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Is There a Benefit of Using an Arbitrary Facebow for the Fabrication of a

Stabilization Appliance?

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Is There a Benefit of Using ub

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S. Parichereh Shodadai, DDS, Dr Med Dent a tio
an Arbitrary Facebow for n
Jens C. Türp, DDS, Dr Med Dent Habilbtes
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the Fabrication of a s e n c e fo r
Thomas Gerds, Dipl-Mathc
Stabilization Appliance? Jörg R. Strub, DDS, Dr Med Dent Habild

Purpose: The aim of this clinical study was to evaluate if an arbitrary facebow registration
and transfer provides significant advantages for the fabrication of an occlusal appliance in
comparison with the omission of such a procedure. Materials and Methods: For 20 fully
dentate adult patients diagnosed with bruxism, two Michigan occlusal splints were
constructed. One of the two upper dental casts was transferred to the articulator with an
arbitrary earpiece facebow; the other maxillary cast was mounted arbitrarily using a flat
occlusal plane indicator. Upon splint delivery, the number of intraoral occlusal contacts
and the time needed for chairside occlusal adjustment were recorded. Results: The
number of occlusal contacts on the appliance fabricated with or without facebow was
similar in most cases both in the articulator and in the mouth. The one-sided Wilcoxon
rank sum test showed with high probability that the use of an arbitrary facebow does not
yield a clinically relevant improvement with regard to the number of occlusal contacts or
the chairside adjustment time. Conclusion: From this pilot study, it appears that for the
fabrication of an occlusal appliance, registration and transfer with an arbitrary earpiece
facebow does not yield clinically relevant benefits. Of course, this conclusion cannot be
transferred to other facebows and is restricted to the levels of clinical relevance defined in
the study. Int J Prosthodont 2001;14:517–522.

It is a characteristic of the human mind, that facts of
common experience are accepted by the majority as
being unworthy of investigation; and it is, as a rule,
only unaccustomed phenomena that excite the cu-
riosity of the generality of mankind.
—T. E. Constant1
becomes essential to “separate the wheat from the
chaff,” ie, to identify (and eliminate) unnecessary di-
agnostic measures and ineffective therapeutic inter-
ventions.4 Recently, it has been estimated that only 8%
of dental treatments are supported by randomized
controlled clinical trials.5 This indicates that for a
great majority of clinically relevant questions, the cur-

C onsidering the growing importance of healthcare

that is based on the best available evidence,2,3 it
aAssistant Professor, Department of Prosthodontics, Dental School,
Albert Ludwigs University, Freiburg, Germany.
b Associate Professor, Department of Prosthodontics, Dental
School, Albert Ludwigs University, Freiburg, Germany.
cStatistician, Department of Prosthodontics, Dental School, and
Institute of Medical Biometrics and Medical Informatics, Albert
Ludwigs University, Freiburg, Germany.
d Professor and Chair, Department of Prosthodontics, Dental
School, Albert Ludwigs University, Freiburg, Germany.
Reprint requests: Dr Jens C. Türp, Abteilung Poliklinik für
Zahnärztliche Prothetik, Universitäts-Zahn-, Mund- und
Kieferklinik, Hugstetterstraße 55, D-79106 Freiburg, Germany.
Fax: + 49 761 270 4925. e-mail: tuerp@zmk2.ukl.uni-freiburg.de
rently existing evidence level may not be based on re-
sults from controlled clinical studies, but rather on un-
controlled observations, recommendations from
respected authorities, or personal beliefs. Too often,
however, clinicians have considered such weak evi-
dence as generally accepted facts.
Facebows are one example of a widely used device
whose clinical relevance has hardly ever been
doubted. The origins of facebows date back to the end
of the 19th century.6,7 According to the seventh edi-
tion of “The Glossary of Prosthodontic Terms,”8 a
facebow is a caliper-like instrument that serves to
record the spatial relationship of the maxillary dental
arch to some anatomic reference point(s) and to trans-
fer this relationship to an articulator. This procedure

Volume 14, Number 6, 2001 517 The International Journal of Prosthodontics

 Arbitrary Facebows for Fabrication of Stabilization Applicances
ensures that the cast of the maxillary dental arch is ori-
ented in an equal or at least comparable distance to
the hinges of the articulator as are the natural maxil-
lary teeth to the assumed “axis of rotation” of the tem-
poromandibular joints.
More popular than the somewhat complex kine-
matic facebows (“hinge and transfer bows,”9 “kine-
matic hinge axis facebows”10), which carry adjustable
caliper ends or side arms for the location of the so-
called transverse horizontal axis (hinge axis) of the
mandible, are arbitrary (earpiece or non-earpiece)11
facebows (“simple facebows”9). Arbitrary earpiece
facebows, also referred to as earbows, relate the max-
illary teeth to the external auditory meatus (by ear rods)
and to a horizontal reference plane, eg, the Frankfort
plane, or the axis-orbital plane.8 In contrast to earlier
recommendations, in which preference was given to
individual registration with kinematic facebows,9 ar-
bitrary facebows are usually favored today.12
During the last decades, nearly every dental text-
book and the vast majority of clinicians have consid-
ered the use of facebows indispensable for diagnosis,
treatment planning, and treatment.7,10,13–15 Facebow
registration has also been deemed necessary for the
fabrication of oral splints such as stabilization appli-
ances (Michigan splints).16,17 Temporomandibular
pain as well as bruxism are doubtless the most fre-
quent indications for these splints.18–20
It is believed that by using facebows the risk of oc-
clusal errors is minimized,11 thereby enhancing the
accuracy of the occlusion of new restorations or oral
appliances upon their insertion. As a clinical conse-
quence, restorations or splints made on casts
mounted in the articulator with facebows should
have more occlusal contacts upon delivery and re-
quire less intraoral occlusal adjustment than those
mounted without a facebow.
In recent years, however, in some,21–24 though not
all,25,26 studies doubts have been cast on the reliabil-
ity of the facebow registration and transfer procedure.
Besides, the clinical relevance of using facebows for
the fabrication of partial dentures, complete dentures,
and other sorts of dental restorations has been ques-
tioned, particularly by clinicians27,28 and professional
organizations from Scandinavia, including the
Scandinavian Society for Prosthetic Dentistry.29 In fact,
Carlsson and Magnusson29 reported in 1999 that “vir-
tually no Scandinavian dentists . . . have been using
facebows for the last two decades.” They state that
“even if theoretically convincing, there is no com-
pelling evidence that the use of a facebow increases
the clinical quality of a restoration fabricated on an ar-
ticulator in comparison with average mounting (with-
out facebow).”29 In addition, and again in contrast to
the view expressed in dental textbooks, experienced
The International Journal of Prosthodontics
Shodadai et al
pyr
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clinicians have argued that facebow registration
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splints.
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The aim of the present clinical study was thereforeub
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to evaluate if an arbitrary earpiece facebow registration catio
te ot n
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and transfer has measurable advantages in comparison
ss e n c e
fo r
with no facebow when making an occlusal appliance.
In particular, the number of occlusal contacts and the
time needed for the chairside adjustment of a newly
delivered maxillary stabilization splint were studied.
Materials and Methods
Twenty adult patients with a complete natural denti-
tion (13 women and seven men) who had been diag-
nosed with dental attrition because of nocturnal brux-
ism took part in this study. All patients were treated by
one clinician. After taking two irreversible hydrocol-
loid impressions of both the maxillary and mandibu-
lar dental arches, an arbitrary facebow registration
and a recording of centric relation were made.
For mounting of the casts, a semiadjustable articu-
lator (SAM 2P, ART 302; SAM Präzisionstechnik) was
used. The facebow registration was carried out with the
Axioquick system (SAM Präzisionstechnik). The main
parts of this system consist of an arbitrary earpiece
transfer bow (ATB 303), a transfer fork assembly (ATB
305), and an adjustable nasion relator (ATB 302) for
establishing an anterior orbital reference point 25 mm
inferior to the midpoint of the nasion. For the registra-
tion, the transfer fork was covered with thermoplastic
impression material (Impression Compound, Kerr) in
the regions of the maxillary canines and first molars and
pressed into position on the maxillary teeth. After
checking the impressions of the tooth cusps, the trans-
fer fork was readapted on the maxillary teeth and the
facebow was mounted and locked in position (Fig 1).
Thereafter, one of the two upper dental casts was trans-
ferred with the facebow to the articulator. In contrast,
the other maxillary cast was mounted arbitrarily with
the help of a flat occlusal plane indicator (ART 280,
SAM Präzisionstechnik), which was set on a posterior
upward angulation of 15 degrees. Its vertical and hor-
izontal rods were fixed on the 5.5-mm and 7.5-mm ref-
erence positions, respectively (Fig 2).
Centric relation was determined by an interocclusal
record. Because the occlusal appliance was con-
structed to be worn during the night, the patient was
fully reclined in the dental chair. Reclining the patient
ensures that the mandibular position corresponds to
the position that the patient assumes when lying on
his or her back. It should be emphasized that this po-
sition does not correspond to the fully reclined (“rear-
most-midmost-upmost”) condylar position. Two lay-
ers of extra-hard pink baseplate wax (Beauty Pink,
Moyco) were glued together, softened in warm water
518 Volume 14, Number 6, 2001
 Shodadai et al
Fig 1 Patient with mounted arbitrary earpiece facebow system.
Fig 2 (above right) Arbitrary mounting of the other maxillary
dental cast with the help of a flat occlusal plane indicator.
Posterior upward inclination 15 degrees; reference position ver-
tical rod 5.5 mm, horizontal rod 7.5 mm.
Fig 3 (right) Stabilization splint with occlusal contacts imme-
diately before chairside adjustment.
(59°C), and adapted on the maxillary teeth. The
mandible was guided by the operator into the wax
until small contacts occurred in the lower surface of
the wax sheet. After removing the wax sheet and chill-
ing it in cold water, aluminum wax (Aluwax Dental
Products) was added into the impressions caused by
the cusps of the mandibular canines and first molars.
The wax sheet was readapted on the maxillary teeth.
Without applying force to the patient’s chin, the
mandible was guided by the operator into the wax dur-
ing active mandibular closing until slight impressions
were seen in the aluminum wax. The wax sheet was
then removed and stored in cold water.
For each patient, two Michigan occlusal splints
made of cold-curing hard acrylic resin (ProBase Cold,
Ivoclar) were constructed successively in the same
manner and by the same experienced dental techni-
cian using the same articulator. The vertical dimen-
sion was increased as minimally as possible by re-
setting the incisal pin of the articulator. At least one
thickness of baseplate wax could be placed between
the canines; this corresponded to an increase in the
length of the incisal pin of the articulator of about 5
to 6 mm compared to the “zero” position. Bennett
angle was set to 15 degrees, and condylar inclination
was adjusted to 45 degrees, as suggested by the pro-
ducer of the SAM 2 articulator.
Volume 14, Number 6, 2001
Arbitrary Facebows for Fabrication of Stabilization Applicances
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ss e n c e
fo r
The splints were fabricated according to the rec-
ommendations given by Geering and Lang31 and Ash
and Ramfjord,11 with the following main features:
complete coverage of the occlusal surfaces of all max-
illary teeth; smooth, flat occlusal surface of the splint;
occlusal contacts of all mandibular supporting cusps;
freedom in centric zone of 0.5 to 1 mm; no incisal
guidance from centric occlusion; and canine guidance
for protrusive and laterotrusive movements, starting
about 1 mm from freedom in centric occlusion. Upon
completion of the two splints, the occlusal contacts of
the mandibular teeth in centric relation as well as dur-
ing protrusive and laterotrusive mandibular move-
ments were marked in the articulator and in the pa-
tient’s mouth with black ribbon. The occlusal contacts
in centric occlusion were counted and photographed
for documentation (Fig 3). The two splints were in-
serted and adjusted in random order. The chairside ad-
justment was stopped as soon as the contact pattern
corresponded to that achieved after completion of
the splint in the laboratory (comparison with the pho-
tographic documentation). The time needed for chair-
side adjustment of the splints was recorded.
Because in one patient the splints did not fit upon
insertion, only 19 patients were included in the final
analysis. For the statistical analysis, the following one-
sided hypotheses were considered: The use of an
519 The International Journal of Prosthodontics
 Arbitrary Facebows for Fabrication of Stabilization Applicances
Table 1 Number of Occlusal Contacts and Time Needed for Adjustment of the
Stabilization Appliances Fabricated without and with Facebow
Occlusal contacts
in the articulator
Without With
Mean 18.4 19
Median 19 19
Minimum 12 11
Maximum 23 24
arbitrary facebow yields more occlusal contacts and is
associated with less time needed for chairside occlusal
adjustment. Differences of up to two occlusal contacts
and a time difference of up to 2 minutes for chairside
adjustment were regarded as clinically irrelevant. The
one-sided Wilcoxon rank sum test was calculated.
Results
The number of occlusal contacts on the appliance
fabricated with or without facebow was similar both
in the articulator and in the mouth (Table 1). The one-
sided Wilcoxon rank sum test was significant (in the
articulator P = .03; in the mouth P = .001). This
means that with high probability the use of an arbi-
trary facebow does not yield more than two more oc-
clusal contacts.
There was great individual variation in both di-
rections for the difference in time needed for chair-
side adjustment of the two appliances (Table 1).
However, the Wilcoxon rank sum test was significant
(P = .013), showing that the use of an arbitrary face-
bow yielded at most up to 2 minutes of spared time
for occlusal adjustment (in fact, the mean time was
very similar; Table 1).
Note that the one-sided Wilcoxon rank sum test
with transposed hypotheses, ie, testing the hypothe-
ses that not using an arbitrary facebow leads to more
occlusal contacts and less adjustment time, was sig-
nificant as well, provided that the same levels of tol-
erance are accepted (for contacts in the articulator P
= .001; for contacts in the mouth P < .001; for ad-
justment time P = .002). These results showed that
both methods were similar, or, as one reviewer sug-
gested, have the same problems.
Discussion
For the majority of the patients included in our in-
vestigation, the omission of an arbitrary facebow did
not lead to a less acceptable outcome as compared
to the use of such a device. Thus, in general our data
support the viewpoint of experienced clinicians such
The International Journal of Prosthodontics
Shodadai et al
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Intraoral occlusal contacts Time required for chairside lica
before adjustment adjustment (min) tio
Without With Without With te ot n
n
ss e n c e
fo r
11.8 11.7 10.4 10.7
12 12 8.5 8
6 6 4 4
17 16 26 27
as Hansson and Lachmann,30 who questioned the
clinical relevance and the necessity of using face-
bows for the fabrication of bite splints.
A combination of factors may explain why most
patients in our investigation did not benefit from the
use of an arbitrary facebow: change (usually increase)
of the occlusal vertical dimension after making the
centric relation interocclusal record; lack of evidence
for pure condylar rotation and the existence of a
condylar hinge axis on mandibular opening; unpre-
dictable and variable condylar movements on
mandibular opening; use of rigid hinge axis articu-
lators; and the presence of temporomandibular pain.
It is still widely believed that mandibular move-
ments from centric occlusion to mandibular rest po-
sition (and the reverse) are characterized by condylar
rotation around a transverse horizontal (hinge) axis. If
this assumption is true, the use of a facebow for mak-
ing an oral splint would ensure that in the articulator
the maxillary cast teeth moved against the mandibu-
lar teeth on the same arc as the mandibular teeth did
in the patient’s mouth.11 However, evidence has been
mounting that the opening-closing movement of the
mandible does not occur as a rotation around a fixed
hinge axis, but as a combination of condylar rotation
and anterior-inferior translation of the condyle-disc
complex around moving instantaneous centers of ro-
tation.32–39 This explains why contact relations at an
increased vertical dimension (inserted bite splint) may
be different from those at centric occlusion or centric
relation occlusion.11 As a consequence, some adjust-
ment of the splint is almost always necessary.11
In addition, during deliberate opening and closing
movements, temporomandibular joints show a marked
intraindividual (left/right) as well as interindividual
variability of the relationship between condylar rota-
tion and anterior condylar translation.39 Articulators,
however, are not able to simulate these highly variable
and complex opening and closing motions.37,40,41
Whether the use of a kinematic facebow and “in-
dividual hinge axis recording” leads to more favorable
results as compared to an arbitrary or no facebow re-
mains to be shown.42 From a clinical viewpoint, it has
520 Volume 14, Number 6, 2001
 Shodadai et al
to be considered that oral appliances are among the
most widely used and most successful devices for the
management of temporomandibular pain and brux-
ism.20 However, the condylar position and mandibu-
lar movements of temporomandibular pain patients
are very likely to differ from those of pain-free indi-
viduals.43–45 Similarly, results from experimental re-
search suggest that sustained tooth clenching leads to
spatial changes in the temporomandibular joints46
and, in the case of eccentric clenching, to three-di-
mensional deviations of the mandible.47 Hence, it
must be seriously questioned whether in patients with
temporomandibular pain and/or bruxism reliable
recording of a (terminal) hinge axis is possible, and
supposing it were, whether such a requirement is
necessary for a successful clinical outcome.
In 1939, Brodie48 wrote: “Someone once made the
observation that if an error or a misconception once
crept into a text book it took fifty years to get it out. The
fifty years have elapsed but the misconceptions about
the movements of the mandible still appear in our
most authoritative text-books.” It is feasible that a sim-
ilar misconception exists with regard to the clinical sig-
nificance of facebows for the fabrication of occlusal ap-
pliances. Because of the possible sequelae of the results
of this pilot study, we recommend a more detailed in-
vestigation on the importance (or nonimportance) of
facebows in general. In view of the Scandinavian ex-
periences,27–29 a look into the value of these traditional
devices for the fabrication of complete and partial
dentures also seems warranted.
From the results of this pilot study, it appears that
for the fabrication of an occlusal appliance the reg-
istration and transfer with an arbitrary earpiece face-
bow can be omitted. Of course, this conclusion might
not be valid when other facebows are used. In addi-
tion, this conclusion is restricted to the levels of clin-
ical relevance defined in our study.
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Literature Abstract

A classification system and algorithm for reconstruction of maxillectomy and

midfacial defects.

Maxillectomy defects become more complex when critical structures such as the orbit, globe,
and cranial base are resected, and reconstruction with distant tissues becomes essential. This
study reviewed all maxillectomy defects reconstructed immediately using pedicle and free flaps
to establish a classification system and an algorithm for reconstruction of these complex prob-
lems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as: type I, lim-
ited maxillectomy (n = 7); type II, subtotal maxillectomy (n = 10); type IIIa, total maxillectomy
with preservation of the orbital contents (n = 13); type IIIb, total maxillectomy with orbital exen-
teration (n = 18); and type IV, orbitomaxillectomy (n = 10). Chewing and speech functions were
assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15
patients (41.7%). Sixteen patients (44.4%) returned to an unrestricted diet, 17 (47.2%) kept a
soft diet, and 3 (8.3%) maintained a liquid diet. Speech was assessed as normal in 14 (38.9%),
near normal in 15 (41.7%), intelligible in six (16.7%), and unintelligible in one patient (2.8%).
Globe and periorbital soft tissue position was assessed in 14 patients with type I and IIIa de-
fects. Oral competence was considered good in all 10 patients with excision/reconstruction of
the oral commissure; however, two patients (20%) developed microstomia after receiving ra-
diotherapy. Esthetic results were evaluated at least 6 months after reconstruction in 50 pa-
tients. They were good to excellent in 29 patients (58%) for whom cheek skin and lip were not
resected, and poor to fair (42%) when the external skin or orbital contents were excised.
Secondary procedures were required in 16 of 50 patients (32.0%). Free tissue transfer pro-
vides the most effective and reliable form of immediate reconstruction for complex maxillec-
tomy defects. Rectus abdominis and radial forearm flaps in combination with immediate bone
grafting or as osteocutaneous flaps reliably provide the best esthetic and functional results.

Cordeiro PG, Santamaria E. Plast Reconstr Surg 2000;105:2331–2346. References: 23. Reprints: Dr
Peter G. Cordeiro, Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan-
Kettering Cancer Center, 425 East 67th Street, New York, New York 10021. e-mail: cordeirp@mskcc.org—
Frankie Sulaiman, Seattle

The International Journal of Prosthodontics 522 Volume 14, Number 6, 2001

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