless of the outcome of made. Therefore, if an average-set-
common the tendency to use CR.27 the first choice, it is necessary to ting facebow (earbow) is employed,
This position is indicated when pre- make a second decision, ie, at which it is essential to record the CR or MI
cise references (or conditioning land- VDO to record the intermaxillary position at the same vertical dimen-
marks) are lacking at the tooth level, position. Having positioned the sion to which the patient will be
since this is a border position, fairly upper model with the earbow, if the restored.
stable, and, to a certain extent, articulator’s vertical dimension is In those situations where only a
reproducible in the time frame nec- changed (eg, if it is closed) after few teeth are to be restored and the
essary to complete the treatment.28 mounting the lower model, it is very remaining teeth form a stable inter-
On the other hand, “Use of the inter- likely that the mandible’s condyles cuspation, the new restorations have
cuspal position for the restoration of and those of the articulator will to conform to the existing occlusion.
individual natural teeth in situations rotate around two different axes.29 No registration material is necessary
where mandibular function is in When the arbitrary axis is not coin- or, if it is used, it is placed only at the
health is most appropriate, provided cident with the patient’s true hinge level of the prepared abutments
that a stable intercuspal position can axis, by closing the articulator after while the intact teeth occlude in the
be identified.”8 This is the situation having removed the recording patient’s MI position.30 In both cases,
where only a few teeth have been material, an error is introduced at it is essential to record the teeth that
prepared and the rest of the denti- the occlusal level (Fig 6). This means do have a definitive contact and
tion is in good occlusal condition that the occlusal contacts on the transfer this information to the tech-
and in a proper occlusal relationship models will differ from those in the nician.

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Fig 7a (right) Clinical example of how the anterior portion of a

complete-arch maxillary provisional is kept in place to record the
intermaxillary position at the correct vertical dimension and spatial
position. The provisional is in place.

Fig 7b (below) Anterior six units and right second molar (the only
intact tooth) maintain the correct spatial position of the mandible.

Fig 7c (below right) Registration material is introduced in the pos-

terior space while allowing verification of the correct centric relation
position. The set zinc oxide eugenol paste has encompassed
enough posterior abutments to ensure that the models of the pre-
pared abutments will not rock, even without an anterior stop.

In extensive rehabilitations, maintain the correct vertical dimen- Conclusions and

when there are no intact teeth to sion and the right space for the reg- recommendations
help identify the correct position, it istration material that is placed only
is useful to keep portions of the pro- at the level of the prepared abut- On the basis of the rationale pro-
visional restorations—generally a ments (Fig 7). posed in this article, the following
few units in the anterior—to register The ideal material for intermax- conclusions are drawn and recom-
CR at the VDO where the patient illary registrations should not offer mendations made by the author
has been functioning. These re- any resistance to the teeth during when selecting the instrumentation
tained anterior provisionals act as a the registration process and should and procedures in preparation for a
deprogramming jig, since there are be fast setting. Once hardened, it prosthetic rehabilitation:
no posterior contacts.31,32 It is man- should be stiff and not distort. The
datory, at this stage, for the muscu- author prefers a zinc oxide eugenol 1. A semiadjustable articulator may
lature to be relaxed; otherwise, the bite-registration paste (Superbite, be employed without fear of in-
reliability of the technique used, Bosworth) supported by a stiff wax troducing gross occlusal dis-
whether active or passive, is com- (Moyco Beauty Pink Extra-Hard Wax, crepancies for the majority of
promised. 33,34 The provisionals Thompson Dental). patients.

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2. The earbow is an adequate Acknowledgments

instrument to position the upper
model in the articulator in a The author wishes to thank Drs Robert
Faucher, Anselm Wiskott, and Jan H. N.
proper relationship relative to the
Pameijer for the advice given in reviewing
hinge axis and the reference this manuscript.
plane; the third point of refer-
ence should be identified in the
infraorbital region at a level such References
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some indications will be given on 10. Kurth L, Feinstein I. The hinge axis of the
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12. Lauritzen AG, Wolford LW. Hinge axis 27. Becker CM, Kaiser DA, Schwalm C.
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Volume 23, Number 1, 2003